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ICD 10 CM coding A 3-month-old female patient is brought in today by her father evaluation of median cleft lip and nose. Defects are nonsyndromic and patient is a good candidate for surgical repair. We discussed risks of surgery and the possibilities of future dental/orthodontic treatment and speech therapy. Dx: Median cleft lip and fissured, notched and cleft nose Codes: , Note: No code order required for this question ADMISSION DATE: 2/13/XX, Discharge Date: 2/15/XX HISTORY: This patient is gravida 2, para 1, 39 weeks gestation, and was seen in my office for all of her prenatal visits. Her prenatal course was uneventful. She was admitted with a history of contractions every 3 to 5 minutes. Cervix was 100% effaced and 9 cm dilated. HOSPITAL COURSE: At the time of admission, patient received IV and was placed on a fetal monitor. Her water broke at 1 am. After 2 hours the patient delivered a baby girl with APGAR scores of 9 at 1 minute and 10 at 5 minutes. Postpartum care was uneventful. The patient was discharged 2 days later. DIAGNOSIS: normal vaginal delivery, single live newborn, 39 weeks gestation Codes: , , Note: of the three required codes, one is the primary code and must be listed first. The remaining codes can be listed in any order. A 14-month-old female is brought in today by her mother for evaluation of several marks on her torso and face. There are 4 flat, reddish-purple lesions ranging from 1.2 cm- 3.9 cm in diameter on the left upper torso and two lesions minimally separated on the left forehead and upper eyelid, mearing 2.3 cm. Mom denies seizures however due to location of facial lesions; I would like to order an MRI to R/O Sturge-Weber syndrome. Dx: Port-wine nevus Code: __________

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