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Case Scenario 1:A patient presents to his physician with symptoms of shortness of breath, loss of taste and smell, and a fever.The patient is not aware of being exposed to the coronavir us. After examination , the physiciar documents suspected COVID -19, and the patient is sent for COVID testing Follow the eight coding steps to assign the appropriate ICD-1 (D) CM code(s) for this scenario.
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4.2
(259 Oylar)
Umay
Elit · 8 yıl öğretmeni
Uzman doğrulaması
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To assign the appropriate ICD-10-CM code(s) for this scenario, follow these eight coding steps:1. **Review the patient's symptoms and clinical documentation**: The patient presents with shortness of breath, loss of taste and smell, and a fever. The physician suspects COVID-19 based on these symptoms.2. **Determine if the condition is established or not established**: Since the patient is not aware of being exposed to the coronavirus, the condition is not established by the patient's history.3. **Identify the appropriate category**: Given the symptoms and the suspected diagnosis of COVID-19, the appropriate category is "Certain conditions originating in the perinatal period" (O00-O9A) for perinatal conditions or "Other infectious and parasitic diseases" (A00-A09, A15-A19, A54) for infectious diseases.4. **Refine the category by using subcategories**: For COVID-19, the specific subcategory would be "Other specified viral diseases, not elsewhere classified" (A89) for "COVID-19".5. **Identify the code for the specific diagnosis**: The specific code for COVID-19 is U07.1.6. **Determine if the code is for a sequela or complication**: In this scenario, there is no mention of a sequela or complication, so the code is for the initial encounter.7. **Identify any additional codes that may be necessary**: Since the patient is being sent for COVID testing, you might also consider coding for the purpose of public health surveillance (Z23.3) if applicable.8. **Assign the code(s)**: Based on the steps above, the appropriate ICD-10-CM code for this scenario is U07.1 (COVID-19) and possibly Z23.3 (Encounter for screening for infectious disease) if the testing is for public health surveillance purposes.Therefore, the appropriate ICD-10-CM code(s) for this scenario are U07.1 and potentially Z23.3.