Instructions:

1. Review the results generated by CAC software.

2. Compare documentation in the case to the list of possible diagnosis, procedure, and service codes generated by CAC software.

3. Select codes that are supported by documentation in the case (from the list of possible codes generated by CAC software).

Case:

54-year-old female patient with recently diagnosed Cushing's syndrome who is scheduled for transsphenoidal surgerypresents today with complaints of fever, muscle pain, and difficulty breathing. She states she thinks it is just a common cold, but she is anxious about other possibilities due to the recent diagnosis of Cushing's and the upcoming surgery. She wants to "cover all bases and be evaluated to determine if there is something else going on." Level 5 emergency department evaluation and management services were provided, and results indicated the patient does indeed have a common cold. The patient was provided with instructions about how to relieve her cold symptoms.

Click to view image in new window:CAC Emergency Department Case 3

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Which ICD-10-CM code is reported for the first-listed diagnosis?

a. R50.9b. J00c. R45.0d. P28.89e. M79.1f. E24.9g. F41.1h. R68.89i. R07.1j. E24.8k. R06.02l. R50.81