HIMP 2210 – Health Data Classification II
Exercise 10.1 – Nervous System, Mental & Behavioural Disorders
Scenario Diagnosis ICD-10-CA / CCI Codes S L E
Type
1. A 75-year-old patient was admitted M I63.4
with hemiplegia. The discharge
summary documents the results of a 1.ZZ.35.HA-1C
CT scan (with contrast) of the brain as
embolism of the middle cerebral
artery. Intravenous thrombolytic
therapy was administered. The
patient was known to have atrial
fibrillation. The final diagnosis was
recorded as stroke.
Occlusion
-artery
--brain or cerebral
---with infarction (due to)
---embolism I63.4
Mandatory to code thrombolytic therapy
as per pg. 97 & 107 of CCS (both SDC and
inpatient visits)
2. An elderly patient with known M I64
hypertension, was admitted 3 I10.0
unconscious to a rural hospital. The
admitting diagnosis was stroke and
the family opted not to transfer her
for imaging investigations. She was
pronounced dead within 24 hours;
final diagnosis is recorded as stroke.
No autopsy was performed.
Lead term:
Stroke I64
At code block I60 – I69, use additional
code to identify presence of hypertension
3. Flaccid hemiplegia on right M I63.0
(dominant) side due to thrombosis of 1 G81.00
the internal carotid artery; patient
was initially treated in ICU then
transferred to the unit where he
received intensive physiotherapy; he
was subsequently transferred to a
rehab facility. Final diagnosis was
recorded as ischemic stroke.
Thrombosis
-artery
--carotid (see also Occlusion, artery,
carotid)
Occlusion
-artery
--carotid
---infarction
----thrombosis I63.0
Hemiplegia
-flaccid
--of dominant side G81.00
Scenario Diagnosis ICD-10-CA / CCI Codes S L E
Type
4. A 92-year-old female was admitted to M I63.4
hospital with abrupt onset of
hemiparesis and confusion. CT scan
ruled out hemorrhagic stroke. The
final diagnosis is ischemic stroke MCA,
likely cardioembolic.
[When the etiology of ischemic stroke
is recorded as “likely” or “probable”,
assign the appropriate code that
describes the specific type of ischemic
stroke and do not assign prefix Q.
There is no further mention of the
hemiparesis, thus any code for this is
assigned, optionally, as diagnosis type
3.]
Stroke
-ischemic (see also Infarction, cerebral)
Infarct
-cerebral
--due to
---embolism
----cerebral arteries I63.4
5. A patient is admitted for assessment M F01.1
and management of dementia due to 3 E10.52
several previous cerebral infarctions
from cerebral arteriosclerosis. The
patient is noted to have type 1
diabetes.
Dementia
-vascular
--multi infarct F01.1
Use additional code for DM at .52 at
F01.1
6. A patient who has known depression M Z51.88
was admitted to day surgery for
electroshock therapy. 1.AN.09.JA-DV
Z51.88 Other specified medical care NEC
Depression is not the MRDx in this case as
this patient is being admitted for ECT.
Depression was already diagnosed in a
previous visit and now the patient is just
coming in for treatment.
7. A 13-year-old male presents to M R06.0
emergency with a diagnosis of 3 F11.1
shortness of breath following snorting
heroin for the first time. The
diagnosis is SOB due to cocaine.
The documentation describes a physical
condition associated with psychoactive
substance use. F11.1 is mandatory to
identify the documented relationship
between the physical condition and the
drug use.
Scenario Diagnosis ICD-10-CA / CCI Codes S L E
Type
8. A patient was admitted to the M F41.9
psychiatric unit and discharged with a 1 F32.9
diagnosis of anxiety and depression.
Lead terms:
Anxiety F41.9
Depression F32.9
Sequencing using the first listed condition
as MRDx as both equal in terms of
complexity and use of resources.
9. A patient is consulted by a psychiatrist M F41.2
and discharged with a diagnosis of
anxiety depression.
Depression
-anxiety F41.2
10. Chronic gastric ulcer with M K25.7
psychological overlay (care directed 1 F54
primarily at the ulcer but patient was
seen and managed by a psychiatrist).
Use additional code for F54 – when this
code is assigned, a code for the physical
disorder must also be coded and in this
case it is the gastric ulcer.
Factor
-psychological
--affecting physical conditions F54
Make a note of the physical conditions
that are associated with F54
11. A patient was admitted to the M F11.0
hospital in an agitated state. She had
self-injected heroin earlier in the
evening and had been hallucinating.
Diagnosis is delirium secondary to
heroin intoxication.
Delirium
-due to
--opioid intoxication F11.0
12. The patient with alcoholism was M F10.3
admitted with “delirium due to 1 F10.0
alcohol intoxication”. While in
hospital he was placed on a
withdrawal regime for which his
withdrawal symptoms consumed the
majority of the stay.
Withdrawal
-state
--alcohol F10.3
(why is this condition MRDx?)
Intoxication
-alcoholic with
--delirium F10.0
(no delirium with withdrawal state and
delirium is captured with alcohol
intoxication)
13. A patient was brought to the hospital M F18.5
with a history of sniffing glue for the
past 3 days. The diagnosis is psychotic
disorder due to acute glue inhalation.
Disorder
-psychotic
--inhalant (intoxication)
