ICD-10Coding Exercises

Coding for ACL Sprain

Patient is a 16-year-old male. During a high school soccer game last week, he suffered a right ACL sprain when his knee

contacted an opposing player’s leg. He came straight to PT without seeing a physician first.

• Patient’s condition:

- Presents with pain, edema, and instability in his right knee- Uses crutches for ambulation- Has pain with walking

Answer!

Primary Codes:

• S83.511A Sprain of anterior cruciate ligament or right knee initial encounter

• W51.XXXA Accidental striking against or bumped into by another person

• Y92.322 Soccer field for place of occurrence

• Y93.66 Activity, Soccer

- Additional Codes:

• R26.2 for difficulty in walking or R26.89for other abnormalities of gait and mobility

• M25.561 for right knee pain

• M25.361 for the right knee instability

• M25.461 for right knee effusion

Left Knee Joint Replacement

Patient is a 74-year-old male who underwent a left total knee replacement one week ago.

• Patient’s condition:

• complains of 6/10 pain in the left knee• presents with left knee effusion and impaired range

of motion in left knee extension and flexion• has pain with walking• is WBAT (weight bearing as tolerated) using a walker

Answer!

Primary Codes:

R26.2 for difficulty in walking or R26.89 for other abnormalities of gait and mobility

M25.562 for left knee pain M25.462 for left knee

effusion M25.662 for left knee

stiffness M62.552 for muscle atrophy

left quads and hamstrings

- Additional Codes:

Z96.652 for presence of left artificial knee joint

Z47.1 for aftercare following joint replacement surgery

Coding for Benign Proximal Vertigo

Patient is a 33-year-old female who presents to physical therapywith a diagnosis of benign paroxysmal vertigo, right ear.

• Patient’s condition:

- Complains of dizziness and nausea

Answer!

• H81.11 for Benign Paroxysmal Vertigo, right ear

• R11.0 for nausea without vomiting

Coding for a Jack-O-Lantern Injury

Patient is a 34‐year-old female. While carving a pumpkin, she accidentally lacerated the digital nerves at her palm as

well as her flexor tendon superficialis and profundus tendons on fingers two through four.

• Patient’s condition:

- Had surgery last week- Presents with complaints of pain, swelling, and weakness of the right wrist, hand, and fingers- Has sensation of “pins and needles” in her hand and fingers

Answer!

• M79.641 pain in right hand• M79.644 pain in right

fingers• -M25.531 pain in right

wrist• -M25.431 for effusion of

right wrist• -M25.441 for effusion of

right hand• R20.2 paresthesia of skin

• M25.631 stiffness of right wrist

• M25.641 stiffness of right hand

• M62.531 and M62.541 for muscle weakness right forearm and hand

• S66.120D, S66.122D, S66.124D for the lacerations

• W26.0XXD for contact with knife

For a more detailed explanation of each senario, and why/how

the codes were chosen

WebPT-ICD-10-Bootcamp-Webinar-08.31.15.pdf