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November 19, 2020
Journal notes – payfordissertation.com
November 19, 2020

ICD PCS 10 MEDICAL CODING
Case 1
his 78-year-old male is status post hip replacement 6 days ago. He is now at the Sunny Hill Rehabilitation Center, where we are currently working on physical and occupational therapy so that he will be able to live at home and function normally.
This patient is working on being able to groom and dress himself. He is very anxious to able to use the shower but would be unable to get into his tub unassisted. Today we worked on walking to the closet/dresser, walking back to the bed, and getting his clothes on unassisted. He did very well, though he tired easily, and we did not get to the bathroom to brush teeth or wash up. The assessment took 60 minutes.
ICD-10-PCS Code Assignment: _____________
Case 2
Audiology Service Note
This 3-year-old twin was born at 27 weeks’ gestation. At the time of birth her weight was 2 pounds, 5 ounces. At birth the child failed the Universal Infant Hearing Screen and was then seen by me for auditory brainstem response evaluation. At 2 years old the child was fit with binaural Oticon Tego postauricular hearing aids. The child presents today for a hearing aid assessment. At this time her canals and TM are clear.
RESULTS:
Testing at an intensity level of 70 dB nHl indicated absolute and interwave latencies that were within normative values. Responses to air-conducted clicks were obtained at intensities down to 30 dB nHl in the right ear and 40 dB nHl in the left ear.
Results are consistent with mild bilateral high-frequency hearing loss. Continued binaural hearing aid use is indicated. Schedule for reevaluation in 3 months.
ICD-10-PCS Code Assignment: ________________
Case 3
This 11-year-old male had a hearing screening at school and was then referred to me for further evaluation. History includes middle ear pathology 2 years ago due to ear infections. At this time the left canal and TM are clear. The right TM is obscured due to cerumen.
A tympanometry was conducted using a tympanometer and found to be consistent with normal middle ear pressure and mobility. Hearing is adequate. No further evaluation at this time.
ICD-10-PCS Code Assignment: ______________

 

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