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CONFIDENTIAL
The National Clinical Coding Examination [UK]
22 March 2016
Paper 1 Practical - ANSWERS 9:30 am - 12:35 pm [THREE HOURS]
Please spend the first 5 minutes reading through the ‘Instructions to Candidates’
This Examination Paper consists of 2 Sections: A and B.
Section A – Practical Coding [30% of the Marks] Section A [1] – ICD-10 Questions 1-15 [15% of the Marks]. Section A [2] – OPCS-4 Questions 16-30 [15% of the Marks]. Answer all questions in the spaces provided on the Examination Paper.
Section B – Case Studies [70% of the Marks] Case Studies 1-7 [10% of the Marks for each Case Study]. Answer all questions using the Answer Sheets provided. Write only on one side of the Answer Sheets provided.
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Section A [1] 15% Write your candidate number on EVERY page
ICD-10 codes are required for the first 15 questions [1 – 15] [OPCS-4 codes are NOT required]
Provide appropriate code(s) for the following conditions in the boxes alongside each question. If more than one code is required, please use separate boxes for each code to make sequencing clear, for example, box 1 should contain the primary diagnosis code. [The number of boxes is not necessarily indicative of the codes required].
Question 1 Open fracture of the left humeral shaft, external cause and 1. S42.31 place of incident unknown. [7 Marks] 2. X59.9 3. CODES AND TITLES 4. S42.31 Fracture of shaft of humerus – Open 5. X59.9 Exposure to unspecified factor – Unspecified place 6.
Index: Fracture (abduction) (adduction) (avulsion) (comminuted) (compression) (dislocation) (oblique) (separation) T14.2 - humerus S42.3 - - shaft S42.3
Tabular: S42.3 Fracture of shaft of humerus Humerus NOS Upper arm NOS 0 closed 1 open
Index: Accident (to) X59.-
Tabular: X59 Exposure to unspecified factor [See at the beginning of this chapter for the classification of the place of occurrence and activity] .9 Unspecified place
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Question 2 Admitted for investigation following a high blood pressure 1. R03.0 reading in the A&E Department. During the admission the 2. I24.9 [or patient’s blood pressure returned to a normal range and I21.9] they were discharged. However, it was acknowledged the 3. I50.1 patient had suffered a myocardial infarction three weeks 4. ago. Known left ventricular failure. [8 Marks] 5. 6. CODES AND TITLES R03.0 Elevated blood-pressure reading, without diagnosis of hypertension I24.9 Acute ischaemic heart disease, unspecified [I21.9 Acute myocardial infarction, unspecified also accepted] I50.1 Left ventricular failure
Index: Elevated, elevation - blood pressure (see also Hypertension) I10 - - reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension R03.0
Tabular: R03.0 Elevated blood-pressure reading, without diagnosis of hypertension Note: This category is to be used to record an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an isolated incidental finding.
Index: Disease, diseased – see also Syndrome - heart (organic) I51.9 - - ischemic (chronic or with a stated duration of over 4 weeks) I25.9 - - - acute or with a stated duration of 4 weeks or less I24.9
Tabular: I24.9 Acute ischaemic heart disease, unspecified
Index: Infarct, infarction (of) myocardium, myocardial (acute or with a stated duration of 4 weeks or less) I21.9
Tabular:
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I21.9 Acute myocardial infarction, unspecified
Index: Failure, failed - heart (acute) (sudden) (senile) I50.9 - - left (ventricular) (see also Failure, ventricular, left) I50.1 Or Failure, failed - ventricular (see also Failure, heart) I50.9 - - left I50.1
Tabular: I50.1 Left ventricular failure
Question 3 Epidemic winter vomiting disease causing severe 1. A08.1 dehydration. [6 Marks] 2. E86.X 3. CODES AND TITLES 4. A08.1 Acute gastroenteropathy due to Norwalk agent 5. E86.X Volume depletion 6.
Index: Disease, diseased – see also Syndrome - winter vomiting (epidemic) A08.1 Or Vomiting (see also Hyperemesis) R11 - winter (epidemic) A08.1
Tabular: A08.1 Acute gastroenteropathy due to Norwalk agent
Index: Dehydration E86
Tabular: E86 Volume depletion
Question 4 Patient admitted with leakage of cerebrospinal fluid from 1. G96.0 the ear. Known to have bipolar affective disorder. [6 Marks] 2. F31.9 3. 4. CODES AND TITLES 5.
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G96.0 Cerebrospinal fluid leak 6. F31.9 Bipolar affective disorder, unspecified
Index: Leak, leakage - cerebrospinal fluid G96.0
Tabular: G96.0 Cerebrospinal fluid leak Excl.: from spinal puncture
Index: Disorder (of) – see also Disease - affective (mood) (see also Disorder, mood) F39 - - bipolar (see also Disorder, bipolar, affective) F31.9 Or Disorder (of) – see also Disease - bipolar F31.9 - - affective F31.9
Tabular: F31.9 Bipolar affective disorder, unspecified
Question 5 Diabetes mellitus due to malnutrition. Severe ketoacidosis, 1. E12.0 patient in hypoglycaemic coma. [6 Marks] 2. E16.2 3. CODES AND TITLES 4. E12.0 Malnutrition-related diabetes mellitus with coma 5. E16.2 Hypoglycaemia, unspecified 6.
Index: Diabetes, diabetic (mellitus) (controlled) (familial) (severe) E14.- - malnutrition-related (insulin- or non-insulin-dependent) E12.-
Tabular: E12 Malnutrition-related diabetes mellitus [See before E10 for subdivisions] .0 With coma
Index: Hypoglycaemia (spontaneous) E16.2
Tabular:
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E16.2 Hypoglycaemia, unspecified
Question 6 Admitted for treatment of mucinous adenocarcinoma of the 1. C44.1 canthus. Also known to have acinar adenocarcinoma of the 2. M8480/3 prostate. [12 Marks] 3. C61.X 4. M8550/3 CODES AND TITLES 5. C44.1 Other malignant neoplasms of skin - Skin of eyelid, 6. including canthus M8480/3 Mucinous adenocarcinoma C61.X Malignant neoplasm of prostate M8550/3 Acinar cell carcinoma
Index: Adenocarcinoma (M8140/3) – see also Neoplasm, malignant - mucinous (M8480/3)
Malignant Primary Neoplasm, neoplastic - canthus (eye) (inner) (outer) C44.1
Tabular: C44.1 Skin of eyelid, including canthus
Index: Adenocarcinoma (M8140/3) – see also Neoplasm, malignant - acinar (M8550/3)
Malignant Primary Neoplasm, neoplastic - prostate (gland) C61
Tabular: C61 Malignant neoplasm of prostate
Question 7 Bilateral Barton’s fractures of the forearms and fractured 1. T02.40 nose following a fall from a skateboard at a sports centre. 2. S02.20 [11 Marks] 3. W02.3 4. CODES AND TITLES 5.
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T02.40 Fractures involving multiple regions of both upper 6. limbs – closed S02.20 Fracture of nasal bones – closed W02.3 Fall involving ice-skates, skis, roller-skates or skateboards – Sports and athletics area
Index: Fracture (abduction) (adduction) (avulsion) (comminuted) (compression) (dislocation) (oblique) (separation) T14.2 - multiple T02.9 - - arm - - - meaning upper limb – see Fracture, multiple, limb, upper
Fracture (abduction) (adduction) (avulsion) (comminuted) (compression) (dislocation) (oblique) (separation) T14.2 - multiple T02.9 - - limb - - - upper (one) T02.2 - - - - with - - - - - other upper limb T02.4 Or Fracture (abduction) (adduction) (avulsion) (comminuted) (compression) (dislocation) (oblique) (separation) T14.2 - limb - - upper T10 - - - both T02.4
Tabular: T02.4 Fractures involving multiple regions of both upper limbs Fractures of sites classifiable to S42.-, S52.-, S62.- and T10 specifies as bilateral 0 closed 1 open
Index: Fracture (abduction) (adduction) (avulsion) (comminuted) (compression) (dislocation) (oblique) (separation) T14.2 - nose, nasal (bone) (septum) S02.2
Tabular: S02.2 Fracture of nasal bones 0 closed 1 open
External Causes of Injury Index:
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Fall, falling (accidental) W19 - involving - - skateboard(s) W02
Tabular: W02 Fall involving ice-skates, skis, roller-skates or skateboards .3 Sports and athletics area
Question 8 Patient with carotid artery plaque admitted for 1. I65.2 endarterectomy. Registered blind due to amaurosis fugax. 2. G45.3 [6 Marks] 3. 4. CODES AND TITLES 5. I65.2 Occlusion and stenosis of carotid artery 6. G45.3 Amaurosis fugax
Index: Plaque(s) - artery, arterial – see Arteriosclerosis
Arteriosclerosis, arteriosclerotic (diffuse) (disease) (general) (obliterans) (senile) (with calcification) I70.9 - carotid artery I65.2
Tabular: I65.2 Occlusion and stenosis of carotid artery
Index: Amaurosis (acquired) (congenital) (see also Blindness) H54.0 - fugax G45.3
Tabular: G45.3 Amaurosis fugax
Question 9 Avulsed brachial plexus nerve due to birth injury. Patient is 1. P14.3 43 years old. [3 Marks] 2. 3. CODES AND TITLES 4. P14.3 Other brachial plexus birth injuries 5. 6.
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Index: Avulsion (traumatic) T14.7 - nerve (root) see Injury, nerve
Injury (see also specified injury type) T14.9 - birth (see also Birth injury) P15.9
Birth - injury P15.9 - - nerve - - - brachial plexus P14.3
Tabular: P14.3 Other brachial plexus birth injuries
Question 10 Myasthenia syndrome due to Type II diabetes mellitus. [7 1. E11.4D Marks] 2. G73.0A 3. CODES AND TITLES 4. E11.4D Non-insulin-dependent diabetes mellitus with 5. neurological complications 6. G73.0A Myasthenic syndromes in endocrine diseases
Index: Myasthenia, myasthenic G70.9 - syndrome in - - diabetes mellitus (see also E10-E14 with fourth character .4) E14.4 G73.0* Or Syndrome – see also Disease - myasthenic (in) G70.9 - - diabetes mellitus – code to E10-E14 with fourth character .4
Diabetes, diabetic (mellitus) (controlled) (familial) (severe) E14.- - type II (nonobese) (obese) E11.-
Tabular: E11.4 Non-insulin-dependent diabetes mellitus with neurological complications
G73.0* Myasthenic syndromes in endocrine diseases Myasthenic syndromes in: Diabetic amyotrophy (E10-E14 with common fourth character .4)
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Question 11 Patient admitted due to post-traumatic stress disorder. 1. F43.1 Acutely intoxicated on admission with a blood alcohol level 2. F10.0 of 87mg/100ml. [9 Marks] 3. Y90.4 4. CODES AND TITLES 5. F43.1 Post-traumatic stress disorder 6. F10.0 Mental and behavioural disorders due to use of alcohol – Acute intoxication Y90.4 Blood alcohol level of 80-99mg/100ml
Index: Disorder (of) - see also Disease - post-traumatic stress F43.1
Tabular: F43.1 Post-traumatic stress disorder
Index: Intoxication - alcoholic (acute) (with) F10.0 Or Intoxicated NEC F10.0
Tabular: F10 Mental and behavioural disorders due to use of alcohol .0 Acute intoxication
External Causes of Injury Index: Factors, supplemental - alcohol - - blood level - - - 80-90mg/100ml Y90.4
Tabular: Y90.4 Blood alcohol level of 80-99mg/100ml
Question 12 Patient admitted with hemiplegia and dysphasia. Diagnosed 1. I63.4 as having suffered a stroke. A CT scan showed an 2. G81.9 embolism of the middle cerebral artery. Known to have 3. M06.94 rheumatoid arthritis affecting the hands. [9 Marks] 4. 5.
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CODES AND TITLES 6. I63.4 Cerebral infarction due to embolism of cerebral arteries G81.9 Hemiplegia, unspecified M06.94 Rheumatoid arthritis, unspecified – Hand
Index: Embolism (septic) I74.9 - artery I74.9 - - cerebral (see also Occlusion, artery, cerebral) I66.9
Occlusion, occluded - artery – see also Embolism, artery - - cerebral I66.9 - - - middle I66.0 - - - - with infarction (due to) I63.5 - - - - - embolism I63.4 Or Hemiplegia G81.9 - embolic (current episode) I63.4
Tabular: I63.4 Cerebral infarction due to embolism of cerebral arteries
Index: Hemiplegia G81.9
Tabular: G81.9 Hemiplegia, unspecified
Index: Arthritis, arthritic (acute) (chronic) (subacute) M13.9 - rheumatoid M06.9
Tabular: M06.9 Rheumatoid arthritis, unspecified 4 Hand
Question 13 63 year old patient admitted with a joint mouse in left 1. M24.01 glenohumeral joint. Patient is known to have mixed 2. G30.8D Alzheimer’s and vascular dementia. [11 Marks] 3. F00.2A 4. 5.
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CODES AND TITLES 6. M24.01 Loose body in joint - Shoulder region G30.8D Other Alzheimer disease F00.2A Dementia in Alzheimer disease, atypical or mixed type (G30.8†)
Index: Mouse, joint M24.0
Tabular: M24.0 Loose body in joint [See site code at the beginning of this chapter] 1 Shoulder region
Index: Alzheimer’s disease or sclerosis G30.9 - dementia in G30.9† F00.9* - - atypical or mixed G30.8† F00.2* Or Dementia (persisting) F03 - in (due to) - - Alzheimer’s disease G30.9† F00.9* - - - mixed type G30.8† F00.2*
Tabular: G30.8† Other Alzheimer disease F00.2* Dementia in Alzheimer disease, atypical or mixed type (G30.8†)
Question 14 Admitted following a seizure. Known temporal lobe epilepsy 1. G40.2 as a residual effect of traumatic subdural haemorrhage 2. T90.5 following a road traffic collision. Patient also known to have 3. Y85.0 asthma. [12 Marks] 4. J45.9 5. CODES AND TITLES 6. G40.2 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures T90.5 Sequelae of intracranial injury Y85.0 Sequelae of motor-vehicle accident J45.9 Asthma, unspecified
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Index: Epilepsy, epileptic, epilepsia G40.9 - temporal lobe G40.2
Tabular: G40.2 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures
Index: Sequelae (of) – see also condition - injury NEC T94.1 - - intracranial (organs) T90.5
Tabular: T90.5 Sequelae of intracranial injury Sequelae of injury classifiable to S06.-
External Cause of Injury Index: Sequelae (of) Y89.9 - motor-vehicle accident Y85.0
Tabular: Y85.0 Sequelae of motor-vehicle accident
Index: Asthma, asthmatic (bronchial) (catarrh) (spasmodic) J45.9
Tabular: J45.9 Asthma, unspecified
Question 15 Jittery baby. [3 Marks] 1. R25.8 2. CODES AND TITLES 3. R25.8 Other and unspecified abnormal involuntary 4. movements 5. 6. Index: Involuntary movement, abnormal R25.8
Tabular: R25.8 Other and unspecified abnormal involuntary movements
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Section A [2] 15% Write your candidate number on every page
OPCS-4.7 codes are required for the next 15 questions [16 – 30] [ICD-10 codes are NOT required]
Provide appropriate code(s) for the following interventions/procedures in the boxes alongside each question. If more than one code is required, please use separate boxes for each code to make sequencing clear, for example, box 1 should contain the primary procedure/intervention code. [The number of boxes is not necessarily indicative of the codes required].
Question 16 Ultrasound examination of kidneys and ureters. 1. U21.6 Examination lasted 30 minutes in the Outpatient 2. Y98.3 Department. [17 Marks] 3. Z41.1 4. Z94.1 CODES AND TITLES 5. Z41.3 U21.6 Ultrasound scan NEC 6. Z94.1 Y98.3 Radiology of three body areas (20 to 40 minutes) Z41.1 Kidney Z94.1 Bilateral operation Z41.3 Ureter NEC Z94.1 Bilateral operation
Index: U21.6 Ultrasound NEC
Tabular: U21.6 Ultrasound scan NEC
Index: Y98.- Radiology Procedures
Tabular: Y98.3 Radiology of three body areas (20 to 40 minutes)
Index: Z41.1 Kidney site
Tabular: Z41.1 Kidney
Index: Z94.- Laterality Operations Or
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Z94.1 Operations Bilateral
Tabular: Z94.1 Bilateral operation
Index: Z41.- Ureter site
Tabular: Z41.3 Ureter NEC
Index: Z94.- Laterality Operations Or Z94.1 Operations Bilateral
Tabular: Z94.1 Bilateral operation
Question 17 Two courses of electroconvulsive therapy, each comprised 1. A83.8 of two treatments. [11 Marks] 2. A83.8 3. A83.9 CODES AND TITLES 4. A83.9 A83.8 Electroconvulsive therapy, other specified 5. A83.8 Electroconvulsive therapy, other specified 6. A83.9 Electroconvulsive therapy, unspecified A83.9 Electroconvulsive therapy, unspecified
Index: A83.- Therapy Electroconvulsive Or A83.- Electroconvulsive Therapy
Tabular: A83.8 Electroconvulsive therapy, other specified
Index: A83.- Therapy Electroconvulsive Or A83.- Electroconvulsive Therapy
Tabular: A83.9 Electroconvulsive therapy, unspecified
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Question 18 Patient admitted with a stump infection requiring a left 1. X09.3 above knee amputation removing three inches of femoral 2. Z94.3 shaft. Previously had a below knee amputation five years 3. ago. [6 Marks] 4. 5. CODES AND TITLES 6. X09.3 Amputation of leg above knee Z94.3 Left sided operation
Index: X09.- Amputation Leg
Tabular: X09.3 Amputation of leg above knee
Index: Z94.- Laterality Operations Or Z94.3 Left Sided Operations Or Z94.3 Operations Left Sided
Tabular: Z94.3 Left sided operation
Question 19 Patient admitted having swallowed his false dental teeth 1. G15.1 plate. Oesophagogastroduodenoscopy (OGD) planned. His 2. dental plate was found and retrieved from the lower 3. oesophagus. The examination did not go any further. [3 4. Marks] 5. 6. CODES AND TITLES G15.1 Fibreoptic endoscopic removal of foreign body from oesophagus
Index: G15.1 Removal from Oesophagus Foreign Body Endoscopic NEC
Tabular: G15.1 Fibreoptic endoscopic removal of foreign body from oesophagus
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Question 20 Excision of three metastases from the liver. [3 Marks] 1. J03.5 2. CODES AND TITLES 3. J03.5 Excision of multiple lesions of liver 4. 5. Index: 6. J03.5 Excision Liver Lesion Multiple
Tabular: J03.5 Excision of multiple lesions of liver
Question 21 Bilateral laser tonsillectomy and laser adenoidectomy. [9 1. F34.3 Marks] 2. E20.1 3. Y08.1 CODES AND TITLES 4. F34.3 Bilateral laser tonsillectomy 5. E20.1 Total adenoidectomy 6. Y08.1 Laser excision of organ NOC
Index: F34.- Tonsillectomy
Tabular: F34.3 Bilateral laser tonsillectomy Note: Use a supplementary code for concurrent excision of adenoid (E20.1, E20.4)
Index: E20.1 Adenoidectomy
Tabular: E20.1 Total adenoidectomy Note: Use as a secondary code when associated with excision of tonsil (F34, F36.6)
Index: Y08.- Laser NOC Or Y08.- Excision Laser NOC
Tabular: Y08.1 Laser excision of organ NOC
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Question 22 Planned delayed appendicectomy; failed laparoscopic 1. H02.2 procedure converted to open. [6 Marks] 2. Y71.4 3. CODES AND TITLES 4. H02.2 Planned delayed appendicectomy NEC 5. Y71.4 Failed minimal access approach converted to open 6.
Index: H02.- Appendicectomy NEC
Tabular: H02.2 Planned delayed appendectomy NEC
Index: Y71.- Operations Late NOC Or Y71.- Late Operations NOC
Tabular: Y71.4 Failed minimal access approach converted to open
Question 23 Left hemicolectomy and creation of a caecostomy. [6 1. H09.5 Marks] 2. H14.9 3. CODES AND TITLES 4. H09.5 Left hemicolectomy and exteriorisation of bowel 5. NEC 6. H14.9 Exteriorisation of caecum, unspecified
Index: H09.5 Exteriorisation Bowel & Excision of Colon Left Or H09.- Hemicolectomy Left
Tabular: H09.5 Left hemicolectomy and exteriorisation of bowel NEC Note: use a secondary code for type of exteriorisation of bowel (H14, H15)
Index: H14.- Caecostomy
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Tabular: H14.9 Exteriorisation of caecum, unspecified Includes: Caecostomy NEC
Question 24 Primary percutaneous endoscopic laser excision of 1. V31.4 thoracic intervertebral disc. [9 Marks] 2. V55.1 3. Y08.1 CODES AND TITLES 4. V31.4 Primary percutaneous endoscopic excision of 5. thoracic intervertebral disc 6. V55.1 One level of spine Y08.1 Laser excision of organ NOC
Index: V31.- Excision Disc Intervertebral Thoracic NEC
Tabular: V31.4 Primary percutaneous endoscopic excision of thoracic intervertebral disc
Index: V55.- Levels Spine Or V55.- Spine Levels
Tabular: V55.1 One level of spine
Index: Y08.- Laser NOC Or Y08.- Excision Laser NOC
Tabular: Y08.1 Laser excision of organ NOC
Question 25 Bronchoscopy with biopsy and brushings taken from both 1. E49.1 main bronchi. [12 Marks] 2. Y21.1 3. Z24.5 4. Z94.1 5. 6.
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CODES AND TITLES E49.1 Diagnostic fibreoptic endoscopic examination of lower respiratory tract and biopsy of lesion of lower respiratory tract Y21.1 Brush cytology of organ NOC Z24.5 Bronchus Z94.1 Bilateral operation
Index: E49.- Biopsy Bronchus Endoscopic NEC Or E49.1 Biopsy Bronchus NEC Or E49.- Bronchoscopy NEC
Tabular: E49.1 Diagnostic fibreoptic endoscopic examination of lower respiratory tract and biopsy of lesion of lower respiratory tract
Index: Y21.- Cytology NOC Or Y21.1 Cytology Brush NOC
Tabular: Y21.1 Brush cytology of organ NOC
Index: Z24.5 Bronchus site
Tabular: Z24.5 Bronchus
Index: Z94.- Laterality Operations Or Z94.1 Operations Bilateral Or Z94.1 Bilateral Operations
Tabular: Z94.1 Bilateral operation
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Question 26 Myringotomy with insertion of ventilation tube through the 1. D15.1 tympanic membrane of the left ear. [6 Marks] 2. Z94.3 3. CODES AND TITLES 4. D15.1 Myringotomy with insertion of ventilation tube 5. through tympanic membrane 6. Z94.3 Left sided operation
Index: Insertion Tube – See Tube D15.1 Tube Tympanic Membrane Ventilation Insertion Or D15.- Myringotomy
Tabular: D15.1 Myringotomy with insertion of ventilation tube through tympanic membrane
Index: Z94.- Laterality Operations Or Z94.3 Left Sided Operations Or Z94.3 Operations Left Sided
Tabular: Z94.3 Left sided operation
Question 27 Manipulative removal of stones from the right 1. F56.2 submandibular salivary duct. [6 Marks] 2. Z94.2 3. CODES AND TITLES 4. F56.2 Manipulative removal of calculus from 5. submandibular duct 6. Z94.2 Right sided operation
Index: F56.2 Removal from Submandibular Duct Calculus Manipulative
Tabular: F56.2 Manipulative removal of calculus from submandibular duct
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Index: Z94.- Laterality Operations Or Z94.2 Right Sided Operations Or Z94.2 Operations Right Sided
Tabular: Z94.2 Right sided operation
Question 28 Wedge excision of ingrown toenail of the right big toe and 1. S68.2 phenolisation of the nail bed on the right big toe. [13 Marks] 2. Z90.6 3. S64.2 CODES AND TITLES 4. Z90.6 S68.2 Excision of wedge of nail 5. Z94.2 Z90.6 Great toe NEC 6. S64.2 Chemical destruction of nail bed Z90.6 Great toe NEC Z94.2 Right sided operation
Index: S68.- Excision Nail
Tabular: S68.2 Excision of wedge of nail
Index: Z90.- Leg Region site NEC
Tabular: Z90.6 Great toe NEC
Index: S64.- Destruction Nail Bed
Tabular: S64.2 Chemical destruction of nail bed
Index: Z90.- Leg Region site NEC
Tabular: Z90.6 Great toe NEC
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Index: Z94.- Laterality Operations Or Z94.2 Right Sided Operations Or Z94.2 Operations Right Sided
Tabular: Z94.2 Right sided operation
Question 29 Endoscopic sphincterotomy of the sphincter of Oddi and 1. J38.1 removal of calculus from bile duct under fluoroscopic 2. Y53.4 image control. [9 Marks] 3. Z30.4 4. CODES AND TITLES 5. J38.1 Endoscopic sphincterotomy of sphincter of Oddi and 6. removal of calculus HFQ Y53.4 Approach to organ under fluoroscopic control Z30.4 Bile duct NEC
Index: J41.1 Removal from Bile Duct Calculus Endoscopic Retrograde
Tabular: J41 Other therapeutic endoscopic retrograde operations on bile duct Excludes: When associated with endoscopic sphincterotomy of sphincter of Oddi (J38)
J41.1 Endoscopic retrograde extraction of calculus from bile duct
Index: J38.- Sphincterotomy Sphincter Oddi Endoscopic
Tabular: J38.1 Endoscopic sphincterotomy of sphincter of Oddi and removal of calculus HFQ
Index: Y53.4 Approach Control Fluoroscopic Or Y53.4 Approach Fluoroscopic Control Or
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Y53.4 Fluoroscopic Control Approach
Tabular: Y53.4 Approach to organ under fluoroscopic control
Index: Z30.- Bile Duct site
Tabular: Z30.4 Bile duct NEC
Question 30 Endoscopic argon plasma coagulation (APC) of a lesion of 1. H20.2 the descending colon. [9 Marks] 2. Y17.1 3. Z28.5 CODES AND TITLES 4. H20.2 Fibreoptic endoscopic cauterisation of lesion of 5. colon 6. Y17.1 Electrocauterisation of lesion of organ NOC Z28.5 Descending colon
Index: Cauterisation – see also Destruction H20.- Destruction Colon Lesion Endoscopic Fibreoptic Or H20.- Destruction Colon Lesion Endoscopic NEC
Tabular: H20.2 Fibreoptic endoscopic cauterisation of lesion of colon
Index: Y17.1 Electrocauterisation Lesion NOC
Tabular: Y17.1 Electrocauterisation of lesion of organ NOC
Index: Z28.- Colon site
Tabular: Z28.5 Descending colon
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Section B [70%] Write your candidate number on EVERY page
Answer all 7 questions in this Section using the Case Study Answer Sheets provided
Case Study Number 1 [18 Marks] Appropriate index trails are required for this Case Study only. To obtain full marks they must exactly replicate the full content of the ICD-10 and OPCS-4.7 Alphabetical Indexes for each code assigned.
Specialty General Surgery Consultant Mr Edwards Date of Admission 18th May 2015 Date of Discharge 18th May 2015 History Prominent sebaceous cyst on left cheek Co-morbidities Hypertension Procedure Excision of lesion from skin of left cheek Diagnosis Sebaceous cyst Management Sutures out at GP in one week. To be followed up in clinic in one month.
Case Study Number 1 ICD-10 Codes OPCS-4.7 Codes 1. L72.1 1. S06.5
2. I10.X 2. Z47.3
3. 3. Z94.3
4. 4.
5. 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Cyst (colloid) (mucous) (retention) S06.- Excision Skin Lesion NEC (simple) - sebaceous (duct) (gland) L72.1 Tabular:
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- skin L72.9 S06.5 Excision of lesion of skin of head or - - sebaceous L72.1 neck NEC Or Sebaceous – see also condition Index: - cyst (see also Cyst, sebaceous) Z47.- Skin Face site L72.1 Tabular: Tabular: Z47.3 Skin of cheek L72.1 Trichilemmal cyst Pilar cyst Index: Sebaceous cyst Z94.- Laterality Operations Or Index: Z94.3 Left Sided Operations Hypertension, hypertensive Or (accelerated) (benign) (essential) Z94.3 Operations Left Sided (idiopathic) (malignant) (primary) (systemic) I10 Tabular: Z94.3 Left sided operation Tabular: I10 Essential (primary) hypertension Incl.: high blood pressure hypertension
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Case Study Number 2 [16 Marks]
Specialty Vascular Surgery Consultant Mr Wilks Date of Admission 6th June 2015 Date of Discharge 10th June 2015 History Emergency admission with ischaemic foot. Doppler performed showed very poor blood flow to right foot, anterior tibial artery occluded. Diagnosis Occlusion of right anterior tibial artery by thrombus Relevant co- Type 1 diabetes, hyperlipidaemia morbidities Management/ Thrombectomy right anterior tibial artery Treatment Discharge Follow up and remove sutures in clinic in 10 days.
Case Study Number 2 ICD-10 Codes OPCS-4.7 Codes 1. I74.3 1. L70.1
2. E10.9 2. Z97.1
3. E78.5 3. Z94.2
4. 4.
5. 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Thrombus – see Thrombosis L70.1 Thrombectomy Artery NEC
Thrombosis, thrombotic (multiple) Tabular: (progressive) (septic) (vein) (vessel) L70.1 Open embolectomy of artery NEC I82.9 - artery, arteries (postinfectional) I74.9 Index: - - limb I74.4 Z97.- Artery Tibia site - - - lower I74.3 Tabular:
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Tabular: Z97.1 Anterior tibial artery I74.3 Embolism and thrombosis of arteries of lower extremities Index: Z94.- Laterality Operations Index: Or Diabetes, diabetic (mellitus) Z94.2 Right Sided Operations (controlled) (familial) (severe) E14.- Or - type I E10.- Z94.2 Operations Right Sided
Tabular: Tabular: E10 Insulin dependent diabetes Z94.2 Right sided operation mellitus [See before E10 for subdivisions] .9 Without complications
Index: Hyperlipemia, hyperlipidemia E78.5
Tabular: E78.5 Hyperlipidaemia, unspecified
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Case Study Number 3 [20 Marks]
Specialty Gynaecology Consultant Mrs Bray Date of Admission 18th August 2015 Date of Discharge 19th August 2015 Reason for Sterilisation Admission Episode Summary Mrs Ellis was admitted for a requested sterilisation. She and her husband have three children and are happy that their family is complete. She is 37 years old with anxiety and depression, and she worries about the stress another child would bring. The plan is to admit the patient including an overnight stay to ensure the patient is comfortable on discharge. Comments Following a bilateral laparoscopic examination of her fallopian tubes Mrs Ellis underwent a laparoscopic bilateral clipping of her fallopian tubes. The procedure was completed without difficulty, however, Mrs Ellis went into post-operative urinary retention and had to be catheterised overnight. A trial without catheter the next day was successful and Mrs Ellis was discharged home.
Case Study Number 3 ICD-10 Codes OPCS-4.7 Codes 1. Z30.2 1. Q35.2
2. R33.X 2. M47.9
3. Y83.1 [Y83.8 is also accepted] 3. M47.3
4. F41.9 4.
5. F32.9 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Sterilization, admission for Z30.2 Sterilisation Female – see also Operation
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Tabular: Q35.2 Clipping Fallopian Tube Bilateral Z30.2 Sterilization Access Minimal Admission for interruption of Or fallopian tubes or vasa Q35.2 Clipping Fallopian Tube Bilateral deferentia Endoscopic
Index: Tabular: Retention, retained Q35.2 Endoscopic bilateral clipping of - urine R33 fallopian tube
Tabular: Index: R33 Retention of urine M47.- Catheterisation Bladder Urethral
External Causes of Injury Index: Tabular: Complication (delayed) (of or M47.9 Urethral catheterisation of bladder, following) (medical or surgical unspecified procedure) Y84.9 - implant, implantation (of) Index: - - artificial M47.- Catheterisation Bladder Urethral - - - internal device (cardiac pacemaker) (electrodes in brain) (heart Tabular: valve prosthesis) (orthopaedic) Y83.1 M47.3 Removal of urethral catheter from [- surgical operation NEC (see also bladder Complication, by type of operation) Y83.9 - - specified NEC Y83.8]
Tabular: Y83.1 Surgical operation with implant of artificial internal device
[Y83.8 Other surgical procedures]
Index: Anxiety F41.9
Tabular: F41.9 Anxiety disorder, unspecified Anxiety NOS
Index: Depression F32.9
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Tabular: F32.9 Depressive episode, unspecified Depression NOS
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Case Study Number 4 [18 Marks]
Specialty Cardiothoracic Surgery Consultant Mr Singh Date of Admission 13th July 2015 Date of Discharge 16th July 2015 Episode Summary George Brown had been found by the cardiologists to have extensive atherosclerotic heart disease and mitral valve regurgitation. He was admitted for a triple coronary artery bypass graft and mitral valve repair. Relevant Medical Hypertension, hypercholesterolemia and hypertensive History/Co-morbidities renal disease. Procedure The operation went smoothly. The mitral valve was repaired and Mr Brown had two coronary arteries bypassed using saphenous vein grafts and an anastomosis of the internal mammary artery to the left anterior descending coronary artery. Discharge Mr Brown was discharged home to recuperate.
Case Study Number 4 ICD-10 Codes OPCS-4.7 Codes 1. I25.1 1. K45.3
2. I34.0 2. K40.2
3. E78.0 3. K25.5
4. I12.9 4.
5. 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Atherosclerosis – see K45.- Anastomosis Artery Mammary Arteriosclerosis Coronary
Arteriosclerosis, arteriosclerotic
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(diffuse) (disease) (general) Tabular: (obliterans) (senile) (with K45.3 Anastomosis of mammary artery to calcification) I70.9 left anterior descending coronary - heart (disease) I25.1 artery Note: Use a supplementary code for Tabular: concurrent replacement of coronary I25.1 Atherosclerotic heart disease artery (K40-K44) Coronary (artery): • atheroma Index: • atherosclerosis Bypass Artery - see also Replacement • disease Artery • sclerosis K40.- Replacement Artery Coronary Graft Vein Saphenous Index: Regurgitation Tabular: - mitral (valve) – see Insufficiency, K40.2 Saphenous vein graft replacement of mitral two coronary arteries Note: Use a supplementary code for Insufficiency, insufficient concurrent repair of valve of heart - mitral I34.0 (K25-K29) Use as a supplementary code for Tabular: concurrent connection of thoracic I34.0 Mitral (valve) insufficiency artery to coronary artery (K45) Mitral (valve): NOS or of • incompetence specified cause, Index: • regurgitation except rheumatic K25.- Repair Valve Mitral Plastic
Index: Tabular: Hypercholesterolemia (essential) K25.5 Mitral valve repair NEC (familial) (hereditary) (primary) Includes: Mitral valvuloplasty NEC (pure) E78.0 Note: Use as a supplementary code when associated with bypass of Tabular: coronary artery (K40-K46) E78.0 Pure hypercholesterolaemia
Index: Disease, diseased – see also Syndrome - hypertensive (see also Hypertension) I10 - renal – see Disease, kidney - kidney (functional) (pelvis) N28.9 - - hypertensive (see also Hypertension, kidney) I12.9
Tabular:
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I12.9 Hypertensive renal disease without renal failure Hypertensive renal disease NOS
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Case Study Number 5 [19 Marks]
Specialty General Medicine Consultant Mr Patel Date of Admission 12th December 2015 Date of Discharge 14th December 2015 Episode Summary Found in an overturned car on a country road, trapped by a seat belt. No other cars were involved. He was the driver and the car skidded on ice before turning over. Minor bruising noted to his forehead. Patient had mild hypothermia from spending four hours in the car at temperatures as low as -5ºc. Co-morbidities Smoker (20 per day) Management / Patient was admitted to the medical ward and slowly Treatment rewarmed. He was kept on 30 minutes observations for the first six hours on the ward. Computed tomography (CT) scan of the head was performed but nothing abnormal was detected. He was allowed to rest before being discharged on the second day after admission. Diagnosis Hypothermia and minor head injury
Case Study Number 5 ICD-10 Codes OPCS-4.7 Codes 1. T68.X 1. U05.1
2. X31.4 2. Y98.1
3. S00.8 3.
4. V48.5 4.
5. F17.1 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Hypothermia (accidental) (due to) T68 U05.1 Tomography Head Computed - low environmental temperature T68 Tabular: U05.1 Computed tomography of head
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Tabular: Index: T68 Hypothermia Y98.- Radiology Procedures
External Causes of Injury Index: Tabular: Exposure (to) Y98.1 Radiology of one body area (or < 20 - cold (accidental) (excessive) minutes) (extreme) (natural) (place) X31 - - due to - - - weather (conditions) X31 Or Cold, exposure to (accidental) (excessive) (extreme) (natural) (place) NEC (see also Exposure, cold) X31
Tabular: X31 Exposure to excessive natural cold .4 Street and highway
Index: Injury - superficial (for contusions, see first Contusion) - - forehead S00.8
Tabular: S00.8 Superficial injury to other parts of head
External Causes of Injury Index: Accident (to) X59 - transport (involving injury to) (see also Table of land transport accident) V99 - - car occupant (in) V49.9 - - - overturning V48.-
Tabular: V48 Car occupant injured in noncollision transport accident [See before V40 for subdivisions] .5 Driver injured in traffic accident
Index:
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Tobacco (nicotine) - harmful use F17.1
Tabular: F17 Mental and behavioural disorders due to use of tobacco .1 Harmful use
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Case Study Number 6 [18 Marks]
Specialty Obstetrics Consultant Mrs Whittaker Date of Admission 7th October 2015 Date of Discharge 8th October 2015 History Patient admitted at 37 +2 weeks gestation for induction of labour. She had been admitted previously at 28 weeks in labour. The contractions at this time were stopped by the use of Terbutaline. After this admission it was agreed to monitor the patient and bring her in at 37 weeks to induce labour. Prostaglandin pessary was inserted but 18 hours later labour had not commenced. Syntocinon (oxytocin) infusion was started. Labour commenced, but despite bulging the membranes remained intact. Permission sought and given for an artificial rupture of membranes (ARM). Performed with a positive outcome. Progressed to a normal delivery of live female infant. Co-morbidities Type 1 diabetes, epilepsy (well managed during pregnancy and not impacting care). Discharge Mum and baby discharged two days post-delivery.
Case Study Number 6 ICD-10 Codes OPCS-4.7 Codes 1. O60.2 1. R24.9
2. Z37.0 2. R15.1
3. O24.0 3. R14.1
4. G40.9 4.
5. 5.
6. 6.
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INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Labor (see also Delivery) R24.- Delivery Normal - early onset (before 37 completed Or weeks of gestation) R24.- Delivery Cephalic Normal - - with - - - term delivery O60.2 Tabular: R24.9 All Tabular: O60.2 Preterm spontaneous labour Index: with term delivery R15.- Induction Labour NEC Or Index: R15.1 Induction Labour Prostaglandin Outcome of delivery Z37.9 Or - single Z37.9 R15.1 Induction Labour Oxytocin - - liveborn Z37.0 Tabular: Tabular: R15.1 Medical induction of labour Z37.0 Single live birth Includes: Induction of labour using prostaglandins Index: Induction of labour using oxytocin Pregnancy (single) (uterine) Induction of labour using misoprostol - complicated by (see also Pregnancy, management, affected by) Index: - - conditions in R14.1 Rupture Amniotic Membrane - - - E10-E14 O24.- Forewater Or Pregnancy (single) (uterine) Tabular: - complicated by (see also Pregnancy, R14.1 Forewater rupture of amniotic management, affected by) membrane - - diabetes (mellitus) O24.9
Tabular: O24.0 Pre-existing diabetes mellitus, insulin-dependent
Index: Epilepsy, epileptic, epilepsia G40.9
Tabular: G40.9 Epilepsy, unspecified
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Case Study Number 7 [18 Marks]
Specialty Orthopaedics Consultant Mr Pinkney Admission Date 24th November 2015 Discharge Date 30th November 2015 Episode Summary Patient admitted for a total hip joint replacement following the breakdown of the patient’s hemiarthroplasty (femoral head) which has been in place for 12 years. Co-morbidities Hypertension, left ventricular failure, congestive cardiac failure, bi-ventricular pacemaker in-situ Treatment Total cemented right hip replacement
Case Study Number 7 ICD-10 Codes OPCS-4.7 Codes 1. T84.0 1. W37.2
2. I10.X 2. W48.0
3. I50.0 3. Z94.2
4. Z95.0 4.
5. 5.
6. 6.
INDEX TRAILS AND TABULAR ENTRIES ICD-10 OPCS-4.7 Index: Index: Complication (from) (of) W37.- Replacement Joint Hip Prosthetic - joint prosthesis, internal (any site) Total Cemented T84.9 - - mechanical T84.0 Tabular: W37.2 Conversion to total prosthetic Tabular: replacement of hip joint using cement T84.0 Mechanical complication of Note: Use a subsidiary conversion internal joint prosthesis from code as necessary
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Index: Index: Hypertension, hypertensive W48.- Replacement Femur Head Prosthetic (accelerated) (benign) (essential) NEC (idiopathic) (malignant) (primary) (systemic) I10 Tabular: W48.0 Conversion from previous prosthetic Tabular: replacement of head of femur NEC I10 Essential (primary) hypertensive Index: Incl: high blood pressure Z94.- Laterality Operations hypertension (arterial) Or (benign) (essential) Z94.2 Right Sided Operations (malignant) (primary) Or (systemic) Z94.2 Operations Right Sided
Index: Tabular: Failure, failed Z94.2 Right sided operation - heart (acute) (sudden) (senile) I50.9 - - congestive I50.0
Tabular: I50.0 Congestive heart failure Congestive heart disease Right ventricular failure (secondary to left heart failure)
Index: Presence (of) - cardiac - - pacemaker Z95.0
Tabular: Z95.0 Presence of cardiac pacemaker
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