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Evaluate the code assignments for the scenario that follows, identifying any errors in coding based on the documentation. Indicate coding corrections (if applicable) in the table below. H&P A 63-year-old woman is admitted with severe, unrelenting headache. CT scan in ER shows an area suspicious for a brain tumor. The woman is admitted to control pain and identify source of primary. She is a diabetic with hypertension. She smokes a pack of cigarettes a day and has for the past forty years. There is a family history of breast cancer with her aunt and sister. Patient will undergo an MRI of the brain and CT of chest and abdomen in hopes of identifying primary source of tumor. Consult This 63-year-old white female is complaining of numbness and tingling to her feet. She is diabetic, type I, with noncompliance with her insulin treatment. She states that she takes half of the required dosage as it is difficult for her to afford her medications. Examination of extremities is indicative of diabetic neuropathy. Have stressed with the patient the need for her to strictly follow her insulin regimen, and follow up for additional tests as an outpatient. Patient needs to have annual foot and eye exams. Progress Note I Patient having CT scans this morning. Will consult with radiology and proceed with recommendations once those results are read. Progress Note II Appreciate consult on diabetic management. Will echo consultant's call for compliance with medication, CT scans showed a night breast lesion, suspicious for stigate TOULESS Appreciate consult on diabetic management. Will echo consultant's call for compliance with medication. CT scans showed a right breast lesion, suspicious for malignancy. Patient was informed and is willing to proceed to OR for mastectomy. CT Report Patient was given contrast material and CT of the chest performed. A density, consistent with a malignancy was identified in the lower-inner quadrant of the right breast. No abnormalities in the left breast or elsewhere in the chest. OR Report Patient was brought to the OR where she was prepped and draped in a sterile manner. She had previously been informed of the risks, benefits, and alternatives to the surgery and elected to proceed. I made standard mastectomy incisions and dissected down to but not including the pectoral muscle. Bleeders were cauterized and hemostasis secured. The breast was lifted off the musculature. The patient did not want reconstruction at this time, so a primary closure was completed. The specimen was sent to pathology. Blood loss was minimal and the patient tolerated the procedure well. She is sent to recovery and will be observed until she meets discharge criteria. I will have her follow up in the office in two weeks to discuss treatment of the brain cancer. Pathology Report Specimen is 0.3942 kgs. of breast tissue, right breast. Microscopic examination reveals adenocarcinoma. Discharge Summary An unfortunate woman who was found to have a breast malignancy (primary) after CT scan identified a metastasis to the brain. She underwent a mastectomy earlier today and is ready for discharge. She will follow up in two weeks to check the healing and discuss further treatment to focus on the brain. She is to follow her medication regimen for diabetes and hypertension. She has been counseled on smoking cessation. Codes Should Be: Codes Assigned: C50.911 C71.9 E10.9 110 F171210 279.4 Z80.3 OHTTOZZ

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