PATIENT: Tom White
SURGEON: David Barton, MD
RADIOLOGY: Morton Monson, MD
PROCEDURE: Transesophageal echocardiogram
INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically
PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease but does not appear to be severe. It appeared to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery yet.What are the three terms that can be looked up in the alphabetical index of the ICD-9-CM manual to identify the correct procedure?
____________________, ___________________, ___________________
PATIENT: Tom White
SURGEON: David Barton, MD
RADIOLOGY: Morton Monson, MD
PROCEDURE: Transesophageal echocardiogram
INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically
PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease but does not appear to be severe. It appeared to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery yet.Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario
ICD-9-CM: __________
PATIENT: Tom White
SURGEON: David Barton, MD
RADIOLOGY: Morton Monson, MD
PROCEDURE: Transesophageal echocardiogram
INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically
PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease but does not appear to be severe. It appeared to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery yet.Identify the two terms that can be looked up in the alphabetical index of the CPT-4 manual to identify the correct procedure: ____________________, ___________________
PATIENT: Tom White
SURGEON: David Barton, MD
RADIOLOGY: Morton Monson, MD
PROCEDURE: Transesophageal echocardiogram
INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically
PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease but does not appear to be severe. It appeared to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery yet.Identify the correct procedure (CPT-4) code(s) for the above scenario:
CPT-4: __________ Modifier: __________
PATIENT: Tom White
SURGEON: David Barton, MD
RADIOLOGY: Morton Monson, MD
PROCEDURE: Transesophageal echocardiogram
INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically
PROCEDURE: The patient received 2 mg of Versed, and a transesophageal probe was advanced to the lower part of the esophagus. We had good visualization of the heart. The mitral valve was thickened with slight prolapse, but there was no significant regurgitation noted. The LV displayed normal size and normal function. The aortic root is normal in size. The aortic valve is calcified with diffuse cusp excursions with still adequate opening. Valve area was variable in different incidents varying from 1 to even above 2.
CONCLUSION: This transesophageal echo shows aortic valve disease but does not appear to be severe. It appeared to be moderately stenotic, and considering the angiography and the hemodynamics, this patient does not need valve surgery yet.What modifier will be appended to the CPT code to indicate only the physician’s portion of the service is being billed? __________________
LOCATION: Outpatient, Hospital
PATIENT: Emily Watts
PHYSICIAN: Marvin Elhart, MD
STUDY: The study is a transthoracic 2-D and color-flow doppler
echocardiography
INDICATION: Chest pain and SVT
M-MODE MEASUREMENTS:
I. Left Atrium is 3.9, aortic root 2.3
II. RV dimension 1.7
III. LV diastole 5
IV. LV systole 2.3
V. Fracture shortening 0.46
VI. Interventricular septum 0.7
VII. Posterior wall thickness 0.7
DOPPLER:
I. Mild mitral regurgitation
II. Mild to moderate tricuspid regurgitation
III. RV systolic pressure 73 mmHg
2-D FINDINGS:
I. Left ventricle is normal in size with good LV systolic function noted
II. Normal left atrium, right atrium, and right ventricle
III. No pericardial effusion seen
IV. Aortic root is normal in size with normal aortic valve
V. The mitral valve is structurally normal with mild mitral regurgitation
VI. Mild tricuspid regurgitation
CONCLUSION:
I. Normal LV size with preserved LV systolic function
II. No significant aortic or mitral valve disease
III. No dilation of the chambers notedIn the intro paragraph as well as the indication it references the abbreviation “SVT.” What does SVT stand for? _____________________
LOCATION: Outpatient, Hospital
PATIENT: Emily Watts
PHYSICIAN: Marvin Elhart, MD
STUDY: The study is a transthoracic 2-D and color-flow doppler
echocardiography
INDICATION: Chest pain and SVT
M-MODE MEASUREMENTS:
I. Left Atrium is 3.9, aortic root 2.3
II. RV dimension 1.7
III. LV diastole 5
IV. LV systole 2.3
V. Fracture shortening 0.46
VI. Interventricular septum 0.7
VII. Posterior wall thickness 0.7
DOPPLER:
I. Mild mitral regurgitation
II. Mild to moderate tricuspid regurgitation
III. RV systolic pressure 73 mmHg
2-D FINDINGS:
I. Left ventricle is normal in size with good LV systolic function noted
II. Normal left atrium, right atrium, and right ventricle
III. No pericardial effusion seen
IV. Aortic root is normal in size with normal aortic valve
V. The mitral valve is structurally normal with mild mitral regurgitation
VI. Mild tricuspid regurgitation
CONCLUSION:
I. Normal LV size with preserved LV systolic function
II. No significant aortic or mitral valve disease
III. No dilation of the chambers notedIdentify the correct diagnosis (ICD-9-CM) code(s) for the above scenario:
ICD-9-CM: __________,
ICD-9-CM: __________,
ICD-9-CM: __________,
ICD-9-CM: __________
786.50 (Pain[s], chest)
397.0 (Endocarditis, tricuspid [valve])
424.0 (Insufficiency/insufficient, mitral)
LOCATION: Outpatient, Hospital
PATIENT: Emily Watts
PHYSICIAN: Marvin Elhart, MD
STUDY: The study is a transthoracic 2-D and color-flow doppler
echocardiography
INDICATION: Chest pain and SVT
M-MODE MEASUREMENTS:
I. Left Atrium is 3.9, aortic root 2.3
II. RV dimension 1.7
III. LV diastole 5
IV. LV systole 2.3
V. Fracture shortening 0.46
VI. Interventricular septum 0.7
VII. Posterior wall thickness 0.7
DOPPLER:
I. Mild mitral regurgitation
II. Mild to moderate tricuspid regurgitation
III. RV systolic pressure 73 mmHg
2-D FINDINGS:
I. Left ventricle is normal in size with good LV systolic function noted
II. Normal left atrium, right atrium, and right ventricle
III. No pericardial effusion seen
IV. Aortic root is normal in size with normal aortic valve
V. The mitral valve is structurally normal with mild mitral regurgitation
VI. Mild tricuspid regurgitation
CONCLUSION:
I. Normal LV size with preserved LV systolic function
II. No significant aortic or mitral valve disease
III. No dilation of the chambers notedIdentify the main term to be researched in the alphabetical index of the CPT-4 manual? _____________________
LOCATION: Outpatient, Hospital
PATIENT: Emily Watts
PHYSICIAN: Marvin Elhart, MD
STUDY: The study is a transthoracic 2-D and color-flow doppler
echocardiography
INDICATION: Chest pain and SVT
M-MODE MEASUREMENTS:
I. Left Atrium is 3.9, aortic root 2.3
II. RV dimension 1.7
III. LV diastole 5
IV. LV systole 2.3
V. Fracture shortening 0.46
VI. Interventricular septum 0.7
VII. Posterior wall thickness 0.7
DOPPLER:
I. Mild mitral regurgitation
II. Mild to moderate tricuspid regurgitation
III. RV systolic pressure 73 mmHg
2-D FINDINGS:
I. Left ventricle is normal in size with good LV systolic function noted
II. Normal left atrium, right atrium, and right ventricle
III. No pericardial effusion seen
IV. Aortic root is normal in size with normal aortic valve
V. The mitral valve is structurally normal with mild mitral regurgitation
VI. Mild tricuspid regurgitation
CONCLUSION:
I. Normal LV size with preserved LV systolic function
II. No significant aortic or mitral valve disease
III. No dilation of the chambers notedIdentify the correct procedure (CPT-4) code(s) for the above scenario.
CPT-4: __________
LOCATION: Outpatient, Hospital
PATIENT: Emily Watts
PHYSICIAN: Marvin Elhart, MD
STUDY: The study is a transthoracic 2-D and color-flow doppler
echocardiography
INDICATION: Chest pain and SVT
M-MODE MEASUREMENTS:
I. Left Atrium is 3.9, aortic root 2.3
II. RV dimension 1.7
III. LV diastole 5
IV. LV systole 2.3
V. Fracture shortening 0.46
VI. Interventricular septum 0.7
VII. Posterior wall thickness 0.7
DOPPLER:
I. Mild mitral regurgitation
II. Mild to moderate tricuspid regurgitation
III. RV systolic pressure 73 mmHg
2-D FINDINGS:
I. Left ventricle is normal in size with good LV systolic function noted
II. Normal left atrium, right atrium, and right ventricle
III. No pericardial effusion seen
IV. Aortic root is normal in size with normal aortic valve
V. The mitral valve is structurally normal with mild mitral regurgitation
VI. Mild tricuspid regurgitation
CONCLUSION:
I. Normal LV size with preserved LV systolic function
II. No significant aortic or mitral valve disease
III. No dilation of the chambers notedBased on the statements in the scenario, which modifier will be assigned to report the physician’s portion of the service? _____________________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.What is the name of the physician that you are coding for? __________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?
ICD-9-CM: __________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Using your CPT-4 manual, review the main term in the index and specify what code range the coder is told to review in order to select the appropriate CPT code? ____________________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.What subsection of the CPT-4 Manual should be reviewed for the CPT code? _____________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Identify the correct CPT-4 procedure (ICPT) code(s) for the above scenario?
CPT-4: _________ Modifier: __________
A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC).
Identify the correct procedure (CPT-4) code for this service:
CPT-4: __________
An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.
Identify the correct diagnosis (ICD-9-CM) code for the above scenario.
ICD-9-CM: __________
An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.
Identify the correct procedure (CPT-4) code for the above scenario:
CPT-4: __________
CPT-4: __________
A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.
Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario:
ICD-9-CM: __________
A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.
Identify the correct procedure (CPT-4) code(s) for the above scenario.
CPT-4: __________
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C.Under what subheading in the Evaluation and Management services section of your CPT-4 manual will you locate the appropriate code for the service provided to patient Andrew Vetter? ______________________
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C.Identify the correct diagnosis (ICD-9-CM) code(s) for the office visit for patient Andrew Vetter:
ICD-9-CM: __________,
ICD-9-CM: __________,
ICD-9-CM: __________
455.6 (Hemorrhoids)
414.00 Coronary atherosclerosis, of unspecified type of vessel, native or graft
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C.Identify the correct procedure (CPT-4) code(s) for the office visit for patient Andrew Vetter:
CPT-4: __________
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Identify the correct diagnosis (ICD-9-CM) code(s) for the hospital emergency department visit for patient Fran Green:
ICD-9-CM: __________,
ICD-9-CM: __________,
ICD-9-CM: __________,
E__________
910.0 (Injury, superficial, chin, abrasion without mention of infection)
916.0 (Injury, superficial, leg, abrasion without mention of infection)
E906.8 (Stepped on by)
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Using the E/M Audit Form provided in Appendix A of your text book, along with the Evaluation and Management Guidelines, determine what level of history was reviewed for patient Fran Green? ___________________
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Using the E/M Audit Form provided in Appendix A of your text book, along with the Evaluation and Management Guidelines, determine what what level of exam was performed for patient Fran Green? _____________
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Identify the correct procedure (CPT-4) code(s) for patient Fran Green?
(NOTE: You are coding for the emergency room physician’s services only, not the hospital facility charges.)
CPT-4:___________________
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify the correct diagnosis (ICD-9-CM) code(s) for the inpatient hospital visit for patient Donald Harris:
ICD-9-CM: __________,
ICD-9-CM: __________
799.02 (Hypoxia)
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify what section of the CPT-4 manual will be used to code the attending physician’s services for the inpatient hospital visit for patient Donald Harris? ___________________
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify the correct procedure (CPT-4) code(s) for the inpatient hospital visit for patient Donald Harris:
CPT-4:_________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Which physician are you coding for? __________________________________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Identify the correct ICD-9-CM diagnosis code(s) for the above scenario:
ICD-9-CM _________,
ICD-9-CM _________,
ICD-9-CM _________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Identify the correct CPT-4 procedure code(s) for the above scenario:
CPT-4: __________,
CPT-4: __________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
What modifier should be added to the CPT-4 code in order to submit the insurance claim?
__________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
What claim form will be submitted for the radiologist’s services?
______________
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
In this scenario, which physician are you coding for?
_________________________________
HEMODIALYSIS PROGRESS NOTE
LOCATION:Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Identify the correct (ICD-9-CM) diagnosis code(s) for the above scenario:
ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________.
ICD-9-CM DX:
403.91 (Hypertension/hypertensive, with renal sclerosis or failure, failure, Unspecified),
585.6 (Disease/diseased, renal, end-stage),
250.40 (Diabetes Mellitus Type II),
285.21 (Anemia, in, end-stage renal disease) RATIONALE: The diagnoses are stated in the Assessment portion of the report. The hypertensive renal disease is reported with 403.91. The ESRD (585.6) is reported additionally per the notes under 403 in the tabular list. The type 2 diabetes is reported with 250.00. These diagnoses were stated in point 1 of the Assessment/Plan section of the report. The anemia of end-stage renal disease is reported with 285.21. This diagnosis was stated in point 2 of the Assessment/Plan section of the report. The diagnosis stated in point 3 is the questionable diverticulosis, which is not reported for professional services. The status post herniorrhaphies and cholecystectomy are not reported as these conditions have no impact on the current episode of care.
HEMODIALYSIS PROGRESS NOTE
LOCATION:Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Identify the correct procedure code (CPT-4) for the above scenario:
CPT-4 __________
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Should a modifier be added to the CPT code in order to submit the insurance claim?
______________
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MDHEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today
POSTOPERATIVE DIAGNOSIS: Tumor of left vocal cord.
OPERATION PERFORMED: Laryngoscopy.
The patient is a 25-year-old student of opera who presented with a lesion of her left vocal cord seen on office laryngoscopy. Today she is seen in the ambulatory suite for further examination of this lesion, using the operating microscope. After the administration of local anesthesia, a direct endoscope is introduced. The operating microscope is brought into the field, and the pharynx and larynx are visualized. The pharynx appears normal. There was a mass noted of the left vocal cord. The mass was approximately 2.0cm in size and was removed in total and sent to pathology for analysis. All secretions were suctioned, and the area was irrigated with saline. The patient had minimal blood loss. It should be noted that the pathology report stated benign tumor of the vocal cord.CPT SERVICE CODE: ___
ICD-9 DX CODE: _____
CPT code PROFESSIONAL SERVICES: 31541 (Laryngoscopy, direct, with operating microscope)
ICD-9 DX Code: 212.1 (Benign neoplasm of the larynx)
This is a direct laryngoscopy of the vocal cords with the removal of a tumor and using the operating microscope. This is coded using 31541.
The lesion on the vocal cords is benign and is coded with 212.1.
POSTOPERATIVE DIAGNOSIS: Mucosal lesion of bronchus.
OPERATION PERFORMED: Bronchoscopy.
The bronchoscopy was passed through the nose. The vocal cords were identified and appeared normal. No lesions were seen in this area. The larynx and trachea were then identified and also appeared normal with no lesions or bleeding. The main carina was sharp. All bronchial segments were visualized. There was an endobronchial mucosal lesion. This was located on the right lower lobe of the bronchus. The lesion was occluding the right lower lobe of the bronchus. No other lesions were seen. With use of fluoroscopic guidance, transbronchial biopsies were taken of the area of the lesion. Brush washings were also done for cytology analysis. The patient tolerated both procedures well and was sent to the recovery area in stable condition.CPT SERVICE CODE(S): _____
MODIFIER: _____
31622-59 (Bronchoscopy, diagnostic, separate procedure).
RATIONALE: Using fluoroscopic guidance, a bronchoscopy is done This is coded as 31628. The report notes that a separate procedure was done to take cytologic brush washings which is coded as a separate procedure with 31622 and adding a -59 modifier.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung.
OPERATION PERFORMED: Bronchoscopy and right upper lobectomy.
The patient was brought into the operating room; and after the administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in the left lateral decubitus position. A thoracotomy incision was made. This exposed the chest muscles, which were incised and retracted. The fourth and fifth ribs were visualized and transected to allow entrance to the chest. A tumor mass was noted involving the right lung upper lobe. The right upper lobe was then removed. Saline was irrigated into the chest. It was noted that the liver and diaphragm appeared to be normal with no lesions seen. After verification that the sponge count was correct, chest tubes were placed for drainage. The surgical wound was closed in layers with chromic catgut and nylon. The patient tolerated this portion of the procedure well.
The patient was then placed in the supine position for the bronchoscopy. The patient was still under anesthesia. A flexible fiberoptic bronchoscope was inserted. Patent bronchi were noted bilaterally. The scope was withdrawn. The patient was awakened and sent to the recovery are in stable condition.ICD-9 CODE: ______________
The patient is diagnosed with carcinoma of the lung which is coded with 162.3.
POSTOPERATIVE DIAGNOSIS: Acute respiratory insufficiency due to ALS.
OPERATION PERFORMED: Tracheostomy.
The patient, a 45-year-old male with ALS, has been experiencing severe shortness of breath of a progressive nature over the last several weeks. After discussion of all risks, the decision has been made to perform a tracheostomy on this patient. The patient was brought into the operating suite for this procedure and placed supine on the table. General anesthesia was given, and the patient was prepped and draped in the usual sterile fashion. A 2.5cm incision was made of the neck over the trachea. The trachea was carefully isolated from the surrounding structures after the tracheal rings were identified. The second ring was identified, and a tube was advanced after incision. The patient’s breath sounds were checked and were adequate. The tracheostoma was packed with gauze, and the ties were secured. A chest x-ray will be done postoperatively to check for tube placement, but breath sounds were good when the patient went to the recovery room.
CPT SERVICE CODE: _____
ICD-9-CM DX CODE(S): _______
ICD-9 DX CODE: 335.20 (Amyotrophic lateral sclerosis), 518.82 (Pulmonary insufficiency)
The patient is having difficulty breathing so a tube is placed into the trachea to facilitate breathing. This is coded with 31600.
The patient has ALS which is coded with 335.20. This has manifested into acute respiratory insufficiency which is coded with 518.82.
PATIENT: Liz Charles
PHYSICIAN: Gregory Dawson. MD
STUDY PERFORMED BY PHYSICIAN ONLY: Nocturnal polysomnogram
without CPAP titration
ENTRANCE DIAGNOSIS: Somnolence
This is a fully attended, multichannel nocturnal polysomnogram, giving the patient 386.6 minutes in bed, 317 minutes asleep with 61 arousals through the night which is
above the normal. It looks like she had some difficulty with sleep maintenance. She had sleep onset at 18.5 minutes, REM latency 171.5 minutes, again a little bit prolonged.
She had 27 respiratory events through the night, a mixture of obstructive apneas and obstructive hypopneas with a respiratory disturbance index of 5.1. Anything over 5 is
considered significant. The longest duration of anyone event was 34 seconds. O2 sat was between 76 and 95%, with 29% of the time spent with O2 sats less than 88%. Heart
rate varied between 55 and 113, somewhat varying with the obstructive events. The patient had grade 1-2 snoring noted, and respiratory disturbance events were most
evident in REM while supine. All five stages of sleep were represented. Basically the only thing abnormal was a reduced amount of REM. OVERALL IMPRESSION: This patient has significant obstructive sleep apnea based
on the respiratory disturbance index of 5.1. which anything over 5 is considered significant, plus the amount of time that the patient spent hypoxic, at less than 88%.
29% of the time was spent that way. So I suspect that the patient does have significant obstructive sleep apnea. We will need a second sitting to do the CPAP titration. The overall impression is obstructive sleep apnea.CPT SERVICE CODE and MODIFIER: ________
ICD·9·CM DX CODE(S): _______
ICD-9-CM DX: 327.23 (Apnea/apneic, sleep, obstructive)
The service is a polysomnogram (95810) reported with modifier -26 to indicate that only the professional portion of the service was provided. 95810 is a polysomnography with CPAP (continuous positive airway pressure). The Procedure Performed section states that it is a nocturnal polysomnography without CPAP. The patient had 5 parameters, or stages met: heart rate, respiratory, snoring, REM, and leg jerks.
The diagnosis or reason for the test was somnolence, 780.09. The findings after the test were obstructive sleep apnea (327.23), which is the correct code to use.
PATIENT:Russell Shergrud
ATTENDING PHYSICIAN:Gregory Dawson, MD
PREPROCEDURE
DIAGNOSIS: Acute respiratory failure
POSTPROCEDURE
DIAGNOSIS: Acute respiratory failure
PROCEDURE
PERFORMED: Intubation with a #8 endotracheal tube
The first attempt was with an 8.5 endotracheal tube, which just did not fit in the vocal cords. I was afraid of causing trauma, so we switched to a #8 endotracheal tube, which went in nicely. He had good return on the capnograph, and we eventually got O2 (oxygen) saturations up to 90%. It took 35 minutes to do that, to get his O2 stats back up from about 60% to over 90% once he was intubated.
I got here toward the middle of the respiratory arrest, so I do not think any sedation was given. A chest x-ray will be taken postprocedure to assure ourselves of a good placement.CPT SERVICE CODE:___
ICD-9-CM DX CODE: ___
ICD-9-CM DX: 518.81 (Failure/failed, respiration/respiratory, acute)RATIONALE: The service is an intubation conducted during an emergency as indicated by the statement “I got here toward the middle of the respiratory arrest.” The emergency intubation is reported with 31500. It would also be acceptable to code this as critical care services (99291 for 30-74 minutes). If critical care codes are used, the intubation would not be reported separately because intubation is bundled into the critical care codes.
The diagnosis is as stated in the Postprocedure Diagnosis section of the report as acute respiratory failure and reported with 518.81.
PATIENT: Margaret Hill
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
POSTOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
PROCEDURE PERFORMED: Laparoscopic cholecystectomy
INDICATION: Mrs. Hill has been having RUQ pain with nausea and vomiting and diarrhea. The patient was found to have chronic cholecystitis with cholelithiasis and she was taken to the operating room.
PROCEDURE: The patient received Ancef 1 gram intravenously preoperatively. She was prepped and draped in the usual manner. An infra umbilical incision was made; the abdomen was entered under direct vision. Two stay sutures of 0 Vicryl were placed on either side of the incision. The Hasson sheath was then inserted. The abdomen was then inflated with CO2 gas. Three additional ports were then placed. The hilum of the gallbladder was then dissected free. The cystic duct and cystic arteries were identified. The cystic duct was clipped with three white clips and divided. The cystic arteries were clipped with three white clips and divided. There was another small branch of the artery encountered up on the gallbladder bed. This was also clipped with three white clips and divided. The gallbladder was then dissected free from the gallbladder bed using hook cautery. The specimen was placed in a bag and brought out through a lateral port. The
lateral port fascia was approximated with 0 Vicryl sutures. The operative area was thoroughly irrigated and the incisions were then closed with 3-0 Vicryl sutures for the subcutaneous tissues and a 4-0 Vicryl subcuticular stitch for the skin. Steri-Strips were
applied. Incisions were then injected with 0.5% Marcaine with Epinephrine. The patient tolerated the operation and returned to Recovery in stable condition.ICD-9-CM: __________
CPT-4: __________
Rationale – The pre/postoperative diagnosis states chronic cholecystitis with cholelithiasis. The pathology report also states the same diagnosis, which is reported with 574.10CPT-4: 47562 (Cholecystectomy)
Rationale: The procedure is a laparoscopic cholecystectomy, 47562. The physician makes an incision in which a trocar is inserted. A laparoscope fitted with a camera and light is inserted through the trocar. Other incisions are made to allow other instruments to be passed into the abdomen. The gallbladder is excised and removed through the trocar. Surgically opening the abdomen to excise the gallbladder would be reported with code 47600.
PREOPERATIVE DIAGNOSIS: Desire for sterilization
POSTOPERATIVE DIAGNOSIS: Desire for sterilization
PROCEDURE PERFORMED: Bilateral tubal ligation, modified Pomeroy technique
ANESTHESIA: General
INDICATION: The patient is a 32-year-old gravida 3, para 3, who underwent spontaneous vaginal delivery yesterday, and affirmed her request for permanent sterilization. Risks and benefits of surgery were discussed with the patient and she elected to proceed with the surgery.
TECHNIQUE: The patient was taken to the operating room where epidural anesthesia was found to be inadequate, and she was therefore given general anesthesia, prepped and draped in the normal sterile fashion. An approximately 15 mm transverse infraumbilical incision was made with the scalpel and blunt dissection to the fascia was made with Kelly clamp. The fascia was grasped between two Kocher clamps, tented up, and entered sharply. The incision was extended bilaterally for about 10 mm. Then the peritoneum was identified, grasped with two hemostats, tented up, and entered sharply to expose the uterus. Then the right fallopian tube was identified, grasped with a Babcock clamp, walked out to its fimbriated end, re-grasped approximately 3 cm from the COfneal region, and the avascular portion of the mesosalpinx was identified and perforated under the fallopian tube with a Mosquito and a length of 0 plain gut was drawn back through the proximal followed by distal ends, and an approximately 3 cm segment of tube was tied and the intervening segment of fallopian tube was excised. The luminal ends were identified and found to be hemostatic. Then a similar procedure was carried out on the left. Following this, the fascia was closed in a running fashion with 0 Vicryl, and the skin was reapproximated with 4-0 Vicryl in subcuticular stitch. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct. The patient was taken to recovery in stable condition.ICD-9-CM: __________ (hint: this one is an V-Code!)
CPT-4: __________
Rationale – There was no medical necessity to perform the tubal ligation, thus a V code is used to report the reason for the service (V25.2)58605 (Ligation, Fallopian tube, Oviduct)
Rationale – The reason for the service was a bilateral tubal ligation. The code description for 58600 states ligation of fallopian tubes. However, the code description for 58605 states that the ligation of fallopian tubes is done “during the same hospitalization/postpartum.” Since the report states that this procedure was performed the day after her vaginal delivery, and the patient is still hospitalized, 58605 would be the correct code to report for the tubal ligation. The procedure was bilateral, and the code (58605) indicates tube(s) and unilateral or bilateral; therefore, the one code reports the bilateral procedure.
PATIENT:Don Dwell
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS:Left ureteral calculus
POSTOPERATIVE DIAGNOSIS:Left ureteral calculus
PROCEDURE PERFORMED: Left ureteroscopic stone extraction under fluoroscopic control
CLINICAL NOTE: The patient is a 50-year-old gentleman with intermittent left renal colic and left distal ureteral stone that has not passed spontaneously.
PROCEDURE: The patient was given a general endotracheal anesthesia, prepped, and draped in the lithotomy position. A 21-French cystoscope was passed into the bladder under direct vision. The urethra was normal. The bladder was normal. The prostate was not obstructed. A guidewire was then advanced up to the left ureter beyond the stone under fluoroscopic control. The patient was ureteroscoped without prior ureteral dilation using a 7-French rigid scope. The stone was visualized, grasped within a 0-tip basket, and withdrawn intact. Repeat ureteroscopy showed no evidence of ureteral abrasion or edema. It was decided not to stent the patient. The bladder was drained. The scope was withdrawn. B and O suppository was placed rectally. The patient was transferred to the recovery room in good condition. We will schedule him for renal ultrasound, KUB (kidney, ureter, bladder), and follow-up in 3 months’ time. The stone will be shown to the patient and then sent for analysis. Pathology Report Later Indicated: Benign calculiICD-9-CM: __________
CPT-4: __________ Modifier: __________
CPT-4: __________
Rationale – The diagnosis is calculus of the ureter, which is reported with 592.1.52352-LT (Ureteroscopy, Third Stage, Removal, Calculus), 76000 (Fluoroscopy, Hourly)
Rationale – The procedure was a ureteroscopic removal of calculus from the ureter and reported with 52352. The physician’s use of fluoroscopic guidance is reported with 76000. 76000 is specific to the physician’s time and is not to be used to report the facility component.
PATIENT: Jack Ehnke
SURGEON:Ira Avila, MD
ATTENDING PHYSICIAN:Ira Avila, MD
PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate, with elevated PSA (prostate specific antigen)
POSTOPERATIVE DIAGNOSIS: Recurrent adenocarcinoma of the prostate
ANESTHESIA: General
PROCEDURE: Please see the preoperative note for indications of the procedure as well as full informed consent. The patient underwent a general anesthetic and was put in a modified frog-leg position. Anesthesia preparation included a central venous line, arterial line, and epidural catheter. After this was achieved, a midline incision was made between the umbilicus and symphysis pubis. This was deepened down through skin and generous subcutaneous tissue to the midline. The retropubic space was entered and developed. The pelvic lymphadenectomy was then performed. This was carried along the usual lines. The lateral extension was the external iliac vein. Tissues surrounding that vein were brought down and around the muscle wall to include the obturator group, preventing injury to the obturator artery, vein, and nerve. Proximally we went to the circumflex iliac branches, including the node of Cloquet, and then used clips across the trunks of the lymphatics. Distally or proximally on the patient, we proceeded to the bifurcation of the iliac vein, ending the dissection at that point. Again, the lymphatic trunks were clipped. Each package was delivered and sent to pathology for frozen section analysis. With the result of negative nodes, we proceeded with surgical removal of the prostate. This was performed in standard fashion.
The Thompson retractor was used with modifications under padded retractors throughout the procedure. This allowed adequate exposure. The margin between the lateral and endopelvic fascia was opened in anteromedial fashion to the puboprostatic ligaments, which were opened. The patient’s size was fairly good, and he had a large prostate so the visualization in the apical area of the prostate was not so great. We finger dissected along the superficial venous complex, reaching the apex of the prostate on each side. The McDougall clamp was placed through the fascia under the superficial venous complex but anterior to the urethra. Space was created there. A TIA-46 stapler was used to staple across the superficial venous complex. The urethra was exposed and opened anteriorly. Sutures at 10 and 2 o’clock were placed, 2-0 chromic, outside to in. The rest of the urethra was mobilized after the catheter was brought up and out of the wound and used for traction device after it was cut. The urethra was incised, and sutures were placed at the 4 and 8 o’clock positions likewise. Apex of the prostate was mobilized using sharp and blunt dissection, carrying it down to the lateral pelvic fascial leaves. These were separated using sharp and blunt dissection off the lateral aspect of the prostate. Clips were used for the small bleeding vessels encountered. The lateral pedicle was then mobilized between clamps and ligated with 0 chromics, each side. Care was again taken to avoid the neurovascular bundle apparatus. The prostate was mobilized anteriorly, and the Denonvilliers’ fascia was opened over the seminal vesicles.Those were dissected posteriorly.
The bladder neck was then incised down just behind the prostate. Because of the large median lobe on the prostate, we had to open the bladder neck somewhat more than normal. We exposed the trigone but did not approach it. The prostate was dissected posteriorly off the bladder neck using sharp and blunt dissection. The seminal vesicles were then approached anteriorly, as was the ampulla of the vas. Each was cross-clamped and ligated. Final hemostasis was achieved at this point with the prostate removed. We everted the urothelium and closed the bladder neck slightly. We then brought the sutures concomitantly from inside to out, at 2, 10, 4, and 8 o’clock. An 18-silicone catheter was placed in the bladder, and the sutures were tied down. Hemovac drains were placed, and the wound was closed with a double-stranded running nylon. Skin clips were placed, and the drains were secured. He tolerated the procedure well overall.
Pathology Report Later Indicated: Adenocarcinoma neoplasm, prostate, benign lymph nodesICD-9-CM: __________
CPT-4: __________ Modifier: __________
Rationale – When cancer has recurred to the same primary site, it is coded as a primary malignancy (185). The benign lymph nodes are not coded unless there had been a metastasis to the lymph nodes. In many operations, such as mastectomies, etc., surgeons also remove lymph nodes as a part of the procedure and to determine metastasis.55845 (Prostate, Excision, Radical)
Rationale – The service was a prostatectomy via incision between the umbilicus and symphysis pubis into the retropubic space with bilateral lymphadenectomy reported with 55845, which is a bilateral code so modifier -50 was not necessary
PATIENT: MaryBelle Wilson
ATTENDING PHYSICIAN: Andy Martinez, MD
SURGEON: Andy Martinez, MD
PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean
POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean
PROCEDURE: Repeat low transverse cervical segment cesarean section
ANESTHESIA: Spinal
COMPLICATIONS: None
FINDINGS: Viable female infant weighing 8 pounds 14.5 ounces, with Apgars of 9 at 1 minute and 10 at 5 minutes
PROCEDURE: The patient was prepped and draped in the supine position with left lateral displacement of the uterine fundus under spinal anesthesia with a Foley catheter indwelling. A transverse incision was made in the lower abdomen, removing the old scar. The fascia was divided laterally. The rectus muscle was divided in the midline. The peritoneum was entered in the sharp manner. An incision was extended vertically. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The uterus was entered in a sharp manner in the lower uterine segment, and the incision was extended laterally with blunt traction. The amniotic fluid was clear. The infant’s head was delivered. The infant was then delivered and bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive care nursery staff in apparent good condition. The placenta was manually expressed. The uterus was delivered from the abdominal cavity and placed on wet lap sponges. A dry sponge was used to ensure remaining products of conception were removed. The cervical os (opening) was ensured patent with a ring forceps. The uterine incision was closed with 0 Vicryl interlocking suture in two layers, with the second layer imbricating the first. A figure-of-eight suture was also placed, which was required for hemostasis. The operative site was irrigated. The bladder flap was reapproximated using 2-0 Vicryl continuous suture. The tubes and ovaries appeared normal bilaterally. The uterus was placed back within the abdominal cavity. The pelvic gutters were irrigated. The anterior peritoneum was reapproximated using 2-0 Vicryl continuous suture. The incision was irrigated. The fascia was closed with 0 Vicryl continuous suture. The incision was irrigated. The skin was closed with staples. All sponges and needles were accounted for at the completion of the procedure. The patient left the operating room in apparent good condition, having tolerated the procedure well. The Foley catheter was patent and draining clear yellow urine at the completion of the procedure.ICD-9-CM: __________
ICD-9-CM: __________ (hint: this one is an V-Code!)
CPT-4: __________
Rationale – The diagnosis is cesarean delivery in a woman who previously delivered by means of cesarean, reported with 654.21. V27.0 reports the outcome of delivery as single liveborn.59510 (Cesarean Delivery, Antepartum Care)
Rationale – The service was a cesarean delivery that included the antepartum care, delivery, and postpartum care and is reported with 59510.
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
What is the main term that you will look for in the alphabetical index of the ICD-9-CM manual?
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?
ICD-9-CM: __________
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
What is the total size are the lesion that was removed? (hint: according to the op report: the lesion = 1 cm, lateral margin = 2 cm, medial margin= 2 cm)
____________________
This would be 2 cm (lateral margin) + 2 cm (medial margin) + 1 cm lesion = 5 cm total.
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
Identify what two terms you can look for in the alphabetical index of the CPT-4 manual to identify the correct procedure? (Hint: one describes procedure, one describes organ)
____________________, ____________________
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
POSTOPERATIVE DIAGNOSIS: Malignant melanoma, mid-chest (1 cm)
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
Identify the correct procedure (CPT-4) code(s) for the above scenario?
CPT-4: __________,
CPT-4: __________ Modifier: __________
12032-51 (Repair, Skin, Wound, Intermediate)
PATIENT: Arnie Holmes
PREOPERATIVE DIAGNOSIS: Right heel ulcer
POSTOPERATIVE DIAGNOSIS: Right heel ulcer with staphylococcus infection
SURGEON: Gary Sanchez, MD
PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone
INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm X 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osteo. If he does having another ongoing infection (this is reportable), this will require antibiotic therapy. Cultures will be obtained of the deep tissues as well as the bone. The procedure and the risks were all discussed with the patient and his wife preoperatively.They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.
PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bones there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surrounding areas are necrotic. We appear to have some area of viability there. Homeostasis was achieved, We washed it out with a liter of antibiotic solution of Bacitracin and Kanamycin using an Ortholav system. the wound was packed open with wet-to-dry dressings. the patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Staphylococcus aureus.What is the main term that you will look up in the ICD-9-CM alphabetical index? ____________________
PATIENT: Arnie Holmes
PREOPERATIVE DIAGNOSIS: Right heel ulcer
POSTOPERATIVE DIAGNOSIS: Right heel ulcer with staphylococcus infection
SURGEON: Gary Sanchez, MD
PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone
INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm X 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osteo. If he does having another ongoing infection (this is reportable), this will require antibiotic therapy. Cultures will be obtained of the deep tissues as well as the bone. The procedure and the risks were all discussed with the patient and his wife preoperatively.They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.
PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bones there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surrounding areas are necrotic. We appear to have some area of viability there. Homeostasis was achieved, We washed it out with a liter of antibiotic solution of Bacitracin and Kanamycin using an Ortholav system. the wound was packed open with wet-to-dry dressings. the patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Staphylococcus aureus.What is the main term that you will look up in the ICD-9-CM alphabetial index for the secondary diagnosis?____________________
PATIENT: Arnie Holmes
PREOPERATIVE DIAGNOSIS: Right heel ulcer
POSTOPERATIVE DIAGNOSIS: Right heel ulcer with staphylococcus infection
SURGEON: Gary Sanchez, MD
PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone
INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm X 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osteo. If he does having another ongoing infection (this is reportable), this will require antibiotic therapy. Cultures will be obtained of the deep tissues as well as the bone. The procedure and the risks were all discussed with the patient and his wife preoperatively.They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.
PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bones there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surrounding areas are necrotic. We appear to have some area of viability there. Homeostasis was achieved, We washed it out with a liter of antibiotic solution of Bacitracin and Kanamycin using an Ortholav system. the wound was packed open with wet-to-dry dressings. the patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Staphylococcus aureus.Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?
ICD-9-CM: __________
ICD-9-CM: _________
041.11 (Infection/infected/infective, staphylococcus aureus)
PATIENT: Arnie Holmes
PREOPERATIVE DIAGNOSIS: Right heel ulcer
POSTOPERATIVE DIAGNOSIS: Right heel ulcer with staphylococcus infection
SURGEON: Gary Sanchez, MD
PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone
INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm X 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osteo. If he does having another ongoing infection (this is reportable), this will require antibiotic therapy. Cultures will be obtained of the deep tissues as well as the bone. The procedure and the risks were all discussed with the patient and his wife preoperatively.They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.
PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bones there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surrounding areas are necrotic. We appear to have some area of viability there. Homeostasis was achieved, We washed it out with a liter of antibiotic solution of Bacitracin and Kanamycin using an Ortholav system. the wound was packed open with wet-to-dry dressings. the patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Staphylococcus aureus.What is the main term that you will look up in the CPT-4 alphabetical index? ____________________
PATIENT: Arnie Holmes
PREOPERATIVE DIAGNOSIS: Right heel ulcer
POSTOPERATIVE DIAGNOSIS: Right heel ulcer with staphylococcus infection
SURGEON: Gary Sanchez, MD
PROCEDURE PERFORMED: Debridement of right heel ulcer down to the bone
INDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm X 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to see how deep this goes. We also need to obtain cultures. We need to determine for sure if he also has osteo. If he does having another ongoing infection (this is reportable), this will require antibiotic therapy. Cultures will be obtained of the deep tissues as well as the bone. The procedure and the risks were all discussed with the patient and his wife preoperatively.They understand, and their questions were answered. I also met with them in the preop holding room, and they had no new questions.
PROCEDURE: The more proximal aspect of this wound on the plantar aspect of the heel went deep basically down to the bone. This was all sharply debrided back. We cleared some of the tissue overlying the bones there. The tissues were basically all necrotic down to there. We sent this off as a specimen. The remainder of the heel ulcer was not as deep. We sharply debrided the eschar off of it. We sharply debrided all of the edges of the wound. The tissues appeared to be viable there. I am somewhat concerned about how much deeper tissue of the foot and surrounding areas are necrotic. We appear to have some area of viability there. Homeostasis was achieved, We washed it out with a liter of antibiotic solution of Bacitracin and Kanamycin using an Ortholav system. the wound was packed open with wet-to-dry dressings. the patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Staphylococcus aureus.Identify the correct procedure (CPT-4) codes for the above scenario?
CPT-4: _____________________
CPT Code: ___
PATIENT: Glory Ann Borden
SURGEON: Mohomad Almaz, MD
DIAGNOSIS:Right carpal tunnel syndrome
PROCEDURE PERFORMED:Right carpal tunnel release
PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released. We identified the median nerve and found that it was free. We did spread the soft tissues surrounding it gently.We then released the tourniquet after 8 minutes of tourniquet time, and bleeding was controlled with pressure and also with electrocautery. We thoroughly irrigated the area with saline. We then closed the skin using 4-0 nylon suture, and a Xeroform dressing was applied under a small pressure dressing. She was taken from the operating room in good condition. She tolerated this very well.
1. Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Glory Ann Borden:
ICD-9-CM: __________
2. Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Glory Ann Borden:
CPT-4: __________ Modifier: __________
2. 64721-RT (Release, Carpal Tunnel)RATIONALE: The service is a carpal tunnel release as indicated in the Procedure Performed section of the report and substantiated within the body of the report. (“We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released.”) This service is described with 64721 with modifier -RT added to indicate right side.
PATIENT: Josh Blake
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Fracture of CI, C2
POSTOPERATIVE DIAGNOSIS: Fracture of CI. C2
PROCEDURE PERFORMED: Placement of a haloINDICATION: Fracture occurred when the patient was involved in an unspecified motor vehicle collision. It is known that Mr. Blake was the driver of the vehicle.
PROCEDURE: The patient’s head was prepped and draped in the usual manner. The head was shaved. The halo apparatus was applied with screws and four-points. Then the vest was applied. The patient was then discharged to the recovery room to have films taken in the recovery room.
1. ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ (hint: this one is an E-Code!)
2. Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Josh Blake:
CPT-4: __________
805.02 (Fracture, vertebra/vertebral, cervical, second
E819.0 (Accident, motor vehicle, driver)RATIONALE: Each fracture site would be coded separately. The C1 fracture would be coded with 805.01, and the C2 fracture with 805.02. As reported in the Indication section, this was an MVC of an unspecified nature, and the patient was the driver. E819 is the code for MVC of unspecified nature with the 4th digit of 0 to show the patient was driving.
2. 20661 (Halo, Cranial)
RATIONALE: A cranial halo is applied to stabilize the patient’s neck to repair C1 and C2 fractures. The application of the halo is coded with 20661.
PATIENT: May Leigh
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DlAGNOSIS: Osteoarthritis, left knee.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Left total knee arthroplasty.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: MinimalFollowing satisfactory preoperative review and assessment and full discussion, the patient was brought to the operating room where under general anesthesia examination confirmed patient to demonstrate excellent appearance of her right total knee and increased
valgus and crepitus of the left knee. The left knee was then elevated, scrubbed, prepped and draped in the usual fashion and utilizing a standard midline incision the subcutaneous tissues were dissected, the medial retinaculum was opened and the underlying knee joint identified with advanced osteoarthritic changes present. The distal femur, proximal tibia and patella were resected in the normal fashion allowing excellent fitting of a #2 femur, a #2 tibia, an 8-tray insert, and a 31 patella. Excellent fit, stability, and range of motion were achieved. The knee joint was thoroughly waterpiked and irrigated, the tibia and femur securely cemented into position followed by the patella.
Once again, excellent fit, stability, and range were achieved. The knee joint was drained with two deep suction Hemovacs. The medial retinaculum was closed with 0 Vicryl, subcutaneous closure with 2-0 Vicryl, cutaneous margins approximated with 4-0 Ethilon in vertical mattress fashion, and a sterile dressing was applied. The patient tolerated the procedure well and returned to PAR in satisfactory condition. There were no intraoperative
complications. Sponge and needle count correct.
1. Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient May Leigh:
ICD-9-CM: __________
2. Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient May Leigh:
CPT-4: __________ Modifier: __________
RATIONALE: The diagnosis is stated in the Postoperative Diagnosis section of the report as osteoarthritis of the knee and is reported with 715.96.2. 27447-LT (Arthroplasty, Knee)
RATIONALE: The surgeon removed the defective bones and then fitted the defective areas with prostheses (artificial knee components). This is a replacement of a defective knee or total arthroplasty. The tibial component and the femoral component were replaced with prostheses that were cemented in place. The patellar component was then replaced with a prosthetic device. The defective area was stabilized and then closed. A total knee arthroplasty is reported with 27447 with modifier -LT to indicate the procedure was performed on the left knee.
PATIENT: Stan Hope
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past shoulder injury
POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder
CLINICAL HISTORY: This is a 57-year-old with a l0-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness.
OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beachchair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion . A standard posterior arthroscopic portal was
created and the camera was introduced. First the back of the joint was inspected and this did not show any evidence of damage. The anterior ligament structures were normal. The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the glenohumeral joint and placed in the subacromial space. There was excellent visualization
of this area. No abnormalities could be identified and there was no evidence
of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on her hospital bed and taken to the recovery room in good condition.1. Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Stan Hope:
ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ (hint: this one is a V-Code!)
2. Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Stan Hope:
CPT-4: __________ Modifier: __________
782.0 (Numbness)
V13.59 (History of, musculoskeletal disorder NEC)
RATIONALE: The diagnostic arthroscopy results were that the shoulder was normal, and, as such, the Postoperative Diagnoses of shoulder pain (719.41) and numbness (782.0) would be the correct codes to use. The patient has a history of musculoskeletal disorder (V13.59).2. 29805-LT (Arthroscopy, Diagnostic, Shoulder)
RATIONALE: The procedure is a diagnostic arthroscopy of the shoulder and is reported with 29805 with modifier -LT to indicate the procedure was performed on the left shoulder.
PATIENT: Larry Frost
SURGEON: Mohomad Almaz, MD
DIAGNOSIS:Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms
OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle (claviculectomy). After satisfactory level of general anesthesia was reached and patient was in the supine position, he was further placed in a beach chair position. A longitudinal incision was created over the region of the left AC joint. At this time, sharp dissection was conducted down to the fascial plane. The fascial plane was then further incised, reflecting both the deltoid and the trapezial fascia and the distal aspect of the clavicle undermining the clavicle; at this time we simply proceeded excising the distal 1 cm of the clavicle with use of a reciprocal saw. With completion of this element of the procedure, the margins of the bone were otherwise unremarkable in gross appearance. It was also significant to note at this time the acromial end of the articulation was unremarkable. The wound was irrigated, followed by controlling of punctate bleeding with use of electrocautery, followed by the closure of the deltotrapezial fascia. At this time I further imbricated sutures for stable repair, followed by repair of subcutaneous and dermal planes. A simple dressing was applied. The patient tolerated the procedure well and was transported to the recovery room in a stable manner.1. Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Larry Frost:
ICD-9-CM: __________
2. Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Larry Frost:
CPT-4: __________ Modifier: __________
RATIONALE: The diagnosis is stated in the Diagnosis section of the report to be degenerative arthritis and reported with 715.31 to indicate a localized osteoarthrosis of the shoulder.2. 23120-LT (Claviculectomy, Partial)
RATIONALE: The key to correctly reporting this service is to be able to translate the removal of a portion of the left clavicle into a claviculectomy. Once this is done the code can be located in the index of the CPT manual and reported with 23120 with modifier -LT to indicate the left side.
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.What is the name of the physician that you are coding for? __________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Using your CPT-4 manual, review the main term in the index and specify what code range the coder is told to review in order to select the appropriate CPT code? ____________________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.What subsection of the CPT-4 Manual should be reviewed for the CPT code? _____________
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.Identify the correct CPT-4 procedure (ICPT) code(s) for the above scenario?
A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC).
Identify the correct procedure (CPT-4) code for this service:
An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.
Identify the correct diagnosis (ICD-9-CM) code for the above scenario.
Identify the correct procedure (CPT-4) code for the above scenario:CPT-4: __________
CPT-4: __________
A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.
Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario:
ICD-9-CM: __________
A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.
Identify the correct procedure (CPT-4) code(s) for the above scenario.
CPT-4: __________
During the evocative suppression testing, the correct codes for the physician’s administration of the evocative or suppressive agents are reported depending on the method of administration.
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Which physician are you coding for? __________________________________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Identify the correct ICD-9-CM diagnosis code(s) for the above scenario:
ICD-9-CM _________,
ICD-9-CM _________,
ICD-9-CM _________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
Identify the correct CPT-4 procedure code(s) for the above scenario:
CPt-4: __________,
CPT-4: __________
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
What modifier should be added to the CPT-4 code in order to submit the insurance claim?
LOCATION: Outpatient, Hospital
PATIENT: Eric Tayes
ORDERING PHYSICIAN: Frank Gaul, MD
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION: Ultrasound of both lower extremities; abdomen ultrasound.
CLINICAL SYMPTOMS: Lower extremity swelling, Respiratory distress.FINDINGS: Ultrasound examination of the deep venous system of both lower extremities is negative. No evidence of deep venous thrombosis in either lower extremity. The posterior tibial, greater saphenous, and popliteal through femoral veins are patent and negative for thrombus bilaterally. Normal phasicity.
Abdomen Ultrasound:
Diffusely coarsened echotexture of the liver with some nodularity consistent with fatty infiltration. Cirrhotic configuration of the liver. Small calcified granuloma in the spleen. The spleen is otherwise negative. There is ascites in all four quadrants. No bile duct dilatation. No gallbladder wall thickening or cholelithiasis. Small amount of fluid adjacent to the gallbladder is likely related to the ascites. The pancreas is obscured by bowel gas. The abdominal aorta is of normal caliber. The right kidney measures approximately 9 cm in length and shows no evidence of hydronephrosis, calculi, or mass. The left kidney measures approximately 9.9 cm in length and shows no evidence of hydronephrosis, calculi, or mass.
What claim form will be submitted for the radiologist’s services?
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
In this scenario, which physician are you coding for?
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Identify the correct (ICD-9-CM) diagnosis code(s) for the above scenario:
ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________.
585.6 (Disease/diseased, renal, end-stage),
250.40 (Diabetes Mellitus Type II),
285.21 (Anemia, in, end-stage renal disease) RATIONALE: The diagnoses are stated in the Assessment portion of the report. The hypertensive renal disease is reported with 403.91. The ESRD (585.6) is reported additionally per the notes under 403 in the tabular list. The type 2 diabetes is reported with 250.00. These diagnoses were stated in point 1 of the Assessment/Plan section of the report. The anemia of end-stage renal disease is reported with 285.21. This diagnosis was stated in point 2 of the Assessment/Plan section of the report. The diagnosis stated in point 3 is the questionable diverticulosis, which is not reported for professional services. The status post herniorrhaphies and cholecystectomy are not reported as these conditions have no impact on the current episode of care
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Identify the correct procedure code (CPT-4) for the above scenario:
CPT-4 __________
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Should a modifier be added to the CPT code in order to submit the insurance claim?
HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD
HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.
LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.
PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.
ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
What claim form will be submitted for the physician?s services? ________________
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C.Under what subheading in the Evaluation and Management services section of your CPT-4 manual will you locate the appropriate code for the service provided to patient Andrew Vetter?
______________________
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C.Identify the correct diagnosis (ICD-9-CM) code(s) for the office visit for patient Andrew Vetter:
455.6 (Hemorrhoids)
414.00 Coronary atherosclerosis, of unspecified type of vessel, native or graft
LOCATION: Outpatient, clinic
PATIENT: Andrew Vetter
PRIMARY CARE PHYSICIAN: Alma Naraquist, MD
CHIEF COMPLAINT: Recheck diabetes.
He has started doing PT to get his strength back and has noted improvement. He has not been having any chest pain or SOB.Past history of CAD.
His DM has been variably controlled. he is taking Lantus 28 units in the evening and Humalog 12 units with meals. He is testing 2-4 times per day. He is having reactions around 3PM about once a week. He does get a warning with the reactions. His sugars are highly variable at all testing times with high and low sugars. His evening sugars tend to be high, and he may overeat after supper.
He continues to have numbness in the feet. There is no edema. His depression seems to be ok.
EXAM: Vitals: Weight is 180. Blood Pressure is 120-70. Patient is alert and conversant. He is near his ideal weight. There is no edema. The foot pulses are normal. The ankle and knee reflexes are normal. There is a slight decrease in the vibratory sensation. The chest is clear. Cardiac: The heart is regular with no murmur or S3. The abdomen is soft and nontender with no masses. The rectum is normal, and there are some small hemorrhoids noted. The stool is hemoccult negative.
IMPRESSION: 1)DM Type I with variable control 2) Hemorrhoids 3)CAD, Stable
PLAN: Anusol suppository bid prn and tub soaks. He may need to cut the noon Humalog by 2 units. See in 4 months with a HgbA1C
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Identify the correct diagnosis (ICD-9-CM) code(s) for the hospital emergency department visit for patient Fran Green:
910.0 (Injury, superficial, chin, abrasion without mention of infection)
916.0 (Injury, superficial, leg, abrasion without mention of infection)
E906.8 (Stepped on by
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Using the E/M Audit Form provided in Appendix A of your text book, along with the Evaluation and Management Guidelines, determine what level of history was reviewed for patient Fran Green? _______________
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Using the E/M Audit Form provided in Appendix A of your text book, along with the Evaluation and Management Guidelines, determine what what level of exam was performed for patient Fran Green? ___
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
MEDICATIONS:
I. Premarin
II. Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.Identify the correct procedure (CPT-4) code(s) for patient Fran Green?
(NOTE: You are coding for the emergency room physician’s services only, not the hospital facility charges.)
CPT-4:___________________
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify the correct diagnosis (ICD-9-CM) code(s) for the inpatient hospital visit for patient Donald Harris:
ICD-9-CM: __________,
ICD-9-CM: __________
799.02 (Hypoxia)
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify what section of the CPT-4 manual will be used to code the attending physician’s services for the inpatient hospital visit for patient Donald Harris? ______
LOCATION: In-patient Hospital
PATIENT: Donald Harris
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient is doing relatively well in general. I believe the sodium of 152 that was done yesterday morning was wrong since it has dropped down to 132 in 6 hours, which is impossible to happen.
He continues to need oxygen and he continues to be hypoxic. His V/Q scan showed intermediate probability, but his ABGs were not suggestive of respiratory alkalosis.PHYSICAL EXAMINATION: Blood pressure seems to be stable. Heart rate is 70 per minute, paced. He is afebrile. he has decreased air entry bilaterally in the bases. I did not hear any crackles. Abdomen is negative. Extremities show no edema.
Chest x-ray shows some bilateral pleural effusions, more on the right side.
Creatinine was 0.8. Basic metabolic panel was normal today with a sodium of 139.
IMPRESSION:
I. Severe congestive heart failure
II. Hypoxia probably related to the bilateral pleural effusions
III. Pleural effusion
PLAN: Keep the patient in ICU. We will involve physical therapy with him today. I will consult the pulmonologist on call in the morning to check on him and see if we could do a therapeutic and diagnostic thoracentesis, and whether we need to do a pulmonary angiogram to make sure he doesn’t have pulmonary emboli. I believe that most of his hypoxia is related to his severe CHF and his pleural effusions. I discussed this with the patient. he agrees with the plan.
Identify the correct procedure (CPT-4) code(s) for the inpatient hospital visit for patient Donald Harris:
CPT-4:_________
Disadvantages: No tracking, can be lost in the mail, no proof of receipt to say when the payer received the claim, unless using registered or certified mail, which is expensive, longer processing time, which results in delayed reimbursement.
is used to record services, procedures, and items in FL 44.
_______________._______________._______________..
in FL 74 a-e and defines a significant procedure as one that is surgical in nature, or carries a
procedural risk, or carries an anesthetic risk, or requires special training.
_____________ procedure
hospital facility charges for services, procedures, and items to payers for reimbursement.
conditions and significant procedures.
replace the ICD-9-CM coding system effective________________________.
for principal and other conditions.
2. FUTURE NEEDS
3. NEWER CANCER CENTER BUILT IF PATIENT USE WARRANTS
2. FISCAL ENTITIES TRACK HEALTH CARE COSTS.
3. RESEARCH
2. SERVICES AND DIAGNOSES MUST CORRELATE.
3. CMS-1500 IN BLOCK 21 AND 24E
(UNSPECIFIED IN DOCUMENTATION)
(HELPFUL, ADDITIONAL INFORMATION)
(TAKE THEM OR LEAVE THEM)
CODES NOT USED AS PRINCIPAL DIAGNOSIS
2. TABLE OF DRUGS & CHEMICALS
3. E CODES
1. SUPPLEMENTARY CLASSIFICATION (V CODES & E CODES)
2.AHIMA- AMERICAN HEALTH INFORMATION MGMT ASSOC.
3. CMS- CENTERS FOR MEDICARE & MEDICAID SERVICES.
4. NCHS-NATIONAL CENTER FOR HEALTH STATISTICS
Modification
Title II: Administrative Simplification
2) Mutually Exclusive Edits
*Avoidance of denied or delayed payment by ins co investigating the medical necessity of services
*Enforcement of medical record-keeping rules by ins co requiring accurate documentation that supports procedure & diagnosis codes.
*Subpoena of medical records by state investigators or the court for review
*Defense of professional liability claim
1) Epidermis (thin, cellular membrane layer that contains keratin)
2) Dermis (dense, fibrous, connective tissue that contains collagen)
3) Subcutaneous layer (thicker & fatter tissue)
1) eccrine sweat glands (most common)
2) apocrine sweat glands (secrete orderless sweat)
*Frontal Bone- forms the anterior part of the skull & forehead
*Parietal Bone- Forms the sides of the cranium
*Occipital Bone- forms the back of the skull, there is a large hole at the ventral surface in this bone, called the foramen magnum, which allows the brain communication w/ the spinal cord
*Temporal Bone- forms the 2 lower sides of the cranium
*Ethmoid Bone- forms the roof of the nasal cavity
*Sphenoid Bones- anterior to the temporal bones
2) responsible for movement of organs
3) to pump blood to the circulatory cystem
2) the place & type of service is specified
3) the content of the service is defined
4) the nature of the presenting problem(s) usually associated w/ a given level is (are) described
5) time is typically specified in the descriptor of the code
*Volume 1- Disease: Tabular List
*Volume 2- Disease: Alphabetic Index
*Volume 3- Procedures: Tabular list and Alphabetic Index
*When a person w/ a resolving disease or chronic condition presents for specific treatment of that disease or condition. (IE; V56.0 is used for extracorporeal dialysis)
*When a circumstance may influence the pt’s health status but is not a current illness (IE; V16.3 is used for family history of coronary artery disease)
*To indicate the birth status of a newborn (IE; V30.0 is uused for a newborn male born in the hospital by c-section)
-Malignant; an accelerated sever form of hypertension w/ vascular damage and a diastolic pressure of 130mmHg>
-Benign; Mild or controlled hypertension & no damage to the vascular system or organs
-Unspecified; This is not specified as benign or malignant in the diagnosis or medical record
Section 2) Table of drugs and chemical
Section 3) Index to External Cause of Injury (E Codes)
-Accident: Poisoning was due to accidental overdose, wrong substance taken, accidents in use of drugs and biologicals, external causes of poisoning classifiable to 980-989
-Therapeutic Use: instances when a correct substance properly taken is the cause of an adverse effect
-Suicide Attempt: the poisoning was self-inflicted
-Assault: poisoning was inflicted by another person w/ intent to kill or injury
-Understand: poisoning cannot be determined whether intentional or accidental
1)Evaluation & Management (E&M) 2)Anesthesia 3)Surgery 4)Radiology 5)Pathology and Laboratory 6) Medicine 7) Category I codes 8)Category III codes
*Indented Codes- these are codes listed under associated stand-alone codes. To complete the the description for indented codes, one must refer to the portion of the stand alone code description before the semi-colon
*Modifiers-provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed by the definition of the code
**2 triangle symbols-represent changes in the text or definition between the triangles
**A bullet-represents a new procedure or service code added since the previous addition of the manual
**A plus sign-indicates add-on codes
**A circle w/ a line through it- represents exemption from use of modifier
1)Service or Procedure
2)Anatomic Site
3)Condition or Disease
4)Synonym/Eponym
5)Abbreviation
-more than 1 procedure is performed in the same surgical episode
-one code does not describe all of the procedures performed
-the secondary procedure is not minor or incidental to the major procedure
Ex; *same operation, different site, *multiple operations, same operative session, *procedure performed multiple times
-chief complaint
-History of present illness (HPI)
-review of systems (ROS)
-Past, family and social history (PFSH)
b;physical examination
c;medical decision making complexity
-surgical procedure performed
-local infiltratration, metacarpal/metatarsal/digital block or topical anesthesia
-Preoperative E/M services; on day immediately prior to the day of the procedure
-immediate postoperative care
-Normal, uncomplicated postop care
2)Personal Insurance- an insurance plan issued to an individual. premium rates are usually higher than group rates and service availability is lessened w/ this type of coverage
3)Pre-paid health plan- pre-determined set of benefits covered under one set annual fee
*****the lowest amount is used as the basis for payment (the allowed charge)
1) Work; represents the amount of time, intensity of effort, and medical skill required of the dr
2) Overhead; practice costs related to the performing of the service
3) Malpractice: cost of medical malpractice insurance
-medical malpractice insurance that covers the insured only for those claims made while the policy is in force is called claims-made coverage
-spouses of a person paying into the Social Security System
-those who received social security disability payments for 24 months
-those diagnosed w/ end stage renal disease (ERSD)
-kidney donors to ERSD pt’s (all expenses related to kidney transplant are covered)
-retired federal employees of the Civil Service Retirement System (CSRS)
B-Spouse of wage earner
C-Disabled Child
D-Widow
HaD- Disabled Adult
M- Part B benefits only
T- Uninsured and entitled only to health ins benefits
-a bed pt in a hospital
-pt’s in a pysch hospital
-bed pt’s in a nursing facility
-pt’s receiving home health care services
-terminally ill pt who has <6 to live and needs hospice care
-terminally ill pt who needs respite care
A) Categorically Needy: 1) families, pregnant women & children 2) Aged and disabled persons 3) Persons receiving institutional or other long-term care in nursing facilities (NF’s) and intermediate care facilities (ICF’s)
B) Medically Needy: 1) medically indigent low-income and families 2)low-income persons losing employer health ins coverage (Medicaid purchase of COBRA purchase)
-outpatient hospital services
-Physician services
-emergency service
-prenatal care
-vaccines for children
-cosmetics procedures necessitated by an injury (elective cosmetic procedures are not included)
-family planning and supplies
2) Extra- preferred provider organization
3) Prime- health maintenance organization plan w/ a point of service option
***All have annual deductibles, w/ the exception of PRIME
a) active duty family members
b) retirees, their families members and survivors of deceased personnel
-most have coordination of benefits (COB) clauses to identify the primary and secondary payer responsibility status for dependent children
-Blocks 14-33, refers to physician info
-verify insurances
-prepare encounter form (should reflect the diagnosis and services provided to pt, this is used as the basis for billing)
-code diagnosis and procedures
-review linkage and compliance, review should include the following *appropriateness of the codes *link between the diagnosis and the procedure *payers rules about the diag and proc *documentation of the procedure *compliance w/ regulations
-calculate physician charges
-prepare claims
-transmit claims
-payer adjudication, claims received by the payers go through a series of steps to determine whether it should be paid
-follow up reimbursement/record retention
II. Claims Processing-payers and clearinghouses verify the info found in the submitted claims about the pt and provider
III. Claims Adjudication-process by which the claim is compared to payer edits and the pt’s health plan benefits to verify that:
-required info is available to process claim
-claim is not a duplicate
-payer rules and procedures have been followed
-procedures performed or services provided are covered benefits
-procedure are not elective
-procedures are not experimental
-procedures are essential for treatment
-procedures are furnished at an appropriate level
-physicians office
-hospital clinic, emergency department, hospital same day surgery unit, ambulatory surgical center (pt is released w/in 23 hrs)
-hospital admission for observation
-Employer Identification # (EIN), also known as federal tax identification #, used by IRS
-SS#, typically not used on claim form unless provider does not have (EIN)
-Provider Identification # (PIN), # assigned by ins co to a physician who renders services to pt’s
-Unique Provider Identification # (UPIN), # assigned to the physician by medicare
-performing Provider Identification provider # (PPIN), dr has a separate PPIN for each group office/clinic in which he/she practices. In the medicare program, in addition to a group #, each member of a group is issued a 8-character PPIN
-Group Provider Number, # is used instead of the individual dr’s # for the performing provider who is a member of a group practice that sub,its claims to ins co under the group name