Varicose vein of heel and mid-foot with presence of ulceration and swelling

Premature menopause with headache

Acute myocardial infarction of the anterolateral wall

Subsequent encounter for obesity resulting from the prescription drug Tryptanol®

Crohn’s disease of ileum with rectal bleeding and abscess

Bilateral central corneal ulcer

Severe generalized abdominal pain with abdominal rigidity

Female with bilateral breast cancer of lower outer quadrant

Acute nonsuppurative otitis media of the right ear

Initial encounter for concussion and edema of the thoracic spine

Initial encounter for third degree burn of the right thigh by gasoline to fifteen percent of the total body surface area

CODING SCENARIO

While chopping vegetables in the kitchen of his mobile home for the local food bank’s Thanksgiving dinner, John Doe lacerated his right thumb causing injury to the nail.

Borderline glaucoma

Congestive heart failure due to hypertension

HIV positive status without symptom

Urinary frequency

Morbid obesity with a BMI of 42 in an adult

Congenital red cell aplastic anemia

Cleft palate involving both the soft and hard palate with bilateral cleft lip

Severe persistent asthma with acute exacerbation

Fatigue fracture of vertebra, lumbar region, and subsequent encounter for fracture with delayed healing

Interstitial cystitis due to E. coli with hematuria

Sleep-related teeth grinding

Non-conclusive HIV-test finding in infants

CODING SCENARIO

Jane and John Doe were shopping at the mall the day after Thanksgiving to take advantage of the sales. While rushing for the newest iPhone, John fell down the stairs. Thankfully, John sustained only minor abrasions to his right elbow.

Routine infant or child health check

Acquired loss of teeth due to trauma, partial

Influenzal myocarditis

Elevated fasting triglycerides

Hungry bone syndrome

Primary open-angle glaucoma, moderate stage in left eye and mild stage in right eye

Dorsal somatic dysfunction

Invasive ductular carcinoma of breast, completely excised

Decompensated COPD with (acute) exacerbation

Concussion without loss of consciousness, initial encounter with neck pain

CODING SCENARIO

A 16-year-old student was at the gymnasium participating in a dancing contest to raise money for her class. She slipped on the gym floor and fell, injuring her left ankle. After she visited the emergency room, it was determined that she did not fracture her ankle. However, she did suffer a sprain to that ankle.

Atrial tachycardia

Irregular astigmatism of both eyes

Shaken infant syndrome, initial encounter

Painful respiration

Neonatal esophageal reflux

Twin pregnancy, one placenta, two amniotic sacs, third trimester with complication of gestational hypertension

Lisping

Subacute monocytic leukemia, in remission

Neoplasm of uncertain behavior of the nasal cavities

Benign carcinoid tumor of the small intestine

Atypical chest pain due to angina

CODING SCENARIO

Due to ailing health, Jane’s grandfather will be moving in with her in a few months. To understand what care is needed, Jane escorted her grandfather to his doctor appointment for the first time. The doctor told Jane that her grandfather was being treated for mild nonproliferative diabetic retinopathy with macular edema. He has type 2 diabetes and takes insulin on a daily basis. He has also developed diabetic cataract in his right eye.