Read the mini-medical-record of the patient’s encounter, then abstract, assign,

Question

Read the mini-medical-record of the patient’s encounter, then abstract, assign, and sequence ICD-10-CM diagnosis codes using the Index and Tabular List. What are the correct code(s)?

A. I63.132, I69.354, I69.398, R13.13 9. INPATIENT HOSPITAL Gender: M Age: 82 Reason for admission: left sided paralysis, inability to walk, inability to formulate words Assessment: cerebral infarction due to embolism in right common carotid artery with pharyngeal dysphagia and left non-dominant hemiplegia Plan: Rehab for mobility and speech, medication to address blood pressure issues. FU with primary care physician Tipe The carotid artery is located in the neck 4ICD-10-CM Codes

Explanation / Answer

The question says the answer is

D.163.131

169.354

169.392

R13.13

Abstraction

Involves reading the entire record of the health encounter and analysing the information to determine what conditions the patient had what caused it and how it was treated. The information comes from a variety of sources within the medical records such as clinical notes ,laboratory and radiology results and operation notes.

Assignment

Finding the appropriate code from the classification for the abstraction and entering the code into the system being used to collect the coded data.

163.131

Sequence

Affecting right dominant side

169.354

Sequence

Can be used to indicate a diagnosis for reimbursement purpose. Short description hemiplegia following cerebral infraction affecting left nondom side

169.391

Dysphagia following cerebral infraction

R13.13

Code that can be used to indicate a diagnosis for reimbursement purpose dysphagia

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