Combo with "scenario’s for CPT coding, ICD-9-CM coding" and 21 others

LOCATION: Outpatient, Hospital
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?
____________________, ___________________, ___________________

stenosis, endocarditis, disease
LOCATION: Outpatient, Hospital
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: __________

424.1 (Stenosis, aortic [valve])
LOCATION: Outpatient, Hospital
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: ____________________, ___________________

Echocardiography, Transesophageal or Transesophageal
LOCATION: Outpatient, Hospital
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: __________

93312-26 (Transesophageal, Doppler Echocardiography)
LOCATION: Outpatient, Hospital
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? __________________

-26
The patient presented to Dr. Elhart with complaints of chest pain and SVT. A 2-D doppler and color-flow doppler was performed at the local hospital in the outpatient department, and Dr. Elhart monitored the echocardiography. You are reporting the service before the test results are known.
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? _____________________

supraventricular tachycardia
The patient presented to Dr. Elhart with complaints of chest pain and SVT. A 2-D doppler and color-flow doppler was performed at the local hospital in the outpatient department, and Dr. Elhart monitored the echocardiography. You are reporting the service before the test results are known.
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: __________

427.89 (Tachycardia, supraventricular)
786.50 (Pain[s], chest)
397.0 (Endocarditis, tricuspid [valve])
424.0 (Insufficiency/insufficient, mitral)
The patient presented to Dr. Elhart with complaints of chest pain and SVT. A 2-D doppler and color-flow doppler was performed at the local hospital in the outpatient department, and Dr. Elhart monitored the echocardiography. You are reporting the service before the test results are known.
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? _____________________

echocardiography
The patient presented to Dr. Elhart with complaints of chest pain and SVT. A 2-D doppler and color-flow doppler was performed at the local hospital in the outpatient department, and Dr. Elhart monitored the echocardiography. You are reporting the service before the test results are known.
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: __________

93306 (Echocardiography, Transthoracic)
The patient presented to Dr. Elhart with complaints of chest pain and SVT. A 2-D doppler and color-flow doppler was performed at the local hospital in the outpatient department, and Dr. Elhart monitored the echocardiography. You are reporting the service before the test results are known.
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? _____________________

-26
RADIOLOGY REPORT
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? __________

Morton Monson, MD
RADIOLOGY REPORT
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: __________

511.9 (pleural effusion)
RADIOLOGY REPORT
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? ____________________

76700-76705
RADIOLOGY REPORT
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? _____________

Ultrasound
RADIOLOGY REPORT
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: __________

76705-26

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: __________

80050

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: __________

255.0

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: __________

80061, 83721

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: __________

428.0

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: __________

80162
OFFICE VISIT
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? ______________________

Office or other outpatient services
OFFICE VISIT
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: __________

250.01 (Diabetes/diabetic [mellitus], type 1, controlled)
455.6 (Hemorrhoids)
414.00 Coronary atherosclerosis, of unspecified type of vessel, native or graft
OFFICE VISIT
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: __________

99213 (Evaluation and Management, Office and Other Outpatient)
LOCATION: Hospital Emergency Department
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__________

837.1 (Dislocation, ankle, open)
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)
LOCATION: Hospital Emergency Department
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? ___________________

Level 2, Expanded problem focused
LOCATION: Hospital Emergency Department
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? _____________

Level 3 Detailed
LOCATION: Hospital Emergency Department
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:___________________

99283 (Evaluation and Management, Emergency Department)
PROGRESS REPORT
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: __________

428.0 (Failure/failed, heart, congestive)
799.02 (Hypoxia)
PROGRESS REPORT
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? ___________________

Evaluation and Management Services
PROGRESS REPORT
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:_________

99232 (Evaluation and Management, Hospital)
RADIOLOGY REPORT
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? __________________________________

Morton Monson, MD
RADIOLOGY REPORT
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 _________

729.81, 786.09, 789.59
RADIOLOGY REPORT
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: __________

93970, 76700
RADIOLOGY REPORT
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?
__________

26
RADIOLOGY REPORT
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?
______________

CMS-1500

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?
_________________________________

George Orbitz, MD

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 __________

Professional Services: 90935 (Hemodialysis)

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?
______________

No, a modifier isn’t needed.
HEMODIALYSIS PROGRESS NOTE
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

CMS-1500
PREOPERATIVE DIAGNOSIS: Lesion of vocal cords.
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.

PREOPERATIVE DIAGNOSIS: Hemoptysis.
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: _____

PROFESSIONAL SERVICES: 31628 (Bronchoscopy),
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.
PREOPERATIVE DIAGNOSIS: Mass of Lung.
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: ______________

ICD-9 DX CODE: 162.3 (Malignant neoplasm of the upper lobe, lung)
The patient is diagnosed with carcinoma of the lung which is coded with 162.3.
PREOPERATIVE DIAGNOSIS: Acute respiratory insufficiency due to ALS.
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): _______
PROFESSIONAL SERVICES: 31600 (Tracheostomy, planned separate procedure)
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.
LOCATION: Outpatient. Hospital
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): _______

Professional Services: 95810-26 (Polysomnography)
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.
LOCATION:Inpatient, Hospital
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: ___

Professional Services: 31500 (Intubation, Endotracheal, Tube) [see rationale for alternate 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.

LOCATION: Inpatient, Hospital
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: __________

ICD-9-CM: 574.10 (Cholelithiasis, with, cholecystitis, chronic)
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.

SURGEON: Gary Sanchez, MD
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: __________

V25.2 (Sterilization/admission for)
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.

LOCATION:Outpatient, Hospital
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: __________

592.1 (Calculus/calculi/calculous, ureter)
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.

LOCATION:Inpatient, Hospital
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: __________

185 (Neoplasm, prostate [gland], Malignant, Primary)
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

LOCATION: Inpatient,Hospital
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: __________

654.21 (Delivery, complicated [by] previous, cesarean delivery, section), V27.0 (Outcome of delivery, single, liveborn)
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.

urticaria
another term for hives
keloid
another term for hyperplastic scar tissue
boil
furnuncle
melanin
is found in the basal layer of the skin
epidermis and dermis
the two layers of the skin
hyodermis
term that relates to the connection of skin to the muscles
LOCATION: Outpatient, Hospital
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?

melanoma
LOCATION: Outpatient, Hospital
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: __________

172.5 (Melanoma, chest wall)
LOCATION: Outpatient, Hospital
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)
____________________

5 cm
This would be 2 cm (lateral margin) + 2 cm (medial margin) + 1 cm lesion = 5 cm total.
LOCATION: Outpatient, Hospital
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)
____________________, ____________________

excision, skin
LOCATION: Outpatient, Hospital
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: __________

11606 (Excision, Lesion, Skin, Malignant)
12032-51 (Repair, Skin, Wound, Intermediate)
LOCATION: Outpatient, Hospital
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? ____________________

ulcer
LOCATION: Outpatient, Hospital
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?____________________

infection
LOCATION: Outpatient, Hospital
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: _________

707.14 (Ulcer/ulcerated/ulcerating/ulceration/ulcerative, ischemic, heel)
041.11 (Infection/infected/infective, staphylococcus aureus)
LOCATION: Outpatient, Hospital
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? ____________________

Debridement
LOCATION: Outpatient, Hospital
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: _____________________

11043, 11046 (Debridement, Skin, Subcutaneous Tissue)
An excision of the left great toe nail and matrix, complete for permanent removal:
CPT Code: ___
11750 TA
Patient sustained second-degree burn of the right thigh that was less than 5% of the total body surface. The skin was completely necrotic. The right thigh was prepared with pHisoHex, and the wound was debrided using a dermatome. Partial thickness, superficial layer of dead skin tissue was removed. Wound was treated with pHisoHex and cleaned, and a sterile outside dressing was applied.
16020, 945.26, 948.00
Mastectomy that is done for gynecomastia:
19300
Removal of 37 skin tags by electrosurgical destruction:
11200, 11201 X 3 units
Destruction of 7 actinic keratoses:
17000, 17003 X 6 units
T/F Free skin grafts are coded according to the site, size and type of repair to the recipient site.
True
Fine needle aspiration of the breast without imaging:
10021
When coding 3 biopsies of the skin, performed at the same visit, the reporting would be:
11100, 11101 X 2
Patient presents for the excision of a scar of the scalp. The lesion was excised, bleeding was electrocoagulated, and the wound was closed with vertical mattress sutures of 3-0 Prolene. Surgical and antibiotic ointment were applied. The patient tolerated the procedure well and left the operating room in good condition.
11423, 709.2
Excision of a pilonidal cyst that was a complicated procedure:
11772
Patient was using a chain saw, which slipped, and the patient sustained a 5.0 cm laceration to the dorsum of the proximal portion of the left index finger, extending through the extensor tendon and capsule. Debridement of tissue was done to facilitate a better repair of this deep laceration. Tendon and capsule were sutured with five 6-0 silk sutures. Bleeders were ligated with plain catgut. Skin was debrided extensively and approximated with seven sutures of 4-0 Dermal.
13132-F1
Patient was prepped and draped and an incision was made along the postauricular sulcus through the drainage point with retraction applied. A 3.0 cm sebaceous cyst was evident, and it was drained. A small bandage was placed over the incision and drainage site.
10060
Incision was made through the skin and fascia over a left breast mass, and lymphatic and blood vessels were clamped. Tumor mass was excised from the wall in its entirety along with normal breast tissue. Drainage tube was placed through a separate stab incision. Layered closure was performed, and a sterile dressing was applied.
19260-LT
The repaired wound should be measured or converted to:
centimeters
T/F E codes are used to clarify the cause of an injury or adverse effect and may be used as a principle or secondary diagnosis.
False
Dermabrasion of the segmental face:
15781
Using the “Rule of Nines,” each adult leg is what percentage of the human body?
18%
T/F A debridement is the cleaning of a surface area and the removal of necrotic tissue by washing or cutting.
True
Bell’s palsy patient underwent harvesting of a graft for residual facial nerve paralysis. Connective tissue fascia was removed from the fascia lata, right leg. Fascia graft was transplanted to the face and sutured into place underneath skin to reanimate paralyzed area of the face.
15840
Patient presents for an excision of a right breast mass. The breast and chest were prepped and draped in a sterile manner. An elliptical incision was made in the central portion of the breast above the palpated mass, including the area of the nipple. This was excised all the way down to the fascia of the breast and then submitted for frozen section which revealed carcinoma of the breast with what appeared to be a good margin all the way around it. We then maintained hemostasis with electrocautery and proceed to close the breast tissue. The skin was closed in a subcuticular manner. Steri-strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition.
19120-RT, 174.1
LOCATION: Outpatient, Hospital
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: __________

1. 354.0 (Syndrome, carpal tunnel)
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.

LOCATION: Outpatient, Hospital
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: __________

1. 805.01 (Fracture, vertebrae/vertebral, cervical, first [atlas]
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.

LOCATlON: Outpatient, hospital
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: __________

1. 715.96 (Osteoarthrosis, lower leg)
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.

LOCATlON: Outpatient, hospital
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: __________

719.41 (Pain[s], joint, shoulder)
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.

LOCATION: Outpatient, Hospital
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: __________

1. 715.31 (Osteoarthrosis, localized, shoulder)
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.

Hidr/o
Sweat
Onych/o
Nail
Trich/o
hair
Burs/o
bursa, sac of fluid near joint
chondr/o
cartilage
erg/o
work
my/o
muscle
myel/o
bone marrow spinal cord
ton/o
tone ; pressure
phren/o
diaphragm
phleb/o
vein
angi/o
vessel
bucc/o
cheek
cholecyst/o
gallbladder
labi/o
lip
stoma, stomat/o
mouth
basal
bottom /base
Os
orifice, opening
ec-, ecto
out or outside
end/o
within
mes/o
middle
dextr/o
right
sinister/o
left
Ab
away from
Ad
toward near
dia
through, complete
per
through
-gram
record of data
-graph
instrument for recording data
scope
instrument for viewing or examining
scopy
examination
-desis
binding or fusion
-ectomy
excision , surgical removal
-pexy
surgical fixation
-traphy
surgical repair
-stomy
surgical creation of an opening
-tomy
incision cutting
-tripsy
crushing
blepharoplasty
performed on the eye
salpingo-oophorectomy
surgical removal of an ovary and tube
tracheostomy
creation of a hole in the trachea
leukocytosis
increase in white blood cells
proximal
nearer to the point of attachment
distal
farther from the point of attachment
superior/ cranial
above ; toward the head
inferior/caudal
below/toward the lower end of the spine
superficial/external
closer to the surface of the body
deep/internal
closer to the center of the body
sagittal
cuts through the midline of the body
transverse(horizontal)
cuts horizontally through the body and separates the body into upper and lower sections
epithelial tissue
where squamus cell and basal cell carcinoma are found which is in the skin
mucous membrane
found in the digestive system
stratum lucidum
epidermis found on palms of hands and soles of feet
long bones
named for elongated shape not size
tubular bones
also referred to as long bones
synovial
most common joint in the body
root meaning of joint
arthro
example of a long bone
metacarpal
RADIOLOGY REPORT
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? __________

Morton Monson, MD
RADIOLOGY REPORT
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?

511.9 (pleural effusion)
RADIOLOGY REPORT
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? ____________________

76700-76705
RADIOLOGY REPORT
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? _____________

Ultrasound
RADIOLOGY REPORT
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?

76705-26

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:

80050

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.

255.0
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: __________

80061, 83721

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: __________

428.0

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: __________

80162
T/F The postmortem codes 88000-88099 represent physician services only.
True
Walter Praxis, a 15-day-old male, was born at 33 weeks’ gestation, and there is concern that he may have hyperbilirubinemia. Therefore, Dr. Stevenson performed a total transcutaneous bilirubin. What are the correct CPT-4 code(s) for these services?
88720
Jane Smith, newly diagnosed with metastatic lumbar spinal tumors, has been referred to Dr. Duncan for the creation of a simple radiation therapy plan. What are the correct CPT-4 code(s) for these services?
77261
What is the name given to grouped laboratory work that represents those tests commonly performed together?
panels
Carl Gadsden, a 13-month-old male, was brought to radiology for a real-time, limited, static ultrasound of his hips. What are the correct CPT-4 code(s) for these services?
76886
Pathologic analysis of sample taken from Patient’s right kidney during a biopsy. What are the correct CPT-4 code(s) for these services?
88305
T/F
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.
True
A patient was admitted to the hospital for removal of a pericardial clot. The physician orders a real time chest ultrasound. Chest magnetic resonance (proton) imaging is also ordered (without contrast.) A pericardiotomy is performed for removal of clot. What are the correct CPT-4 code(s) for these services?
76604, 71550, 33020
T/F Pathologists have specific codes for clinical pathology consultations.
True
According to the CPT Index, in what section would you locate codes to report venipunctures and arterial punctures?
Surgery
T/F There are four subheadings in the radiology section.
False
T/F According to the CPT manual there are different codes for Helicobacter pylori (H. pylori) depending on the source of the specimen.
True
T/F According to the Chemistry Guidelines in the CPC manual: When coding chemistry tests, an analyte is measured in multiple specimens from different sources, or in specimens that are obtained at different times, the analyte is reported separately for each source and for each specimen.
True
Mr. Pollack, a 51-year-old male, was diagnosed with intrinsic laryngeal cancer, supraglottic T1 tumor. With the tumor confined to one subsite in the supraglottis, Dr. Westerman provided radiation treatment delivery, with a single port, simple block, of 4.5 MeV. What are the correct CPT-4 code(s) for these services?
77402
Olivia Kane, a 61-year-old female, was experiencing pain in her back that radiated around her trunk. She was also suffering with spastic muscle weakness. Dr. Neumours ordered a radioisotope bone scan of Olivia’s lumbar spinal area. The scan identified a metastatic invasion of L1-L3. What are the correct CPT-4 code(s) for these services?
78300
Max Wellington, a 15-year-old male, is brought into Dr. Eller’s office with severe right leg pain. Dr. Eller takes x-rays of his right femur, AP and PA, to determine whether or not Max’s leg is fractured. What are the correct CPT-4 code(s) for these services?
73550
What is the modifier used to identify the technical component of a radiologic procedure?
-TC
T/F The phrase “with contrast” represents contrast material administered intravascularly, intra-articularly, or intrathecally.
True
T/F For repeat laboratory tests performed on the same day, the correct modifier is -51.
False
T/ F When a pathologist provides a comprehensive consulation for a complex diagnostic problem with review of the patient’s history and medical records, the service is reported with CPT code 80500.
False
According to the guidelines for Radiation oncology, these codes include normal follow-up care during the course of treatment and ________ following its completion.
includes 3 month global period
RADIOLOGY REPORT
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? __________________________________

Morton Monson, MD
RADIOLOGY REPORT
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 _________

729.81, 786.09, 789.59
RADIOLOGY REPORT
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: __________

93970, 76700
RADIOLOGY REPORT
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?

26
RADIOLOGY REPORT
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?

CMS-1500

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?

George Orbitz, MD

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 __________.

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 __________

Professional Services: 90935 (Hemodialysis)

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?

No, a modifier isn’t needed.

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? ________________

CMS-1500
OFFICE VISIT
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?

______________________

Office or other outpatient services
OFFICE VISIT
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:

250.01 (Diabetes/diabetic [mellitus], type 1, controlled)
455.6 (Hemorrhoids)
414.00 Coronary atherosclerosis, of unspecified type of vessel, native or graft
OFFICE VISIT
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
99213 (Evaluation and Management, Office and Other Outpatient)
LOCATION: Hospital Emergency Department
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:

837.1 (Dislocation, ankle, open)
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
LOCATION: Hospital Emergency Department
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? _______________

Level 2, Expanded problem focused
LOCATION: Hospital Emergency Department
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? ___

Level 3 Detailed
LOCATION: Hospital Emergency Department
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:___________________

99283 (Evaluation and Management, Emergency Department)
PROGRESS REPORT
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: __________

428.0 (Failure/failed, heart, congestive)
799.02 (Hypoxia)
PROGRESS REPORT
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? ______

Evaluation and Management Services
ROGRESS REPORT
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:_________

99232 (Evaluation and Management, Hospital)
-opia
Vision
-omia
Smell
-tropia
To turn
-algesia
Pain sensation
-algia
Pain
-cele
Hernia
-esthesia
Feeling
-iatry
Medical treatment
-ictal
Pertaining to
-kines/o
Movement
-paresis
Incomplete paralysis
-plegia
Paralysis
-agon
Assemble
-drome
Run, relationship to conducting, to speed
-emia
Blood condition
-in
A substance
-ine
A substance
-tropin
Act upon
-uria
Urine
-ectomy
Removal
-edema
Swelling
-itis
Inflammation
-megaly
Enlargement
-oid
Resembling
-oma
Tumor
-penia
Deficient
-pexy
Fixation
-phylaxis
Protection
-poiesis
Production
-ase
Enzyme
-chezia
Defecation
-iasis
Abmormal condition
-phagia
Eating
-prandial
Meal
-eal
Pertaining to
-lithiasis
Condition of stones
-lysis
Separation
-plasty
Repair
-rrhaphy
Suture
-tripsy
Crush
-one
Hormone
-stomy
New opening
-arche
Beginning
-cyesis
Pregnancy
-gravida
Pregnancy
-rrhexis
Rupture
-parous
To bear
-para
Woman who gave birth
-rrhea
Discharge
-salphinx
Uterine tube
-tocia
Labor
-version
Turning
-dilation
Widening, Expanding
-emia
Blood
-graphy
Recording process
-osis
Condition
-sclerosis
Hardening
-stenosis
Blockage, Narrowing
-tomy
Cutting, incision
-ar
Pertaining to
-ary
Pertaining to
-capnia
Carbon dioxide
-centesis
Puncture to remove (Drain)
-dynia
Pain
-ectasis
Strecthing
-gram
Record
-graph
Recording instrument
-meter
Measurement or instrument that measures
-metry
Measurement of
-osmia
Smell
-oxia
Oxygen
-phonia
Sound
-pnea
Breathing
-ptysis
Spitting
-rrhage
Abnormal, excessive flow
-rrhagia
Abnormal, excessive flow
-scopy
To examine
-spasm
Contraction of muscle
-sphyxia
Pulse
-thorax
Chest
-asthenia
Weakness
-blast
Embryonic
-clast
Break
-clasia
Break
-clasis
Break
-desis
Bind together
-listhesia
Slipping
-malacia
Softening
-physis
To grow
-porosis
Passage, cavity formation
-schisis
Spilt
-tome
Instrument that cuts
-coccus
Spherical bacterium
-ia
Condition
-opsy
Veiw of
Abstractor
hospital employee who converts documented procedurs and diangoses into medical codes
Abuse
coding practices that lead to improper reimbursement by error because they do not meet medical necessity, ex. changing diagnosis to be covered by insurance
Accreditation
an examination process the healthcare facility goes through to evaluate the facilities policies, procedures, and performance to meet higher standards.
Accredited
Having seal of approval after being evaluated and demonstrating quality standards
Act/ Law/ Statute
Legislation passed through Congress and signed by President or passed over his veto
Actual Charge
The amount the provider charges for medical services or supplies. Not always paid in full.
Additional Benefits
Health care services not covered by Medicare and are offered through the Medicare Advantage Organization for no additional premium. The benefits must equal the ACR (Adjusted Community Rating)
Adjudication
Health Insurance Claims process at the insurance company
Adjusted Average Per Capita Cost (AAPCC)
Estimate of how much Medicare will spend in a year for an average beneficiary
Administrative Code Sets
Non medical code sets that characterize a general business situation rather than a medical condition.
Administrative Costs
Medicare, Medicaid, CMS refer to this as their expenses to have the program, operating expenses, program management, etc.
Administrative Data
Health insurance information stored in automated information system about enrollment, eligibility, claims, etc.
Administrative Law Judge (ALJ)
hearing officer who presides over appeal conflicts between providers or beneficiaries, and Medicare contractors (MAC’s)
Administrative Simplification
Part of HIPAA authorizing HHS (Health and Human Services) to 1. adopt standards for transactions & code sets; 2. adopt standard identifiers for health plans; 3. adopt standards to protect security & privacy of personally identifiable health information.
Administrative Simplification Act
Signed 12/17/01 allows HHS (Health & Human Services) to exclude providers from Medicare for HIPAA non-compliance of electronic claims and prohibit paper claims except in certain situations
Admission Date
The date the patient was admitted for inpatient care, outpatient, or start of care.For hospice, enter effective date of election of hospice benefits.
Admitting Diagnosis
Diagnosis code indicating patient’s diagnosis at admission
Admitting Physician
The doctor responsible for admitting a patient to the hospital or other inpatient health facility
Advance Beneficiary Notification (ABN)
A notice from provider to patient that Medicare may deny payment. Patient must sign before services are provider, otherwise patient is not responsible if Medicare does not cover.
Advanced Directive
Statement written by patient on how they want medical decisions to be made. May include a Living Will or Durable Power of Attorney for healthcare.
Allowed Charge
Individual charge determination by carrier for a covered service or supply.
Ambulatory Care
All types of health services that do not require an overnight stay.
Ambulatory Care Sensitive Conditions (ACSC)
Medical condtions that if treated immediatly and managed properly should not require hospitalization.
Ambulatory Payment Classification (APC)
Medicare’s outpatient prospective payment system in which services are grouped based on the resources needed and payment is fixed within each group
Ambulatory Surgery Center (ASC)
Outpatient surgery center not located in the hospital. Patient’s may stay a few hours up to 1 night.
American Hospital Association (AHA)
Represents concerns of instituitional providers. They host the National Uniform Billing Committee (NUBC) which consults under HIPAA
American Medical Association (AMA)
Professional organization maintains CPT code sets, secretariat to National Uniform Claim Committee (NUCC) which consults under HIPAA. ASC payment group rate.
ASHIM
American Society of Health Informatics Managers, Inc. is a non-profit group of computer professionals that specialize in health information technology (HIT). They are certified through Certified Health Informatics System Professionals (CHISP)
Ancillary Services
Professional services by a hospital or inpatient facility. Xrays, drugs, labs, etc.
Appeal
Complaint by hospital or patient about a health care payment
Approved Amount
The fee Medicare sets as reasonable and pays to the provider.
Assigned Claim
Claim submittted by a provider who accepts Medicare
Assignment
Agreeing to acccept Medicare fees as payment in full
Attending Physician
Licensed physician who certifies the patient services via medical necessity and is primarily responsible for the patient’s medical care and treatment.
Automated Claim Review
Claim review and etermination via system edits and don’t require human intervention
Basic Benefit
Includes Medicare covered benefits (except hospice) and additional benefits
Beneficiary
The name of a person who has health care insurance through the insurance program
Benefit Payment
Amount paid by insurance after the deductible and coinsurance have been deducted
Benefit Period
Episode of care within hospitals & skilled nursing facilities (SNF). Begins on admission and ends 60 days after care has ended
Benefits
The money or services provided through an insurance policy
Board Certified
Doctor specializing in certain area of medicine and who passes an advanced exam. Primary care and specialists can both be board certified
Business Associate
Someone performs a function on behalf of a covered entity but is not part of the covered entity’s workforce, outside business manager.
Capitation
Specified amount of money is paid to a health plan or doctor regardless of the services rendered in that period. One lump sum.
Care Plan
Written plan of services patient will receive to ensure the patient’s best care physically, mentally & socially
Caregiver
Someone who cares for a patient who is ill, disabled, or aged. Can be relatives, friends or someone who is paid.
Case Management
Physician, nurse, or other person tracks use of facilities and resources of a patient to be sure they are receiving the care they need.
Case Mix
Distribution of patients into categories reflecting severity of illness or resource uses.
Case Mix Index
The average Diagnostic Related Groups (DRG) relative weight for all Medicare admissions
Catastrophic Illness
Serious and costly health problem that could be life-threatening or cause disability. Costs can cause patient financial hardship.
Catastrophic Limit
The highest amount a beneficiary is required to pay out of pocket during a certain period of time for certain covered charges.
Center for Disease Control and Prevention (CDC)
Organization that protects public health through monitoring disease trends, investigation outbreaks, implementing illness, and injury control.
Center for Medicare & Medicaid Services (CMS)
The Heath & Human Services (HHS) agency responsible for Medicare & parts of Medicaid. Maintains UB-04, oversight of HIPAA and maintains HCPCS code set & Medicare remittance advice (RA) remark codes. They promote higher quality care
Certification
the hospital passed a survey done by a state government agency. Medicare only covers hospital stays in hospitals that are certified or accredited.
Civilian Health and Medical Program (CHAMPUS)
Run by department of defense. Used to give medical care to active duty but now this is called TRICARE
Charge Description Master (CDM)
Electronic billing table where charge amounts are kept in a centralized place.
Claim
Request for payment for services or benefits received. Claims are called bills through Medicare Part A
Claim Adjustment Reason Codes
Identifies the reason for any difference in charge and payment. This code set is used in the X12 835 Claim Payment & Remittance Advice and the X12 837 Claim transactions and is maintained by Health Care Code Maintenance Committee
Claim Status Code
Identifies the status of a claim. This code set is used in the X12N 277 Claim Status Inquiry and Response transactions and is mainted by the Health Care Code Maintenance Committee
CMS Agent
State survey agency who participates in Medicare surveys and certification process. ex. private physician consulting with the State Agency (SA) or CMS regional office.
UB-04
Claim form used by hospitals and facilities for billing procedures and services.
CMS1500
Claim form used for billing physiicans and other services, ex physical therapy.
Code of Federal Regulations
Official compiliation of federal rules and requirements
Code Set
Set of codes used to encode data elements terms, codes, concepts, required under HIPAA
Coinsurance
Percentage of medical bill the beneficiary is responsible for paying.
Community Mental Health Services
Facility provides outpatient services for children, elderly, chronically ill, & residents discharged from inpatient treatment at a mental health facility. 24 hour day emergency care, partial hospitalization or psychosocial rehab, & screening for admission to inpatient facility.
Comprehensive Inpatient Rehabilitation Facility
Inpatient rehabilitation to patient’s with physical disabilities.
Comprehensive Outpatient Rehabilitation Facility (CORF)
Outpatient rehabilitation
Conditional Payment
A payment made by Medicare in which another payer is responsible. Ex,, Auto is in litigation, if they pay, then Medicare will be reimbursed
Consolidated Omnibus Budget Recondiliation Act (COBRA)
A law that helps keep people covered by employer groups after coverage ended due to death of a spouse, losing a job, reduced hours, leaving voluntarily, or getting a divorce. The beneficiary may have to pay the premium however there is no administrative fee.
Coordination of Benefits
The process of determining which policy is first when a patient has 2 health care plans.
Coordination Period
A period of time where the employer group health will pay first on the bill and Medicare will pay 2nd.
Cost Rate
Ratio of cost of the program on an incurrerd basis during a year to the taxable payroll for the year.
Cost Report
Report required from providers on an annual basis in order to make proper determination of amounts payable under Medicare program.
Cost Sharing
The cost of medical care the patient must pay, coinsurance, deductible, etc.
Covered Benefit
A health service or item that is included in the health plan and paid for partially or in full.
Covered Charges
Services or benefits for which a health plan makes either partial or full payment.
Covered Entity
Under HIPAA, this is a health plan, clearninghouse, or provider who transmits any health information in electronic format in connection with HIPAA transaction.
Covered Services
Services for which a carrier pays as defined and limited by coverage or statute. physician care, outpatient hospitals, diagnostic tests, DME, ambulance, and other health services.
Critical Access Hospital
Small facility that gives limited outpatient and inpatient hospital services in rural areas
Current Dental Terminology (CDT)
Medical code set of dental procedures maintained and copyrighted by American Dental Association (ADA) and adopted by the secretary of Health and Human Services (HHS) as a standard for reporting dental services and transactions
Current Procedural Terminology (CPT)
Medical code set of physician and other services, maintained and copyrighted by American Medical Association (AMA) and adopted as a standard for reporting physician and other services.
Custodial Care
Non-skilled personal care attendance (PCA) to help with Activities of Daily Living (ADL) like eating, bathing, etc.
Custodial Care Facility
Provides room and board, and other personal assistance on a long term basis but does not include medical care.
Date of Service
The actual date a particular service was performed
Deductible
An annual amount or out of pocket expense the subscriber must pay either individually or per family.
Deductible (Medicare)
The amount a beneficiary must pay for health care before Medicare begins to pay, either Part A or Part B. These amounts vary every year.
Demographic Data
Describes the characteristics of the enrollee populations within a managed care entity, age, sex, race, etc
Demonstrations
Projects and contracts that CMS has signed with various health care organizations. Used to evaluate the effects and impact of various health care initiatives and the cost of implications to the public.
Department of Health and Human Services (DHHS)
Administers many of the social programs at the federal level dealing with the health and welfare of citizens of the United States. (Parent of CMS)
Descriptor
The text defining a code in a code set
Designated Code Set
Medical code set or administrative code set required to be used by the adopted implementation specification for standard transaction
Diagnosis
Disease, signs, or symptoms that indicate the patient’s condition and support medical necessity for services provided.
Diagnosis Code
Code within the ICD-9 that explains the reason for the medical encounter and for underlying conditions that contribute to the patient’s care and effect treatment receive or length of stay.
Diagnosis Related Groups (DRG’s)
Classification system that groups patients according to diagnosis, type of treatment, age and other relevant criteria. Under the prospective payment system (PPS), hospitals are paid a set fee for treating patient’s in a DRG category.
Disability
Inability to engage in activity for medical reasons expected to last more than 12 months
Discharge Planning
Process of deciding what a patient needs to move smoothly from one level of care to another, ex. hospital to nursing home.
Disproportionate Share Hospital
Large share of low income patients. States subside under Medicaid and Medicare inpatient payments are higher.
Downcode
Reduce the value and code of a claim when documentation does not support the level of service billed by provider.
DRG Coding
The MS-DRG categories used by hospitals on discharge billing.
Dual Eligibility
Persons covered under Medicare and Medicaid
Durable Medical Equipment (DME)
Medical Equipment ordered by a doctor for use in the home. Must be reusable, ex. walker, wheelchair.
Durable Medical Equipment Regional Carrier (DMERC)
A private company that contracts with Medicare to pay bills for durable medical equipment (DME)
Electronic Data Interchange (EDI)
Exchange of transactions from one computer to another in a standard format
EDI Translator
A software tool for accepting an EDI transmission and converting data into another format
Edit
Logic within Standard Claims Processing System that selects claim data and determines the payment
Emergency Care
When patient’s health is in serious danger and every second counts
Emergency Room (Hospital)
Part of hospital where emergency diagnosis and treatment of illness is provided 24 hours a day
Emergency Medical Treatment and Active Labor Act (EMTALA)
Requires Medicare participating hospitals provide appropriate screening examination to any patient that requests such an exam. The patient must be stabilized before transferring care.
Encounter Data
Detailed data about the patients services provided by a managed care entity. Similiar to that of a claim form. Sometimes called “shadow claims”
Enrollment Period
Certain period of time when a subscriber can join a health plan.
Episode of Care
Health care services given during a certain period of time, usually during a hospital stay.
Explanation of Benefits EOB(Remittance Advise (RA)- Medicare)
Explanation from insurance with details of payment, denials, etc.
Exclusions
Not covered by insurance carrier, ex. prescriptions, eye care
Facility Charge
Insurance companies pay less and charge a cost for the facility where services where rendered.
Federal Register
Daily publication for rules of federal agencies and organizations as well as executive orders and other presidential documents.
Fee Schedule
A complete listing of fees used by the health plan to pay
Fiscal Intermediary
A private company that contracts with Medicare to pay Part A and some Part B claims. (Also called Intermediary)
Fixed Capital Assets
The net worth of facilities and other resources
Formulary Drugs
Listing of prescription medications that are approved for use and/or covered by plans
Fraud and Abuse
Fraud is to purposely bill services not given or for higher reimbursement than give. Abuse is payment for services billed by mistake but should not have been paid for.
Freedom of Information Act (FOIA)
Law requiring US government to give information to the public when it receives a written request, only records of executive branch. NOT congress, federal courts, state or local governments or private groups.
Fully Accredited
Designation that all standards have been met and approved by Center for Medicare and Medicaid Services (CMS) without any other actions.
Group Health Plan
Health plan providing coverage to employees & families and supported by employer.
Guidelines
Developed by appropriate groups to assist providers with decisions in specific clinical situations.
Health Care Clearinghouse
Public or private entity that processes data from nonstandard to standard and/or receives standard transactions from another entity to convert
Health Care Code Maintenance Committee
Administered by Blue Cross Blue Shield Association (BCBSA) maintains coding schemes used in X12 transactions and elsewhere. They include claim adjustment reason codes, claims status category codes and claim status codes.
Health Care Prepayment Plan (HCPPP)
Managed care organization that pays for all in network services after a monthly premium, deductible and copayment. Out of network services are payable by the patient.
Health Care Provider
Person trained and licensed to give health care and has a licensed place to treat patients. Doctors, nurses, or hospitals are examples.
Health Care Quality Improvement Program (HCQIP)
Supports mission of CMS to assure health security for beneficiaries and improving quality of care.
Health Employer Data and Information Set (HEDIS)
Set of standard performance measures that give you information about the quality of a health plan. Center for Medicare and Medicaid Services (CMS) collects HEDIS data for Medicare patients.
Health Insurance Association of America (HIAA)
Represents the interest of commercial health care insurers. Participates in HCPCS Level II code data sets.
Health Insurance Claim Number (HICN)
Number assigned to insurance carrier/ beneficiary identifying them as the insurance subscriber.
Health Plan
Entity that assumes the risk of paying for medical treatment.
Health Common Procedural Coding System (HCPCS)
Medical code set that identifies health care procedures, equipment and supplies for claim submission purposes. Level I is Current Procedural Terminology (CPT) maintained by the AMA. Level II is alpha numeric identifying items not found in CPT and maintained by Center for Medicare and Medicaid Services (CMS) and Blue Cross Blue Shield Association (BCBSA) and the Health Insurance Association of American (HIAA)
Precedence
Instructions and Guidelines of the classification take precedence over guidelines.
Section I
general coding guidelines and chapter specific guidelines
Section II
selection of principal diagnosis for non outpatient settings
Section III
Additional diagnoses in non-outpatient settings
Section IV
Outpatient coding and reporting
E&M
physicians’ work
New Patient
one who has not received any medical services by same physician or physician of the same specialty in the practice within the last 3 yrs.
Established Patient
someone who has received medical services with in the last 3 yrs from the physician or another physician of the same specialty who belongs to the same group practice
Chief Complaint
a brief statement describing the symptom, problem, diagnosis, or condition that is the reason a patient seeks medical care
Volume 1
aka Tabular, contains the disease and condition codes and the descriptions with the V codes and E codes
Volume 2
this is the alphabetic index of volume 1
Volume 3
NOT USED ON CPC EXAM contains codes for surgical, therapeutic, and diagnostic procedures; used primarily by hospitals
Volume 1 & Volume 2
used in the inpatient and outpatient settings by physicians
V codes
used to identify health care encounters that occur for other reasons other than illness or injury or to identify patients whose illness is influenced by special circumstances or problems
E codes
used to describe the reason or external cause of injury, poisoning and other adverse effects.
ICD updates
Yearly usually in October
Tabular List
aka Volume I Consists of 17 chapters based on either body system or cause or type of disease. The codes range from 001-999.
Alphabetic Index
aka Volume II, look here first for codes
Chapters
are the main division in the ICD-9-CM
Sections
are composed of a group of three-digit codes representing a group of conditions or related conditions
Categories
Composed of three-digit codes representing a single disease or condition. The three-digit code is used only if it is not further subdivided.
Subcategories
Provide a 4th digit which is more specific then a category code in terms of cause, site, or manifestation of the condition. This must be used if available.
Subclassification
Provides a 5th digit which gives the highest specificity of description to a condition. Use of it is mandatory if it is available. A code not reported to the full number of digits required is invalid
nonessential modifiers
Terms in parenthesis who’s presence/absences has no effect on the code.
essential modifiers
are not enclosed in parentheses and are SUB TERMS that DO affect the selection of appropriate code
Malignant hypertension
severe form of hypertension w/vascular damage and a diastolic pressure of 130 mmHg or greater
Benign Hypertension
Mild or controlled hypertension and no damage to the vascular system or organs
Unspecified Hypertension
this is not specified as benign or malignant in the diagnosis or medical record
Malignant Neoplasm
further classified as to primary, secondary, or carcinoma in situ
Primary malignancy
the original cancer site. malignant tumors are considered primary unless documented as secondary or metastatic
Secondary malignancy
cancer that has metastasized(spread) to a secondary site either adjacent or remote region of the body
Carcinoma in situ
IN CELL – cancer that is localized and has not spread to adjacent tissues or distant parts of the body
Benign Neoplasm
noninvasive, non-spreading, nonmalignant
Uncertain behavior
uncertain whether benign or malignant; borderline malignancy
Unspecified Nature
a neoplasm is identified; however, no nature of the tumor is documented in the diagnosis or medical record
Table of Drugs and Chemicals
contains a list of drugs and chemicals with the corresponding poisoning codes and E codes; part of Volume I
NEC
not elsewhere classified; represents other specified; when code is not available for a condition the tabular includes an NEC entry
NOS
not otherwise specified; equivalent of unspecified
Other codes
usually with a 4th digit 8 or fifth digit 9; use when the medical record provides detail for which a specific code does NOT exist; NEC index entries; means “other”
unspecified
usually with 4th digit 9 or 5th digit 0; when info does not give enough information to assign specific code, NOS; means “not specified”
AND
means AND or OR in a title
WITH
means associated with or due to
SEE
another term should be referenced; go to the main term referenced with the “see” not to locate the correct code
SEE ALSO
another main term that may also be referenced that may provide additional index entries that may be useful; not necessary if original main term provides the necessary code; might indicate a different way to look it up
Guidelines
Guidelines are a set of rules developed to accompany and complement official conventions and instructions provided within the ICD9CM.
when can you code 388.xx first
See I.C.6
How do you code hypertension with heart disease?
Code 402.xx followed by the type of heart failure is mentioned; See I.C.7.a.2 for the answer.
How do you code hypertension with ESRD.
First code is 403.xx followed by the ESRD
How do you code poisonings?
Poisonings – see guidelines I.C.17.e.2
trephination
drilling a hole in the skull to expose the dura mater
tentorium cerebelli
an extension of the dura mater, separates the cerebrum from the cerebellum
F wave
voltage change after electrical stimulation above the distal region of a nerve; used to measure NCV
H reflex
hoffman reflex; reaction of muscles after electrical stimulation sensory fibers; used to dx proximal disease
slanted brackets
in the alpha listing indicate mandatory additional codes and the order in which to list them
Adren/o ; Adrenal/o
Adrenal gland; epinephrine
Adrenocortic
Adrenal cortex
Endocrin/o
Endocrine glands or system
Hypophys/o
Pituitary gland ; Hypophysis
Insul/o
Pancreatic Islets
Parathyr/o ; Parathyroid/o
Parathyriod gland
Pituitar/o
Pituitary gland; Hypophysis
Thyr/o ; Thyroid/o
Thyroid gland
Cerebr/o
Cerebrum
Cortic
Cerebral Cortex; outer portion
Encephal/o
Brain
Gangli/o ; Ganglion
Ganglion
Gil
Neuroglia cells
Medull/o
Medulla Oblongata medulla(inner section) ; Middle , Soft, Marrow
Mening/o ; Menige/o
Meninges
Myel/o
Spinal Cord; Bone Marrow
Narc/o
Stupor, Numbness, Sleep
Neur/o ; Neur/i
Nervous system, Nervous tissue ; Nerve
Psych/o
Mind
Radicul/o
Spinal nerve root
Somn/o ; Somn/i
Sleep
Colp/o
Vagina
Episi
Vulva
Gyn/o ; Gynec/o
Woman
Hyster/o
Uterus
Mast/o
Breast ; Mammary gland
Men/o ; Mens
Menstruation
Metr/o : Metr/i
Uterus
O/o
Ovum ; egg cell
Oophor/o
Ovary
Ov/o ; Ovul/o
Ovum: egg cells
Salping/o
Oviduct ; Tube
insurance claim form
a form that is completed by providers for the purpose of submitting charges for medical services and supplies to various third-party payers.
Claim forms contain
fields for recording data about the provider, insured, date of service, and charges
provider
an individual or entity that provides medical services/supplies to patients ex: physician, physician assistant, nurse practitioner, clinic, laboratory, radiology, hospital and ambulatory surgery center
reimbursement
the payment received from a third-party payer for services rendered by the provider to a patient which is determined based on the information reported on the claim form.
manual claim submission
paper claim that is typed or computer generated on paper and sent by mail. Advantages: ability to review the claim before submission
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.
electronic media claim (EMC)
claim that is transmitted through electronic data interchange
electric data interchange (EDI)
process of sending data from one computer to another by telephone line or cable
optical character recognition (OCR)
The ability of a scanning device to recognize handwritten or typed characters and convert them to electronic form as text, not images.
optical scanning
process where the claim form is scanned and the data is transferred into a computer system. Claim forms are outlined in red, which allows the scanner to pick up only data in the fields.
non compliance
most payers require electronic submission of claims. Providers who are not equipped to submit electronic claims will not be in compliance with these payer guidelines.
The purpose of claim forms is to submit charges for medical services and supplies to various third-party payers for reimbursement.
True
Third-party reimbursement for medical services and/or supplies is determined based on the information reported on the claim.
True
A computer template defines all the information required on the claim for the payer, and specific payer edits can also be programmed.
TRUE
Manual submission of claims results in reduced processing time. Reimbursement for manual claims may be generally received within 7 to 14 days.
False
The CMS-1450 (UB-04) is used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.
False
Claim forms can be submitted to third-party payers _______ on paper or by _______.
MANUALLY, ELECTRONIC TRANSMISSION
Two claim forms that are used for submission of claims to payers are the _________and the _____________.
CMS-1500, CMS-1450 (UB-04)
The electronic claims process can be accomplished by ______ transmission or transmission through a ____________.
direct, clearinghouse.
A ________ is an organization that reformats claim data received from various providers to meet compatibility specifications for various payers.
clearinghouse
The standard transaction format for the CMS-1500 is the ______ and the format for the CMS-1450 (UB-04) is the ______.
ANSI X12 837, ANSI X12 8371
Claim form used by institutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement.
CMS-1450
The process of sending data from one computer to another by telephone line or cable.
(EDI) electronic data interchange
A group of claims that is prepared and transmitted together.
BATCH
A claim that is transmitted through electronic data interchange (EDI).
ELECTRONIC MEDIA CLAIM
Claim for used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.
CMS-1500
An individual or entity, such as a doctor or hospital, that provides medical services and/or supplies to patients.
Provider
A process whereby the claim form is scanned and data on the claim are transferred into a computer system.
OPTICAL SCANNING
Provisions outlined under this legislation require the electronic transmission of most health care transactions.
HIPAA
An organization that reformats claim data received from providers to meet compatibility specifications for submission to various payers.
clearinghouse
A claim that is typed or computer generated on paper and sent by mail.
PAPER CLAIM
The CMS-1500 and the CMS-1450 (UB-04) are the claim forms used to submit charges to payers for reimbursement.
True
The CMS-1500 consists of 33 blocks and the CMS-1450 consists of 33 fields referred to as form locators (FL).
False
The federal tax identification number (TIN) is a number assigned to the facility by the internal revenue service for tax reporting services. TIN is also referred to as the employer identification number (EIN)
True
The HIAA and the AMA developed the CMS-1450.
FALSE
The SUBC are responsible for the oversight of state-specific CMS-1450 billing requirements.
TRUE
The term ______ ________ refers to the period of time calculated from the date of service that claims have to be filed within, such as 90 days.
TIMELY FILING
The _____ _______ ______ is a unique number assigned by the hospital to identify the patient account for the claim.
patient control number (PCN)
The term _______ ________ refers to the insurance company that is responsible to pay the claim, after the primary and secondary payers have issued a payment determination.
tertiary payer
The ________ _______ _________ is a number assigned to a patient’s medical record by the facility (hospital).
MEDICAL RECORD NUMBER
The ________ _______ __________ ________ was formed by american hospital association in 1975 to develope a single billing form and a standard data set that could be used nationally by institutional providers. Today, this organization maintains the integrity of the CMS-1450 data set.
NATIONAL UNIFORM BILLING COMMITTEE
Information regarding the patient’s condition is recorded in what fields on the cms-1500.
BLOCK 14-23
The fields on the CMS-1450 that are used to report two-digit alphanumeric value codes and the dollar amount associated with the code.
FL 39-41 (A-D)
What field on the CMS-1500 is used to record charge information including the date of service, type of service, place of service, procedure code, days or units, and charges?
BLOCK 24A-24J
The fields on the CMS-1450 used to record information regarding the facility, when the patient was admitted and discharged, and the patient’s name and address.
FL 1-41
The fields on the CMS-1500 that are used to record information about the provider who rendered the services including the provider’s name, address identification number, and tax indentification.
block 25-33
The four-digit type of bill number is recorded in this field on the CMS-1450 to provide information about the facility bill type.
FL 4
The two-digit number that represents the admission and discharge hour is recorded in these fields on the CMS-1450.
FL 13 AND 16
Information about the patient such as name, address, zip code, phone, sex, and employer is recorded in these fields on the CMS-1500.
BLOCK 1 -13
The fields on the CMS-1450 used to record the patient control number and the medical or health record number.
FL 3A AND 3B
This field on the CMS-1450 is used to report the name and address of the individual who is responsible for paying the claim.
FL 38 (1-5)
The acronym HCPCS in FL 44 stands for Health Care Procedure Coding System.
false
The “x” in a revenue code such as 025x indicates that the last digit is variable and it is used to further specify the service category.
true
The difference between principle diagnosis and other diagnosis is that the principle diagnosis is the condition determined after study. Other diagnoses are conditions that existed at the time of admission or occurred during the patient’s stay that were treated or those that affected treatment.
true
A revenue code and the standard abbreviated description are recorded in FL 50.
false
The external cause of injury codes are used to describe the procedure performed.
FALSE
______ ________ are four numeric digits and they were developed by the NUBC to categorize like services and items.
REVENUE CODE
Item 12 of UHDDS defines a ________ ________ as one that is surgical in nature, or carries a procedural risk, or carries a anesthetic risk, or requires special training.
SIGNIFICANT PROCEDURE
The ______ ______ is the provider who is responsible for the patient’s care during the inpatient hospital stay.
ATTENDING PHYSICIAN
Written authorization from a patient for the payer to forward benefits to the provider is called an ________ _______ _________.
assignment of benefits
The standard unique health identifier for health care providers, for use in filing and processing health care claims and other transactions, is called _________ ________ ________.
NATIONAL PROVIDER IDENTIFIER
Fields used to record charge information including revenue code, standard description, HCPCS, unit, charge, and non-covered charge.
FL 42-49
Field used to record HCPCS level l CPT and HCPCS level ll medicare national procedure codes.
FL 44
Group name and number for each payer are recorded in
FL 61-62 (A-C)
Admitting diagnosis is recorded in
FL 69
fields used to record ICD-9-CM Volume lll or ICD-10-PCS procedure codes that represents the principal procedure and other significant performed during the stay?
FL 74 (A-E)
Field used to provide additional information required by the payer for the claim to be processed.
FL 80
Principle diagnosis and other diagnoses are recorded in these fields.
FL 67 A-Q
Fields used to record the insured’s name for each payer recorded on the claim form.
FL 58 (A-C)
The patient reason for visit is recorded in this field on outpatient claims.
FL 70
Treatment authorization codes obtained from the primary, secondary or tertiary payer is recorded in these fields.
FL 63 (A-C)
The purpose of a claim form is to submit charges to a patient.
False : The claim form is used to submit charges to payers for reimbursement.
Manual claim submission is more efficient than electronic claim submission.
False : Electronic claim submission is more efficient.
CMS-1500 is used to submit non-institutional charges to a payer for reimbursement.
True
The CMS-1450 (UB-04) has 33 fields.
False: The CMS-1450 (UB-04) has 81 fields.
Claim form completion instructions vary by payer.
True
The _________ ______ ________ _________ _________ ______ ________ coding system
is used to record services, procedures, and items in FL 44.
Health Care Common Procedure Coding System (HCPCS)
. A patient’s written permission for the payer to send payment to the provider is called the
_______________._______________._______________..
assignment of benefits
The condition determined after study is the __________________ diagnosis.
principle
. Item 12 of UHDDS states that all __________________ _______________ are to be reported
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.
significant procedures
The procedure performed for definitive treatment of the principal diagnosis is called the
_____________ procedure
principle
The __________________ claim form is utilized by institutional providers to submit
hospital facility charges for services, procedures, and items to payers for reimbursement.
CMS-1450 (UB-04)
The ____________ acronym represents the coding system used today to report patient
conditions and significant procedures.
ICD-9-CM
In accordance with HIPAA provisions, the ________________________ coding system will
replace the ICD-9-CM coding system effective________________________.
ICD-10-CM, OCTOBER 1, 2014.
Inpatient claims require the reporting of a __________ ____ ___________ ____ indicator
for principal and other conditions.
Present on admission (POA)
The CMS-1450 (UB-04) contains 81 fields referred to as _______________.
form locators (FL)
The field used to record four-digit codes used to categorize services, procedures, and items.
FL 42
The field used to record the principal procedure.
FL 74
The field used to report the standard abbreviated description of revenue codes.
FL 43
The fields used to report the principal and other diagnoses.
FL 67 (A-Q)
The field used to record the HCPCS Level I and HCPCS Level II Medicare National code.
FL 44
A single numeric digit is reported in this FL on the CMS-1450 (UB-04) to describe the priority (type) of the admission or visit.
FL 14
The _______ ______is reported in FL 42 on the CMS-1450 (UB-04) to describe the category of services as defined by the National Uniform Billing Committee (NUBC)
REVENUE CODE
The CMS-1450 (UB-04) is used to submit facility charges for ambulatory surgery and inpatient services.
TRUE
Which section of the CMS-1450 (UB-04) is used to provide information about charges submitted on the claim form?
FL 42-49
ALVEOLUS
Area where oxygen and carbon dioxide are exchanged
BRONCHIAL
pertaining to the bronchus
CAVITY
hollow space
EPIGLOTTIS
flap of cartilage that automatically covers the opening of and keeps food from entering the larynx during swallowing
ESOPHAGUS
the passage between the pharynx and the stomach
EUPNEIC
pertaining to normal breathing
INTERCOSTAL
between the ribs
LARYNX
voice box; passageway for air moving from pharynx to trachea; contains vocal cords
LOBE
large division of a lung
MEDIASTINUM
the part of the thoracic cavity between the lungs that contains the heart and aorta and esophagus and trachea and thymus
NASOPHARYNX
portion of the throat posterior to the nasal cavity and above the soft palate
PARIETAL PLEURA
the outer layer of the pleura that lines the walls of the thoracic cavity, covers the diaphragm, and forms the sac containing each lung
STERNUM
anterior bone of thorax; breast bone
THORAX
the chest; elastic, bony cage that serves as a protective framework for the heart, lungs, and other internal organs
TRACHEA
membranous tube with cartilaginous rings that conveys inhaled air from the larynx to the bronchi
What are three factors of E/M codes?
Place of service, type of service, and patient status.
Place or setting in which the service was provided is called?
Place of service
There are different codes for outpatient and inpatient settings.
True
Kind of service provided is called?
Type of service
Codes are divides based on the types of service.
True
How many types of patients statuses are there?
four
Has not received professional services from the physician or another physician of the same specialty and sub specialty in the same group practice within the past 3 years.
New patient
has received professional services from the physician or another physician of the exact same specialty and sub specialty in the same group practice within the past 3 years.
Established patient
Has not been formally admitted to a health care facility.
Outpatient
Has been formally admitted to a health care facility.
Inpatient
The three key components are the history, examination,and a medical decision-making complexity.
True
Is the subjective (patient provided) information that the physician elicits regarding to the chief complaint
History
There are four elements of history.
True
What are the four elements of history?
Chief Complaint(CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and Social History (PFSH)
CC
Chief Complaint
HPI
History of Present Illness
ROS
Review of Systems
PFSH
Past,Family, and Social History
A concise statement describing the symptom,problem,condition,diagnosis,physician recommended return or other reason for the encounter/ visit usually in patient’s words is called a
chief complaint
Is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present
History of Present Illness
Location means
Site on the body
Quality means
Characteristics, such as throbbing, sharp
Severity means
How intense or on a scale of 1/10
Duration means
How long for this problem or episode
Timing means
When does it occur
Context means
Under what circumstances does it occur
Modifying factors means
What makes it better or worse
Associated signs and symptoms means
what else is happening when it occurs
The extent of the HPI as problem focused, expanded problem focused, detailed, or comprehensive is based on the physician’s professional judgement depending on the needs of the patient.
True
What are the two levels of HPI
Brief (1-3 elements) and extended(4 or more elements)
The problem-focused and expanded problem-focused levels of history contain a brief review of the problems surrounding why the patient is being seen that day.
True
The detailed and comprehensive levels of history contain an extended review of the HPI elements.
True
An inventory of the body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced.
Review of Systems
A review of the patient’s past experience with illnesses, injuries, and treatment .
Past History
A review of medical events in the patient’s family
Family History
An age appropriate review of past and current activities
Social History
is a review that is focused on the organ system involved in the chief complaint
Problem pertinent ROS
Includes a review of the system directly involved in the chief complaint, plus related (up to nine) systems.
Extended ROS
Includes at least 10 of the 14 Organ Systems
Complete ROS
is a review of the pas, family,and social history of the patient
PFSH
What are the two levels of PFSH?
pertinent and complete
What are the four levels of history?
problem focused, expanded problem focused, detailed, and comprehensive
When the physician focuses on the CC and a brief history of the present problem of a patient.
Problem focused
When the physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.
Expanded problem focused
When the physician focuses on a CC and obtains an extended history of the present problem.
Detailed
When the physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH
Comprehensive
Is the subjective information the patient provides the physician
History
Objective information that the physician gathers.
Examination
Head (Including face)
Body Area
Neck
Body Area
Chest (Including Breast and axillae)
Body area
Abdomen
Body Area
Genitalia, groin,and buttocks
Body Area
Back
Body Area
Each extremity
Body Area
Ophthalmologic (eyes)
Organ System
Otolaryngologic (ears,nose,mouth, and throat)
Organ System
Cardiovascular
Organ System
Respiratory
Organ System
Gastrointestinal
Organ System
Genitourinary
Organ System
Muscoskeletal
Organ System
Integumentary (Skin)
Organ System
Neurologic
Organ System
Psychiatric
Organ System
Hematologic/ Lymphatic/ Immunologic
Organ System
What are the four levels of examination?
Problem focused,expanded problem focused, detailed, and comprehensive
Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA
Problem Focused
A limited examination of the affected area BA or OS and other related BAs or OSs. It involves a limited examination of 2-7 BAs or OSs
Expanded problem focused
An extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs
Detailed
Encompasses at least 8 OSs without counting BAs
Comprehensive
The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination.
True or False
When abstracting a medical record count both the
BAs and OSs`
Constitutional on the exam count as 1 OS and that OS counts when calculating the examination.
True or False?
the key component of MDM is based on the__________ of the decision the physician must make regarding the patient’s diagnosis and care.
complexity
Complexity of decision making is based on three elements.
True or False?
What are the three elements of decision making?
number of diagnoses or management options, Amount and/or complexity of data to review, and risk of complication and/or death if the condition goes untreated.
What are the four types of MDM complexity?
straightforward, low, moderate,and high
Blood pressure, sitting
Constitutional(OS)
Blood pressure, lying
Constitutional(OS)
Pulse
Constitutional(OS)
Respiration
Constitutional(OS)
Temperature
Constitutional(OS)
Height
Constitutional(OS)
Weight
Constitutional(OS)
General appearance
Constitutional(OS)
Minimal diagnosis and/or management options, minimal or none for the amount and complexity of data to be reviewed,and minimal risks to the patient of complications or death if untreated.
Straightforward
Limited number of diagnosis and/or management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated
low complexity
multiple diagnosis and or management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
moderate complexity
extensive diagnosis and or management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for complications or death if the problem is untreated.
high complexity
____________ factors are those conditions that help the physician to determine the extent of history, examination, and decision making necessary to treat the patient
Contributory
What are the three contributory factors?
counseling, coordination of care, and the nature of the presenting problem.
Involves discussion of diagnostic results, impressions, and recommended diagnostic studies; prognosis; risks and benefits of treatment;instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education.
Counseling
A physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long- term nursing facility.
Coordination of care
a disease, conditon, illness, injury, symptom, sign finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter
Presenting problem
How many types of presenting problems are there?
five
What are the five types of presenting problems?
Minimal, Self-limited, low severity, and moderate severity
A _______ problem is a blood pressure reading, a dressing change,or another service that can be performed without the physician being immediately present.
Minimal
also called a minor presenting problem
self-limited
The risk of complete sickness without treatment is low, there is no risk of death without treatment, and full recovery without impairment is expected.
low severity
the risk of complete sickness without treatment is moderate, there is moderate risk of death without treatment and an uncertain prognosis or increased probability of impairment exists,
moderate severity
The risk of complete sickness without treatment is high to extreme, there is a moderate to high risk of death without treatment, or there is a strong probability of severe, prolonged functional impairment.
High severity
What are two measurements of time?
Face-to-face time and unit/floor time
_________ time is the time a physician spends directly with a patient during an office visit obtaining the history, performing an examination, and discussing results.
Face-to-Face time
Inpatient time is measured as ________ time and is used to describe the time a physician spends in the hospital setting dealing with the patient’s care.
unit/floor time
_______ services are based on time
Discharge
More than one physician can use the subsequent care codes on the same day. This is called
Concurrent Care
Who maintains the primary responsibility for the overall care of the patient,no matter how many other physicians are providing services to the patient, unless a formal transfer of care has occurred.
attending physician
These codes are reported for either inpatients or outpatients who are admitted and discharged on the same day.
Observation or Inpatient Care Services (99234-99236)
______________ are reported on the final day of services for a multiple-day-stay in a hospital setting.
Inpatient Hospital Discharge Services
Findings that were not the reason for the test.
Incidental findings
WHAT ACT REQUIRED THE USE OF ICD-9-CM CODES FOR OUTPT CLAIMS?
MEDICARE CATASTROPHIC ACT OF 1988
HOW ARE ICD-9-CM CODES USED FOR RESEARCH?
1. HEALTH CARE QUALITY
2. FUTURE NEEDS
3. NEWER CANCER CENTER BUILT IF PATIENT USE WARRANTS
WHAT IS THE PURPOSE OF ICD-9-CM CODES? (3 REASONS TO USE)
1. FACILITIES TRACK PATIENT USE
2. FISCAL ENTITIES TRACK HEALTH CARE COSTS.
3. RESEARCH
ICD-9-CM CODES ON INSURANCE FORMS
1. DIAGNOSIS ESTABLISH MEDICAL NECESSITY
2. SERVICES AND DIAGNOSES MUST CORRELATE.
3. CMS-1500 IN BLOCK 21 AND 24E
ICD-9-CM CONVENTION: NEC
NOT ELSEWHERE CLASSIFIABLE-NO MORE-SPECIFIC CODE EXISTS
NOS
NOT OTHERWISE SPECIFIED
(UNSPECIFIED IN DOCUMENTATION)
BRACKETS [ ]
ENCLOSE SYNONYMS, ALTERNATIVE WORDING, OR EXPLANATORY PHRASES.
(HELPFUL, ADDITIONAL INFORMATION)
PARENTHESES ( )
CONTAIN NONESSENTIAL MODIFIERS
(TAKE THEM OR LEAVE THEM)
COLON :
TABULAR, COMPLETES STATEMENT WITH ONE OR MORE MODIFIERS
} BRACE
TABULAR, MODIFYING STATEMENTS TO RT OF BRACE
LOZENGE
CAN INDICATE CODE UNIQUE TO ICD-9-CM
SECTION MARK
CAN BE FOOTNOTE INDICATOR
BOLD TYPE
CODES & CODE TITLES IN TABULAR, VOLUME 1
ITALICIZED TYPE
ALL EXCLUDES NOTES
CODES NOT USED AS PRINCIPAL DIAGNOSIS
SLANTED BRACKETS
ENCLOSE MANIFESTATIONS OF UNDERLYING CONDITION. (CODE UNDERLYING CONDITION FIRST)
INCLUDES NOTES
IN CHAPTER, SECTION OR CATEGORY
EXCLUDES NOTES
CONDITIONS ARE CODED ELSEWHERE
AND
MEANS AND/OR
WITH
ONE CONDITION WITH (IN ADDITION TO) ANOTHER CONDITION.
CODE, IF APPLICABLE, ANY CAUSAL CONDITION FIRST
MAY BE FIRST-LISTED DX IF NO CAUSAL CONDITION APPLICABLE OR KNOWN
CROSS REFERENCES
DIRECTS YOU TO “SEE” OR “SEE ALSO”
NOTES
DEFINE TERMS & GIVE FURTHER CODING INSTRUCTION
EPONYMS
DISEASE OR SYNDROME NAMED FOR PERSON
ETIOLOGY
CAUSE OF DISEASE
MANIFESTATION OF DISEASE
SYMPTOM
COMBINATION CODE
ETIOLOGY & MANIFESTATION IN ONE CODE
SECTIONS
1. INDEX TO DISEASES
2. TABLE OF DRUGS & CHEMICALS
3. E CODES
SUBTERMS ARE INDENTED___SPACES.
2
MAJOR DIVISIONS OF VOL 1 TABULAR
1. CLASSIFICATION OF DISEASES AND INJURIES. (CODES 001.0-999.9)
1. SUPPLEMENTARY CLASSIFICATION (V CODES & E CODES)
MAIN PORTION OF ICD-9-CM
CLASSIFICATION OF DISEASES & INJURIES
ICD-9-CM QUIDELINES WERE DEVELOPED BY THESE PARTIES.
1.AHA-AMERICAN HEART ASSOC
2.AHIMA- AMERICAN HEALTH INFORMATION MGMT ASSOC.
3. CMS- CENTERS FOR MEDICARE & MEDICAID SERVICES.
4. NCHS-NATIONAL CENTER FOR HEALTH STATISTICS
AHA
AMERICAN HEART ASSOCIATION
AHIMA
AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION
CMS
CENTERS FOR MEDICARE & MEDICAID SERVICES
NCHS
NATIONAL CENTER FOR HEALTH STATISTICS
APPENDIX A
WHERE IS THE TEXT THAT CONTAINS RESOURCES TO VIEW THE “ICD-9-CM OFFICIAL GUIDELINES FOR CODING & REPORTING”?
MULTIPLE CODING FOR SINGLE CONDITION.
ETIOLOGY (CAUSE) & MANIFESTATION(SYMPTOM) SLANTED BRACKETS
burns to multiple sites in the same anatomic area
are reported with 9 at the end of the ICD 9
highest degree
burns in the same anatomic site with muliple burns are coded with the higest degree.
burns
important to code for the cause of the burn and the place of occurence -remember to assign the activity and external cause status based on current coding guidelines.use E CODES
late effect
resudyak effect condition produced after the acute phase of an illness or injury has terminated. there is no time limit on when it can reoccur . NEED TO HAVE: 2 codes the condition or nature of the late effect is first followed by the late effect.
treatment for malignacy
the only exception to the guidelines rule is that if the patient admissions/encounter is solely for the administration of chemotherapy,immunotherapy or radiation therapy. assign the V58.X code as the first listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secibdart diagnosis.
Assignment of benefits
Written authorization from a patient for the payer to forward benefits to the provider.
Attending physician
The provider responsible for the patient’s care during an inpatient hospital stay.
Batch
A group of claims prepared and submitted together.
Clearinghouse
An organization that reformats claim data received from providers to meet compatibility specifications for submission to various payers.
Electronic data interchange (EDI)
The process of sending data from one computer to another by telephone line or cable.
Electronic media claim (EMC)
A claim that is transmitted through electronic data interchange (EDI).
Form locator (FL)
A term used to describe each data field on the CMS-1450 (UB-04).
Insurance claim form
A form completed by providers for the purpose of submitting charges for medical services and supplies to various third-party payers such as insurance companies and government programs
Medical record number (MRN)
A number assigned by the facility (hospital) to a patient’s medical record. The medical record number is also referred to as the health record number (HRN).
National Provider Identifier (NPI)
A standard unique health identifier that health care providers use in filing and processing health care claims and other transactions. NPIs are issued through the National Provider System (NPS) developed by CMS. Effective May 23, 2007, the NPI replaced all identifiers that were previously used.
National Uniform Billing Committee (NUBC)
Committee formed by the American Hospital Association in 1975 to develop a single billing form and standard data set that could be used nationally by institutional providers. Today, the role of the NUBC is to maintain the integrity of theUB-04 data set.
North American Industry Classification System (NAIC) code
A unique code assigned to each business within the United States. The NAIC code classifies the business and it is used for statistical purposes by various agencies in the United States.
Optical scanning
A process whereby the claim form is scanned and data on the claim are transferred into a computer system.
Paper claim
A claim that is typed or computer generated on paper and sent by mail.
Provider
An individual or entity that provides medical services and/or supplies to patients such as a doctor or hospital.
Reimbursement
The payment received from a third-party payer for services rendered to patients by the provider.
Revenue codes
Codes developed and maintained by the National Uniform Billing Committee (NUBC) to categorize like services and items. Revenue codes are four numeric digits.
State Uniform Billing Committees (SUBC)
Committees created to oversee implementation of the CMS-1450 (UB-04) at the state level.
Tertiary payer
Refers to the third insurance.
Timely filing
Refers to the period of time required that claims have to be filed within, such as 90 days. Timely filing is generally calculated from the date of service.
Unique Provider Identification Number (UPIN)
A unique number assigned to the provider by the Medicare Fiscal Intermediary
AMA
American Medical Association
CMS
Centers for Medicare and Medicaid Services
CMS-1450 (UB-04)
Uniform Bill Revised 2004
EDI
Electronic Data Interchange
EIN
Employer Identification Number
EMC
Electronic Media Claim
ER/ED
Emergency Room, Emergency Department
FL
Form Locator
HCPCS
Health Care Common Procedure Coding System
HIAA
Hospital Insurance Association of American
HIPAA
Health Insurance Portability and Accountability Act
HIPPS
Health Insurance Prospective Payment System
HRN
Health Record Number
ICD-9-CM
Modification
International Classification of Diseases, 9th Revision, Clinical
MRN
Medical Record Number
NAIC
North American Industry Classification System Code
NPI
National Provider Identifier
NUBC
National Uniform Billing Committee
OCR
Optical Character Recognition
PoA
Present on Admission
RA
Remittance Advice
SUBC
State Uniform Billing Committee
UB-04
CMS-1450 Universal Bill implemented in 2007
UPIN
Unique Provider Identifcation Number
Medical Billing & Coding as a Career
*Claims assistant professional or claims manager, *Coding Specialist, * Collection Manager, *Electronic Claims Processor, *Insurance Billing Specialist, * Insurance Coordinator, *Insurance Counselor, *Medical Biller, *Medical & Financial Records Manager, * Billing & Coding Specialist
What are Medical Ethics?
Standards of conduct based on moral principle. They are generally accepted as a guide for behavior towards pt’s, dr’s, co-workers, the gov, and ins co’s.
What does acting within ethical behavior boundaries mean?
carrying out one’s responsibilities w/ integrity, dignity, respect, honesty, competence, fairness, & trust.
Legal Aspects of of Medical Billing & Coding:
Compliance regulations:
Most billing-related cases are based on HIPPA and False Claims Act
Health Insurance Portability & Accountability Act (HIPPA)
Enacted in 1996, created by the Health Care Fraud & Abuse Control Program-enacted to check for fraud and abuse in the Medicare/Medicaid Programs and private payers
What are the 2 provisions of HIPPA?
Title I: Insurance Reform
Title II: Administrative Simplification
What is Title I of HIPPA?
Insurance Reform-primary purpose is to provide continuous ins coverage for worker & their dependents when they change or lose jobs. Also *Limits the use of preexisting conditions exclusions *Prohibits discrimination from past or present poor health *Guarantees certain employees/indv the right to purchase new health ins coverage after losing job *Allows renewal of health ins cov regardless of an indv’s health cond. that is covered under the particular policy.
What is Title II of HIPPA?
Administrative Simplification-goal is to focus on the health care practice setting to reduce administrative cost & burdens. Has 2 parts- 1) development and implementation of standardized health-related financial & administrative activities electronically 2) Implementation of privacy & security procedures to prevent the misuse of health info by ensuring confidentiality
What is the False Claims Act (FCA)?
Federal law that prohibits submitting a fraudulent claim or making a false statement or representation in connection w/ a claim. Also protects & rewards whistle-blowers.
What is the National Correct Coding Initiative (NCCI)?
Developed by CMS to promote the national correct coding methodologies & to control improper coding that lead to inappropriate payment of Part B health ins claims.
How many edits does NCCI include?
2: 1)Column 1/Column 2 (prev called Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Column 1/Column 2 edits (NCCI)
Identifies code pairs that should not be billed together b/c 1 code (Column 1) includes all the services described by another code (Column 2)
Mutually Exclusive Edits (NCCI)
ID’s code pairs that, for clinical reasons, are unlikely to be performed on the same pt on the same day
What are the possible consequences of inaccurate coding and incorrect billing?
*delayed processing & payment of claims *reduced payments, denied claims *fine and/or imprisonment *exclusion from payer’s programs, loss of dr’s license to practice med
Who has the task of investigate and prosecuting health care fraud & abuse?
The Office of Inspector General (OIG)
Fraud
knowingly & intentionally deceiving or misrepresenting info that may result in unauthorized benefits. It is a felony and can result in fines and/or prison.
Who audits claims?
State & federal agencies as well as private ins co’s
What are common forms of fraud?
billing for services not furnished, unbundling, & misrepresenting diagnosis to justify payment
Abuse
incidences or practices, not usually considered fraudulent, that are inconsistent w/ the accepted medical business or fiscal practices in the industry.
What are examples of Abuse?
submitting a claim for services/procedures performed that is not medically necessary, and excessive charges for services, equipment or supplies.
What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?
Risk Management
Patient Confidentiality
All pt’s have right to privacy & all info should remain privileged. Only discuss pt info when necessary to do job. Obtain a signed consent form to release medical info to ins co or other individual.
When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?
When using for TPO, Treatment (primarily for the purpose of discussion of pt’s case w/ other dr’s) Payment (providers submit claims on behalf of pt’s) & Operations (for purposes such as training staff & quality improvement)
What is Employer Liability?
Means physicians are legally responsible for their own conduct and any actions of their employees (designee) performed w/in the context of their employment. Referred to as “vicarious liability. A.K.A “respondent superior”-“let the master answer”. Means employee can be sued & brought to trial
What is Employee Liability?
“Errors & Omissions Insurance”-protection against loss of monies caused by failure through error or unintentional omission on the part of the indv or service submitting the claim. ****Some dr’s contract w/ a billing service (clearinghouse) to handle claims submission, & some agreements contain a clause stating that the dr will hold the co harmless from “liability resulting from claims submitted by the service for any account”, means dr is responsible for mistakes made by billing service, errors & omissions is not needed in the instance. ******However, if dr ever asks the ins biller to do the least bit questionable, such as write of pt’s balances for certain pt’s automatically, make sure you have a legal document or signed waiver of liability relieving you of responsibility for such actions.
What is a Medical Record & what is it comprised of?
documentation of the pt’s social & medical history, family history, physical exam findings, progress notes, radiology & lab results, consultation reports and correspondence to pt- Is the foremost tool of clinical care and communication.
What is a medical report?
part of the medical record & is a permanent legal document that formally states the consequences of the pt’s exam or treatment in letter or report form. IT IS THIS RECORD THAT PROVIDES INFO NEEDED TO COMPLETE THE INS CLAIM FORM.
Reasons for Documentation
Important that every pt seen by dr has comprehensive legible documentation about pt’s illness, treatment, & plans for following reasons:
*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
Retention Of Medical Records
Is governed by state & local laws & may vary from state-to-state. Most dr are required to retain records indefinitely, deceased pt records should be kept for @ least 5 years
Med Term
Diagnosis suffixes:
-algia
pain
-emia
blood condition
-itis
inflammation
-megaly
enlargement
-meter
measure
-oma
tumor, mass
-osis
abnormal condition
-pathy
disease condition
-rrhagia
bursting forth of blood
-rrhea
discharge, flow
-sclerosis
hardening
-scopy
to view
Procedural Suffixes:
-centesis
surgical puncture
-ectomy
removal, resection, excision
-gram
record
-graphy
process of recording
-lysis
separation, breakdown, destruction
-pexy
surgical fixation
-plasty
surgical repair
-rrhapy
suture
-scopy
visual examination
-stomy
opening
-therapy
treatment
-tomy
incision, to cut into
Common Prefixes:
a, an
without
ante
before
anti
against
brady
slow
dys
painful, difficult
endo
inside, within
epi
upon, above
ex
out, out of
hemi
half, partial
hypo
below, deficient
infra
below
inter
between
neo
new
oligo
scanty, little
pan
all
para
beside
per
through
poly
many
pre
before, in front of
pseudo
false
sub
under
supra
above, beyond
tetra
four
Common Root Words
arth
cartilage
cephal
head
cardi
heart
cholecyst
gall bladder
chondro
cartilage
colp
vagina
derm
skim
enter
intestine
episi
vulva
gastro
stomach
gloss
tongue
hepato
liver
hyster
uterus
lapar
abdomen
lact
milk
lith
stone
mast
breast
myo
muscle
nat
birth
oophor
ovary
oste
bone
pneum
lung
rhin
nose
salping
fallopian tubes
stomat
mouth
Directional Terms:
Anterior, Ventral
front surface of the body
Posterior, Dorsal
back side of the body
Superior
above another structure
Inferior
below another structure
Proximal
near the point of attachment to the trunk
Distal
far from the point of attachment to the trunk
Medial
pertaining to the middle of the body
Lateral
pertaining to the side
Frontal, Coronal
Vertical plane dividing the body into anterior & posterior portions
Sagittal
vertical plane dividing the body into right & left sides
Transverse, Cross-sectional
Horizontal plane dividing the body into upper & lower portions
Anatomy & Physiology
A professional medical coder must have knowledge of anatomy & physiology so that coding assignment is quick & accurate.
What is the 1st body system for which medical procedures are described in the CPT manual?
The Integumentary System (the skin and it’s accessory organs) Integument means covering. It is a complex system of specialized tissues containing glands, nerves and blood vessels.
How much area does the skin cover?
an area of 22 sq ft (an average adult). It is the largest organ of the body
What is the main function of the skin?
To protect the deeper tissues from excessive loss of minerals, heat & water. It also provides protection form diseases by providing a barrier. It accomplishes its diverse functions w/ assistance from the hair, nails and glands.
SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS)
produce secretions that allow the body to be moisturized or cooled.
How many layers to the skin?
3;
1) Epidermis (thin, cellular membrane layer that contains keratin)
2) Dermis (dense, fibrous, connective tissue that contains collagen)
3) Subcutaneous layer (thicker & fatter tissue)
Hair, Nail & Glands
Hair
composed of tightly fused meshwork of cells filled w/ hard protein called karatin. Has its roots in the dermis & together w/ their coverings, is called HAIR FOLLICES. Main function is to assist in regulating body temp. Holds heat when body is cold by standing on end & holding a layer of air as insulation.
Nails
cover & protect the dorsal surface of the distal bones of the fingers & toes. Part that is visible is nail body, nail root is under skin @ the base of the nail and nail bed is the vascular tissue under the nail that appears pink when the blood is oxygenated or blue/purple when it is oxygen deficient.
What is the moon like white area of the nail called?
lunula
What is the eponychium?
the cuticle at the lower part of the nail sometime referred to as such
SEBACEOUS GLANDS
located in the dermal layer of the skin over the entire body, expect for palm of hands and soles of feet. Secrete oily substance called SEBUM. SEBUM CONTAINS LIPIDS THAT HELP LUBRICATE THE SKIN & MINIMIZE WATER LOSS. It is the overproduction of sebum during puberty that contributes to acne in some people
SUDDORIFEROUS GLANDS
sweat glands that are tiny, coiled gland found on almost all body surfaces. They are most numerous in the palms and soles of feet. Coiled sweat glands originate in the dermis and straighten out to extend up through the epidermis. Tiny opening at surface is called a PORE.
How many types of sweat glands?
2;
1) eccrine sweat glands (most common)
2) apocrine sweat glands (secrete orderless sweat)
What organ secretes hormones?
the adrenal glands, they secrete epinephrine & steriods
Integumentery Vocabulary
Albino
deficient in pigment (melanin)
Collagen
structural protein found in the skin & connective tissue
Melanin
major skin pigment
Lipocyte
a fat cell
Macule
discolored, flat lesion (freckles,, tattoo marks)
Polyp
benign growth extending from the surface of the mucous membrane
Fissure-
groove or crack like sore
Nodule
solid, round or oval elevated lesion more than 1 cm in diameter
Ulcer
open sore on the skin or mucous membrane
Vesicle
small collection of clear fluid; blister
Wheal
Smooth, slightly elevated, edematous (swollen) area that is redder or paler than the surrounding skin
Alopecia
absence of hair form areas where it normally grows
Gangrene
death of tissue associated w/ the loss of blood supply
Impetigo
bacterial inflammatory skin disease characterized by lesion, pustules, and vesicles
Multigravida
a pregnant woman who has had at least one previous pregnancy
The Musculoskeletal System
includes bones, muscles & joints. Acts as a framework for the organs, protects many of those organs, and also provides the body w/ the ability to move
What are bones connected to one another by?
by fibrous bands of tissues called LIGAMENTS
What are muscles attached to the bone by?
tendons
What is the fibrous covering of muscles called?
the fascia and the aricular cartilage, covers the end of many bones and serves as a protective function.
Bones
complete organs made up of connective tissue called OSSEOUS. Inner core of bones is comprised of HEMATOPOIETIC tissue. This is where the red bone marrow manufactures blood cells. Other parts of the bones are storage areas for minerals necessary for growth, ie; calcium and phosphorous
How are bones categorized?
as belonging to either the AXIAL SKELETON or the APPENDICULAR SKELETON.
Axial Skeleton
consist of the skull, rib cage & spine
Appendicular Skeleton
made up of the shoulder, collar, pelvic, arm & legs
Long Bones
typically very strong, are broad at the ends and have large surfaces for muscle attachment. IE: HUMERUS & FEMUR.
Short Bones
are small w/ irregular shapes, they are found in wrist and ankle
Flat Bones
are found covering the soft body parts, IE; SHOULDER BLADES, RIBS AND PELVIC BONES
Sesamoid Bones
small, rounded bones that resemble a sesame seed. they are found near joints and increase the efficiency of muscles near a joint. IE, KNEE CAP
The Axial Skeleton-Skull, Rib Cage, Spine
Skull
made up of 2 parts, the cranium and the facial bone
Cranium
includes following bones
*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
Facial Bones
Zygoma
cheekbone
Lacrimal Bones
paired bones at the corner of each eye that cradle the tear ducts
Maxilla
upper jaw bone
Mandible
lower jaw bone
Vomer
bone that forms posterior/inferior part of the nasal septal wall between the nostrils
Palatine bones
Make up part of the roof of the mouth
Spinal/Vertebral Column
is divided into 5 regions from the neck to the tailbone. There are 26 bones in the spine & are referred to as the VERTABRAE
Cervical
Neck Bones
Thoracle
Upper Back
Lumbar
Lower Back
Sacral
Sacrum
Coccygeal
Coccyx (tailbone)
Rib Cage
There are 12 pairs of ribs. The 1st 7 pairs join the sternum anteriorly through the cartilaginous attachments called COSTAL CARTILAGE. The TRUE RIBS #’s 1-7 attach directly to the sternum in the front of the body. The FALSE RIBS, #’s 8-10 are attached to the sternum by cartilage. Ribs 11 & 12 are FLOATING RIBS, b/c they are not attached at all
The Appendicular Skeleton
Upper Appendicular Skeleton
includes the shoulder girdle which is made up of the SCAPULA, CLAVICLE, & UPPER EXTREMITIES
Scapula
or shoulder blades are flat bones that help support the arms
Clavicle
or collarbone, is curved horizontal bones that attach to the upper sternum at one end, these bones help stabilize the shoulder
Upper Extremities
consist of the following:
Humerus
upper arm bone
Ulna
lower medial arm bone
Radius
lateral lower arm bone (in line w/ the thumb)
Carpals
Wrist bones, there are 2 rows of 4 bones in the wrist
Metacarpals
the 5 radiating bones in the fingers. These are the bones in the palm of the hand.
Phalanges
finger bones, each finger has 3 phalanges, except for the thumb. The 3 phalanges are the proximal, middle and a distal phalanx. The thumb has a proximal and distal
Lower Appendicular
can be divided into the pelvis and the lower extremities
Pelvis
superior & widest bone
Ischium
lower portion of the pelvic bone
Pubic Bone
lower anterior part of the bone
Lower Extremeties
Femur
thighbone
Patella
kneecap
Tibia
shin
Fibula
smaller, lateral leg bone
Malleolus
ankle
Tarsal
hind foot bone
Metatarsal
midfoot bone
Phalanx
toe bones, 14 in all (2 in great toe, 3 in each of the other toes)
Joints
parts of the body where 2 or more bones of the skeleton join. Different joints have different ROM (range of motion), ranging from no movement at all to full range of movement
No ROM
most synarthroses are immovable joints held together by fibrous tissue
Limited ROM
amphiathroses are joints joined together by cartilage that is slightly moveable, such as the vertebrae of the spine or the pubic bone
Full ROM
diathroses are joints that have free movement, Ball-and-socket joints (hip) and hinge joints (knees) are common diathroses joints (synovial joints)
Synovial Joints
free moving joints, are surrounded by joint capsules. Many of the synovial joints have BURSAE-SACS OF FLUID THAT ARE LOCATED BETWEEN THE BONES OF THE JOINT AND THE TENDONS THAT HOLD THE MUSCLES IN PLACE.
Muscles
Muscle is tissue comprised of cells. Have the ability to contract & relax.
What are the 3 different functions of the human muscles?
1) allow the skeleton to move
2) responsible for movement of organs
3) to pump blood to the circulatory cystem
How are muscles attached to bones?
by strong, fibrous bands of connective tissues called tendons.
Muscle Actions
Extension
to increase the angle of the joint
Flexion
to decrease the angle of the joint
Abduction
movement away from the midline
Adduction
movement towards the midline
Supination
turning the palm or foot upward
Pronation
turning the palm or foot downward
Dorsiflexion
raising the foot, pulling the toes toward the shin
Plantar Flexion
lowering the foot, pointing the toes away form the shin
Eversion
turning outward
Inversion
turning inward
Protraction
moving a part of the body forward
Retraction
Moving a part of the backward
Rotation
revolving a bone around its axis
Fractures
broken bone, most occur as a result of trama, however some disease such as cancer or osteoporosis can also cause spontaneous fractures. Can be classified as simple or compound. Simple fractures don’t rupture the skin as compound fractures split open the skin allowing for an infection to occur.
Communicated Fracture
the bone is crushed and/or shattered
Compression Fracture
the fractured area of the bone collapses on itself
Colles Fracture
the break of the distal end of the radius at the epiphysis often occurs when the pt has attempted to break his/her fall
Complicated Fracture
the bone is broken and the ends are driven into each other
Hairline Fracture
a minor fracture appears as a thin line on x-ray; and may not extend completely through the bone
Greenstick Fracture
the bone is partially bent & partially broken, this is a common fracture in children b/c their bones are still soft
Pathologic Fracture
any fracture occurring spontaneously as a result of disease
Salter-Harris Fracture
a fracture of the epiphyseal plate in children
Sprains, strains and dislocation/subluxation
SPRAIN is a traumatic injury to the joint involving the soft tissue, soft tissue includes the muscles, ligaments and tendons.
Strain
lesser injury, usually this is a result of overuse or overstretching
Dislocation
is when the bone is completely out of place
Subluxation
bone is partially out of joint
Evaluations & Management Review
The E&M section include codes that pertain to the nature of the physicians work. Codes depend on type of service, pt status, and place where service was rendured. The E&M section is divided into broad categories such as office visit, hospital visits, and consultations
Basic Format of the levels of E&M services
1) a unique code # is listed
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
New Patient
defined as one who has not received medical services w/in the last 3 years
Established Patient
defined as someone who has recieved medical services w/in the last 3 years from the physician or another physician of the same specialty who belongs to the same group practice
Chief Complaint
brief statement describing the symptom, problem, diagnosis, or condition that is the reason the pt seeks medical care
How many Volumes to ICD manual?
3;
*Volume 1- Disease: Tabular List
*Volume 2- Disease: Alphabetic Index
*Volume 3- Procedures: Tabular list and Alphabetic Index
Volume 1-Index to Diseases, Tabular List
contains the disease and condition codes and the descriptions, also contains the V codes and E codes
Volume 2-Index to Diseases, Alphabetic Index
the is the alphabetic index of Volume 1; use this first then volume 1 to confirm codes
Volume 3-Procedures
contains codes for surgical, therapeutic, and diagnosis procedures, used primarily in hospitals
Which volume(s) are used in the inpatient and outpatient settings (physician office)?
Volume’s 1 & 2
How to ensure you have chosen the correct code?
First locate the code in the alphabetic index (Volume 2) then cross-reference this code in the Tabular List (Volume 1)
Supplementary Classification Codes
What are V codes?
Supplementary Classification of Factors Influencing Health Status and Contact of Health Services-supplementary classification code used to identify health care encounters that occur for reasons other that illness or injury or to indentify pt’s whose illness is influenced by special circumstances or problems. Can be found in both Volume 1 & Volume 2
What are circumstances when V codes are used?
*When a person who is not currently sick encounters health services for some specific reason such as to act as an organ donor or receive a vaccination. (IE; V59.3 is the code for donor of bone marrow)
*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)
What are E codes?
Supplementary Classification of External Causes of Injury and Poisoning-supplementary classification codes used to describe the reason of EXTERNAL CAUSE of injury, poisoning and other adverse effects. Can be found in both Volumes ! & 2.
What codes are used to classify environmental events, circumstances, and conditions as the cause of injury, poisoning & other adverse effects and capture how the injury or poisoning happened, the intent and the place where the event happened?
E codes
/When is the ICD manual updated
Annually, Usually in October
How many chapters does the Tabular List(Volume 1) contain?
17; based on either body system or cause or type of disease
What do the codes range from? (ICD-Volume 1)
001-999
Chapters
are the main division on the ICS-9-CM, they are divided into secctions
Sections
composed of a group of 3 digit categories representing a group of conditions or related conditions, they are divided into categories
Categories
are composed of 3 digit codes representing a single disease or condition. the 3 digit code is used only if it is not further subdivided. There are about 100 category codes and most requires a 4th digit (subcategory code) Ex; 242
Subcategories
provide a 4th digit code (one digit after the decimal point) which is more specific that category code (3 digit) in terms of causes, site, manifestation of the condition. This must be used in available. Ex; 242.0
Subclassification
provides a 5th digit code which gives the highest specificity of description to a condition. Use of it is mandatory when available. A code not reported to the full # of digits required is invalid ex; 242.01
Level of detail in coding
a category code is used only if it is not further subdivided. Where subcategory and subclassifaction codes are provided, their assignment is mandatory. A code is invalid if it has not been coded to the level of specificity required for that code.
Sequencing the diagnosis
the diagnosis, condition, or other reason for the encounter or visit shown in the medical record to be chiefly responsible for the services provided is listed first. Coexisting conditions that were treated or medically managed or influenced by the pt during the encounter are listed as additional codes. (Conditions that were previously treated and no longer exist are not coded.) If personal history or family history has an impact on current care or influence treatment, history code may be assigned as a secondary code
Alphabetic Index (Volume 2)
Everything in the Index is listed by condition-that is, diagnosis, signs, symptoms, and conditions such as pregnancy or admission
Nonessential Modifers
the main term may be followed by these in paranthesis, their presence or absences does not have an effect on the the selection of the code listed for the main term
Essential Modifiers
Terms indented two spaces to the right below the main term called subterms. Are essential modifiers b/c they have bearing on the right selection of the code.
Hypertension table
found in the Index under the main term “Hypertension” and it contains a list of conditions that are due to or associated with hypertension. The Table classifies the conditions as:
-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
Neoplasm Table
this is located in the Index under the main term “Neoplasm” and is organized by anatomic site. Each site has 6 columns w/ 6 possible codes determined by whether the neoplasm is malignant, benign, of uncertain behavior or of unspecified nature
Describe the 6 columns of the neoplasm table
Malignant
further classified as to primary, secondary or carcinoma in situ
Primary Malignancy
the original cancer site. Malignant tumors are considered primary unless documented as secondary or mastastic
Secondary Malignancy
cancer that has metastasized (spread) to a secondary site either adjacent or remote region of the body
Carcinoma (Ca) in Situ
cancer that is localized and has not spread to adjacent tissues or distant parts of the body
Benign
noninvasive, non-spreading, nonmalignant
Uncertain Behavior
uncertain whether benign or malignant, borderline malignancy
Unspecified Nature
a neoplasm is identified; however, no nature of the tumor is documented in the diagnosis of the medical record
Choose the code that represents the current status of the neoplasm
a neoplasm code is assigned if the tumor has been removed and pt is still receiving chemotherapy tx or radiation. A V code is assigned if the tumor is no longer present or if the patient is not receiving treatment, but is returning for follow-up care
3 sections to Alphabetic Index
Section 1) Index to diseases
Section 2) Table of drugs and chemical
Section 3) Index to External Cause of Injury (E Codes)
Section 1: Index to diseases
each term is followed by the code or codes that apply to that term
Section 2: Table of Drugs and Chemicals
contains a list of drugs & chemicals w/ the corresponding poisoning code and E codes. The E codes are used to explain the circumstances surrounding the poisoning which may be:
-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
Section 3: Index to External Cause of Injury (E codes)
this is the index for the E codes. It classifies in alphabetical order, environment events and other conditions as the cause of injury and other adverse effects.
Health Care Financing Administration Common Procedure Coding System
HCPCS Reference Manual
Who assigns NPI#’s & what are they?
The CMS assigns a standard unique identifier known as National Provider Identifier (NPI).
Who developed HCPCS & What is it?
The CMS developed Healthcare Common Procedure Coding System (HCPCS) which is a collection of codes for procedures, supplies, products, and services that may be provided to Medicare/Medicaid beneficiaries and also to those enrolled in a private health ins program. Codes are divided into 2 levels:
Level I Codes
Consist of codes found in the CPT manual. They have five position numeric codes used to report physicians services rendered to patients.
Level II Codes (National Codes)
codes formulated thru the joint efforts of the CMS, the health insurance association of america, and the bcbs association.they are five position alpha-numeric codes for physician and non-physician services not found in the cpt(level 1), start w/ a letter followed by 4 #’s and make up more than 2,400 5 digit alphanumeric codes divided into 22 sections, each covering a related group of items. Most of these items are supplies, materials or injections that are covered by medicare. Some codes are for physicians & non-physician services not found in the CPT (Level I) Ex; E section is for the Durable Medical Equipment category which covers reusable medical equipment ordered by the physician for use in the home, such as wheelchairs or portable oxygen tanks.
Level III Codes
codes that were used locally or regionally have been eliminated by the CMS since the implementation of the HIPPA. Some of the codes are now in the Level II
CPT
Current Procedural Terminology- codes from CPT code book used to report services and procedures by dr’s. The CPT coding system uses a 5 digit numeric system for coding services rendered by dr’s. Some codes use a 2 digit modifier to five a more accurate description of the services rendered
Who publishes CPT and updates it?
The American Medical Association (AMA) and they update it annually withe a new one coming out each November & becoming effective on January 1st of the following calender year
Category I Codes
represents services and procedures widely used by many health care prof in clinical practice in multiple locations and have been approved by the FDA
Category II Codes
supplemental codes used for performance measures. Although these codes are intended to facilitate data collection about the quality of care, their use is optional. Cat II codes are published twice a yr, Jan 1st and July 1st
Category III Codes
temp codes for emerging technology, services and procedures. If a Cat III code is available, it is reported instead of Cat I unlisted code
How many sections to the CPT Manual?
8; each section begins w/ guidelines that provide specific coding rules for that section. Guidelines at the beginning of the section are applicable to all codes in the section, while notes that pertain to specific codes appear before or after such codes. Guidelines usually contain definitions of terms, applicable modifiers, subsection info, unlisted services, special reports of info, or clinical samples. The 8 sections are
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
What format does CPT coding system use and why?
Indented format, to save space
2 types of CPT Codes
*Stand Alone Codes; contain the full description of the procedure for the code
*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
Other CPT Codes
*Add-on codes- used for procedures that is always performed during the same operative session as another surgery in addition to the primary service/procedure and is never performed separately
*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
How do you know if an update has been made to the CPT manual?
**A triangle- represents a change in the code description since the last edition. The change may be minor or significant and it could be an addition, deletion, or revision
**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
How many parts to CPT Manual?
t3; the main text, the appendices and the alphabetic index and is divided into 6 sections; these sections are subdivided into
Evaluation & Management
99201-99499 (going to dr feeling 99% leave getting high 5)
Anesthesia
00100-01999, 99100-99140 (knocked out=0)
Surgery
10021-69990 (Surgery always want to feel 100%)
Radiology (including nuclear medicine and diagnostic ultrasound)
77010-79999 (RPM-789)
Pathology and Laboratory
80048-89356 (RPM-789; P=8)
Medicine (except anesthesiology)
90281-99199, 99500-99602 (RPM-789, M=9)
Add-on codes
some procedures are carried out in addition to the primary procedure performed. Designated as “add-on” codes w/ a “+” sign and they apply only to procedures performed by same dr to describe additional intra-service work provided. Are never used alone, rather they are always reported in addition to the primary procedure code. All add-on codes are modifier -51 (multiple procedures) exempt
Location Methods
The CPT Index is arranged in alphabetic order by main terms which are further divided by subterms. There are 5 location methods;
1)Service or Procedure
2)Anatomic Site
3)Condition or Disease
4)Synonym/Eponym
5)Abbreviation
CPT Modifiers
these are 2 digit add-ons attached to regular codes to tell 3rd party payers of circumstances in which the services or procedures were altered. All modifiers are listed in CPT appendix A. Modifiers relevant to each of the CPT sections are also found in the section guidelines. One must use the modifier that depicts the circumstances most accurately.
-24 Unrelated E/M Service by the same physician during a postoperative period
this is attached to the code of the E/M service provided to a pt during the postop period to indicate that the service is not part of the postoperative care which is usually part of the package of services of the surgery performed. Major surgical procedures will usually have a postop period of 90 days, minor, 10 days. Used only w/ E/M codes
-26 Professional Component
Most procedures have both professional (physician) and technical components. This modifier is attached to the procedure to indicate that the dr provided only the professional componenet
-32 Mandated Services
used to indicate that the service provided was required by 3rd party payer, gov, legislative or regulatory body. this does not include second opinion requested by a pt, family member, or another physician
-50 Bilateral Procedure
used when the same procedure is performed on a mirror-image part of the body
-51 Mulitple Procedure
used when
-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
-58 Staged or Related Procedure or Service by the same Physician during the Postoperative Period
used to explain that the procedure or service done during a postop period was planned at the time of the original procedure. also used if a therapeutic procedure is performed b/c of the findings from a diagnostic procedure
-78 Return to Operating Room for a Related Procedure During the Postoperative Period
to report a circumstance in which the dr returns to the operating room to address a complication stemming from the initial procedure (third party payers usually pay the surgery portion of the complications surgical package b/c the pt remains in the postop period of the initial procedure. documentation must clearly indicate the reason for the return to the operating room)
79 Unrelated Procedure or Service by the same physician during the postoperative period
used to indicate that the procedure or service provided during the postop period was not associated w/ the period. payment for the full fee of the subsequent procedure is requested and a new global period starts
-90 reference (outside) laboratory
used to indicate that the procedure was done by outside lab and not by reporting facililty
-99 Multiple Modifiers
used to report a procedure or service that has more than one modifier but the payer does not allow the addition of multiple modifiers to the code. is attached to the procedure code and the multiple modifier are listed in block 19 of claim form
Evaluation and Management (E/M Codes)
these are listed 1st in the CPT manual b/c they are used by all different specialties. they cover physician services that are performed to determine the best course for pt care.
What are the key components of E/M?
a; history
-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
Unlisted Procedures
Procedures considered experimental, newly approved, or seldom used may not be listed in the CPT manual. Can be coded as unlisted procedures. they are located at the end of the subsections or subheadings. when unlisted procedure code is reported must be described in the accompanying documentation
Surgical Package
also called “global surgery” includes a variety of services rendered by a surgeon which includes the following:
-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
What is Health Insurance?
A contract between a policyholder (one who purchases the contract) and an insurance carrier to reimburse the policyholder of all or most medical expenses
What 3 ways can an individual obtain health insurance?
1)Group Ins-when a group of employees & their dependents are insured under 1 group policy issued to the employer. Generally the employer pays the premium or portion of premium and the employee pays the difference.
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
Indemnity Insurance
also known as a fee-for-service. under this plan, the services that are paid for are listed in the policy and payments are based on the physicians charge for the service. there are no restrictions as to the physicians or hospital the beneficiaries may use and pre-approval of medical visits are not required. Each yr the beneficiary must meet a deductible, after which the benefit may cover for all or part of the charge. Usually a co-insurance for each service applies
HMO
Health Maintenance Organization- managed care plan that provides wide range of services to individuals that are enrolled. Generally least costly but most restrictive. Uses a gatekeeper (primary care physician) whom the pt is required to visit initially for any case. If the pt goes to another physician w/o prior approval pcp pt will be responsible for all costs. Physician-Hospital Organization is when physicians, hospitals, and other health care providers contract w/ one or more HMO’s or directly w/ employers to provide care.
PPO
Preferred Provider Organization- basically same as HMO however PPO’s charge a higher premium than HMO’s in exchange for more flexibility & more options for beneficiaries, No gatekeeper and pt choose dr they want to see as long as they are in network, if pt chooses to see dr not in network they will shoulder all costs.
POS
Point-of-service- managed care plan that gives beneficiaries the option whom to see for service. If the beneficiary see provider w/in network they will receive benefits similar to HMO but if they choose to see a provider not in the network, the POS will still pay for the services but at a rate significantly lower than the in-network dr and difference will be billed to pt
Preferred Provider Plan
the type of plan a patient may have where they can see providers outside their plan, the pt is responsible for higher portion of the fee
How is a fee schedule determined?
UCR method, the usual, customary, and reasonable- the carrier compare *the dr’s most frequent charge for a given service (the usual) *the average charge of all providers of similar training/experience in a given geographical area (the customary) *the actual charge submitted on a claim (must be reasonable to the provider)
*****the lowest amount is used as the basis for payment (the allowed charge)
Relative Value Payment Schedule Method
involves the use of relative value scales which assign a relative weight to individual services according to the basis for the scale. Services that are more difficult, time consuming, or resource intensive to perform typically have higher relative values than other services
Medicare’s Resource Based Relative Vale Scale (RBRVS) Payment Schedule
under this schedule a procedure’s relative value is the sum total of 3 elements
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
How are payments determined under Medicare’s RBRVS?
by multiplying a code’s relative value by constant dollar amount called the conversion factor (multiplier). The conversion factors are determined annually by the CMS in cooperation with congress. The conversion factor varies according to the type of service provided such as medical, surgical, non-surgical
A geographic practice cost index is applied to account for the economic variation across the different area of the country
true
What % does Medicare pay?
80%
What portion of services do the beneficiary pay?
20%, deductible, premiums, and for non-covered services
The St. Anthony Relative Value for Physicians (RVP)
unlike the RBRVS the RVP has no geographical adjustment factor or individual RVU component to calculate. However, for each category of procedures, a separate conversion factor must be developed
Contracted Rates w/ MCO’s
physicians agree to provide services at a discount of their usual fee in return for a pool of existing pt’s
Capitated Rates
the dr provides a full range of contracted services to covered pt’s for a fixed amount on a periodic basis. While guaranteed a fixed amount the dr assumes the risk that the cost of providing the care the pt’s may exceed the payment amount. the only additional charge may be a co-payment and a deductible co-insurance
Medicare
is the federall gov’s health ins program created by Social Security Act of 1965 titled “Health Insurance for the Aged & Disabled” It is administered by the CMS, formally known as Health Care Financing Administration (HFCA)
Who is Medicare available to?
-persons aged 65 or older, retired on Social Security Benefits
-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)
What are Medicare Health Insurance Claim Numbers (HCIN’a)?
issued by CMS and are usually SS #’s with letter (alpha) or letter/number (alphanumeric) suffixes.
Common Suffixes used by Medicare:
A-Wage earner (upon retirement)
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
Medicare Part A
aslo called the Hospital Insurance for the Aged and Disabled. It covers institutional providers for inpatient, hospice, and home health services, such as the following
-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
How do individuals that are not eligible for Social Security Obtain Medicare Part A?
By paying a premium and they must enroll in Part B this is however limited to applicants 65+ and US resident. A deductible is req for each episode of illness and a co-insurance applies for hospitalizations of more than 60 days
Medicare Part B
referred to as Supplementary Medical Insurance (SMI). coverage is a supplement of Part A, which covers medical expenses, clinical lab services, home health care, outpatient hospital treatment, blood, and ambulatory surgical services.
What out of pocket costs for beneficiaries are associated w/ Medicare part B?
Contains an annual deductible that must be met b4 benefits begin, beneficiaries pay 20% of the Medicare-approved amount for services after the deductible has been met. Premiums are usually deducted from the monthly SS check.
How are services paid to physicians associated w/ Medicare Part B?
services are paid according to a fee schedule which is based on the relative value multiplied by the geographical adjustment and conversion factors. All dr’s in a given area are paid the same for same service regardless of specialization. However, non par’s are paid 5% less for assigned claims. Non PAR’s, not accepting assignment, can charge no more than 115% of the participating allowance w/o facing possible Medicare fines and penalties.
Medicare Part C
Medicare Managed Care Plans (formally Medicare Plus (+) Choice Plan) was created to offer a # of healthcare services in addition to those available under Part A & Part B. The CMS contracts w/ managed care plans or PPO’s to provide Medicare benefits. A premium similar to Part B may be required for coverage to take affect
Medicare Part D
Prescription Drugs- enacted by the Medicare Prescription Drug, Improvement and Modernization Act in Dec 2003 and began implementation in Jan 2006 where Medicare beneficiaries can enroll in the Medicare Prescription drug plan. the beneficiaries have the choice of among several plans that offer drug coverage for which they pay a monthly premium
Claim Status
Various terms are used to describe the state of submitted forms.
Clean Claim
has all required fields accurately filled out, contains no deficiencies and passes all edits, the carrier does not require investigation outside of the carrier’s operation before paying the claim
Dirty Claim
contains errors and omissions, usually these claims do not pass front end edits they are either processed manually for resolving problems or rejected for payment
Invalid Claim
contains complete necessary information but is incorrect or illogical in some way
Rejected Claim
requires investigation and needs further clarification
What is an Advance Beneficiary Notice?
a document provided to a Medicare beneficiary by a provider prior to a service being rendered letting the beneficiary know of his/her responsibility to pay if Medicare denies the claim
What is Medigap?
Medicare Supplemental Insurance-to pay for medical services and items not covered by Medicare and Medicare’s coinsurance and deductible. Medigap is a private insurance designed to help pay for those amounts that are typically the pt’s responsibility under Medicare. there are several standard Medigap policies established by the federal gov w/ the ins industry
Medicaid
a federal program administrated by state gov to provide medical assistance to the needy, each state sets its own guidelines for eligibility and services, therefore benefits and coverage may very widely from state to state
How is eligibility for Medicaid classified?
divided into 2 classifications
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)
Medicaid is the payer of last resort
True
Medicaid and Medicare (dual coverage)
if pt has Medicare and Medicaid, medicaid usually pays for the Medicare Part B deductible, coinsurance, and monthly premium amounts.
Some of the Services covered by Medicaid
-inpatient hospital services
-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
Workers Compensation
is a state required ins plan, the coverage of which provides benefits to employees and their dependents for work related injury, illness or death. Each state has established minimum # of employees required before this laws comes into effect. Further, not all states offer WC plans
Who covers cost of Workers Compensations?
employers pay for premiums, the amount of which will depend on the specific job, occupational category, and level of risks
What are the 5 types of benefits offered?
1) Medical treatment 2) Temporary disability 3) Permanent disability 4) Vocational rehabilitation 5) Death benefits for survivors
Disability Insurance
defined as reimbursement for income and lost as a result of of a temporary or permanent illness or injury. When pt’s are treated for disability diagnosis and other medical problems, separate pt records must be maintained. Disability ins does not pay for healthcare services, but provides the disabled person w/ financial insurance
Liability Insurance
a policy that covers losses to a 3rd party caused by the insured, by an object owned by the insured, or on premises owned by insured. Liability ins claims are made to cover the cost of medical care for traumatic injuries, lost wages, and in many cases, remuneration for the “pain and suffering” of the insured party. Most health ins contracts state that health ins benefits are secondary to liability ins.
TRICARE
regionally managed health care program for active duty and retired members of the armed forces, their families and survivors. It is a service benefit and contains no premium. TRICARE is the new title for CHAMPUS program (Civilian Health and Medical Program of the Uniformed Services)
What are the 3 types of plans covered under TRICARE?
1) Standard- fee-for service, cost-sharing plan
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
How are co-payments determined with TRICARE?
according to 2 programs
a) active duty family members
b) retirees, their families members and survivors of deceased personnel
CHAMPVA
(Civilian Health and Medical Program of the Veteran Affairs)- was created to provide medical benefits to spouses and children of veterans w/ total, permanent service related disabilities or for surviving spouses and children of a veteran who died as a result of service related disability. It is a service benefit therefore no premiums. Members who receive TRICARE do not qualify for CHAMPVA
Commercial Carriers
-are for profit organizations that operate in the private sector selling different health ins benefits plans to groups or individuals. Most have predefined pt yearly deductibles and coinsurance generally based on the 80/20 split. EX; Aetna, Cigna, Travelers, and Prudential
-most have coordination of benefits (COB) clauses to identify the primary and secondary payer responsibility status for dependent children
Gender rule
male of household is primary payer
Birthday rule
the plan of the parent whose birthday falls earlier in the year (month and date, not year) is primary to that whose b-day falls later in the calender year. If both parents have same birthday, then the plan of the parent who has had the longest coverage is primary. **In case of divorce, the plan of the parent w/ custody of the children is the primary payer unless the divorce settlement states otherwise
Blue Cross/Blue Shield Plans
group of independently licensed local companies, usually nonprofit that contracts w/ dr’s and other health entities to provide services to their insured companies and individuals. Most BC/BS plans offer HMO’s, PPO’s and POS plans
Blue Cross
covers hospital services, outpatient care, some institutional services and home care
Blue Shield
covers physician services, and in some cases, dental, outpatient services and vision care
What are BC/BS plans reimbursement methodologies?
physician reimbursement had been based on the UCR method but more plans have adapted the RBRVS method while some are using capitated rates.
Paper Claim
traditional method used by providers for submission of charges to ins co’s. The most commonly used form is the CMS-1500. Few plans will still accept the physicians encounter forms or superbill and Medicare will only accept claims onthe CMS-1500
Electronic Claim
alternative to paper claim, submitted to payer directly by physician or clearinghouse. Are usually paid faster. Most electronic claims software have self-editing features that detect and report entries that may cause to be rejected, such as invalid codes or incomplete claims
What is a clearinghouse?
an entity that receives transmission of claims for dr’s offices, separate the claims by carriers and performs software edits on each claim to check for errors. One this process is complete, the claim is then sent to proper ins carrier. The dr pays the clearinghouse a fee for their services. A result of the review is sent back to the claims preparer using and audit/edit report
What are the 2 major sections of a claims form?
-Blocks 1-13, refers to pt info
-Blocks 14-33, refers to physician info
What should be done in absences of payer provided instructions for completing claim form?
Instructions on the claim form
Basic Billing & Reimbursement Steps:
-collect pt 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
Life cycle of Insurance Claims
I. Claims submission-transmission of claims data either electronically or manually to payers or clearinghouses for processing
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
Non-covered benefit
any procedure or service reported on the ins claims that is not listed in the payer’s master benefit list. This will result in the denial of the claim. Providers may be able to recover the charges from the pt
Unauthorized Benefit
procedure or service provided w/o proper authorization or was not covered by a current authorization. The claim is denied and the provider cannot bill the pt for the charges
What does Medical Necessity edit check for?
-procedure codes match the diagnosis code
-procedure are not elective
-procedures are not experimental
-procedures are essential for treatment
-procedures are furnished at an appropriate level
VI. Payment
once the claim is approved for payment, a remittance advice (RA) is sent to the provider and an explanation of benefits (EOB) is mailed to the policyholder
Assignment of Benefits
reimbursement is sent directly from payer to provider
Accept Assignment
mean the provider agrees to accept what the ins co approves as payment in full for the claim
New Patient
Individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
Established Patient
Individual who has received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years.
Inpatient
term used when a patient is admitted to the hospital w/ the expectation that the pt will stay for a period of 24 hrs or more
Outpatient
pt who receives treatment in any of the following settings:
-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
Consultation
service performed by a physician whose opinion or advice is requested by another physician in the evaluation or treatment of a pt’s illness or suspected problem. The consultation does not assume any responsibility for the pt’s care and must send a written report back to the requesting physician
Fee-for-service
fee that is charged for each procedure or service performed by the physician. This fee is obtained from a FEE SCHEDULE, which is a list of charges or allowances that have accepted for specific medical services. The system in which fee schedules are determined is referred to a USUAL, CUSTOMARY, AND REASONABLE, (UCR)
Fiscal Intermediary
an ins co that bids for a contract w/ CMS to handle the medicare program in a specific area
Explanation of Benefits (EOB)
describes the services billed and includes a breakdown of how the payment is determined (sent to pt)
Premium
the cost of ins coverage paid annually, semi-annually or monthly to keep a policy in effect
Deductible
a cumulative out-of-pocket amount that must be paid annually by the policyholder before benefits will be paid by the ins co
co-payment
cost-sharing requirement for the insured to pay at the time of service. This amount is usually a specific dollar amount
Coinsurance
percentage of the cost of covered services that a policyholder or a secondary ins pays. A common payment % for coinsurance is 80/20 which indicates that 20% is the coinsurance for the beneficiary or secondary ins is responsible
Coding
process of converting diagnosis, procedures, and services into numeric and alphanumeric characters
Medical Neccessity
defined by Medicare as “the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury”
Exclusion and Limitations
conditions, situations, and services not covered by the ins carrier
Pre-certification
to determine coverage for a specific treatment such as surgery, hospitalization or tests, under the insured’s policy
Pre-determination
to determine the pt’s benefits and the maximum dollar amount that the ins company will pay. Often the 1st step of the ins verification process, it is completed prior to the first visit
Pre-authorization
requirement for some health ins plans to obtain permission for a service or procedure before it is done. It indicates that a specific procedure or service is deemed “medical necessary”
Qualified diagnosis
working diagnosis which is not yet established
Eligibility
the qualify factor or factors that must be met before a pt receives benefits
Coordination of benefits (COB)
when 2 ins co work together to coordinate payment of the benefits
encounter form
also called the superbill; it is a listing of the diagnosis, procedures, and charges for a pt’s visit
Itemized statement
statement of the pt’s account history, showing dates of service, detailed charges, payment (deductibles, co-pays), the date the ins claim was submitted, applicable adjustments and account balance
Peer Review Organization (PRO)
a state based group of physicians working under gov guidelines to review the cases and determine their appropriateness and quality of professional care
Health Insurance Portability And Accountability Act (HIPPA)
deals w/ the prevention of healthcare fraud and abuse of patients on Medicare/Medicaid
Civil Monetary Penalties Law (CMPL)
law passed by the fed gov to prosecute cases of medicaid fraud
The Good Samaritan Act
was developed to protect healthcare professionals from liability of any civil damages as a result of rendering emergency care
Remittance Advice
an electronic or paper-based report of payment sent by the payer to the provider
The Patient Care Partnership (Patients Bill of Rights)
was developed to promote the interests and well being of the pt’s and residents of the healthcare facility. This bill has still not become law
Physician
a doctor of medicine or osteopathy, dental medicine, dental surgery, podiatric medicine, optometry, or chiropactic medicine legally authorized to practice by the state in which he/she performs
Health Practitioner
includes, but is not limited to, physician assistant, certified nurse-midwife, qualified psychologist, nurse practitioner, clinical social worker, physical therapist, occupational therapist,, respiratory therapist, certified registered nurse anesthetist, or any other practitioner as may be specified
Group Practice
group of 2 or more physicians and non-physician practitioners legally organized by a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association
Physician’s Identification Numbers
-State license #, dr must obtain this # in order to practice w/in a state
-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
epidermis
the outer most layer of skin
skin or accessory organs
sudoriferous glands, sebaceous gland, nail
para-
beside
trich/o
combining form meaning hair
lunula
white area at the base of nail plate
hypodermis
subcutaneous tissue
eosin/o; juand/o; cyan/o
refers to color
escharotomy
surgical incision into dead tissue
-plasty
surgical repair
paronychium
soft tissue around nail border
pustule
pimple
Stage III pressure ulcer
full thickness loss of skin up to but not through fascia
atopic
type of dermatitis may be exogenous or endogenous and is most common in children and infants
papulosquamous
psoriasis, pityriasis, and lichen are three types of this disorder
pityriasis
begins with a herald spot
erysipelas
skin infection is caused by group A beta-hemolytic streptococci, and the lesions appear as firm red spots with itching, burning, and tenderness
herpes simplex
produces cold sores
verrucae
caused by human papillomavirus
keratoacanthoma
tumor that occurs in hair follicles
squamous cell
type of superficial carcinoma is rarely metastic
tubular
another name for long bones
sesamoid
bones found near joints
zygoma
type of irregular bone
diaphysis
part of shaft bone
cranium parts
spenoid, ethmoid, parietal
ear bones
malleus, stapes, incus
epiphyseal
describes growth plate
acetabulum
depression on lateral hip surface into which the head of femur fits
olecranon
tip of the elbow
synarthrosis
describes an immovable joint
compound fractue
AKA open fracture
osteoporosis
common bone disorder in postmenopausal women resulting from lower levels of calcium and potassium
ankylosing spondylitis
progressive inflammatory disease and leads to a rigid spinal column
osteogenic
type of tumor arises from bone cells
multiple myoma
this type of tumor is most common type of malignant bone tumor that occurs in those over 40 and is progressive and generally fatal
dermatomyositis
general muscle inflammation with an accompanying skin rash
chondrosarcoma
cartilage tumor that usually occurs in middle-aged and older individuals
reduction
returning of bone to normal alignment
sprain
result of overuse or overextension of a ligament
primary osteoarthritis
known as idiopathic
lower respiratory tract
traches, bronchi, lungs
larynx
another name for voice box
trachea
windpipe
septum
divides the interior of the nose
atel/o
incomplete
spir/o
breath
pan-
all
ARDS
abbreviation for adult respiratory distress syndrome – involves difficuty in breathing
FEV1
forced expiratory volume in 1 second – amount of air patient can expel from the lungs in 1 second
-pnea
breathing
adult respiratory distress syndrome
acute injury to alveolocapillary membrane that results in edema and atelectaisis
empyema
condition in which pus is in pleural space and is often a complication of pneumonia
most common types of atelectasis
adhesive, compression, obstuction
pneumoconiosis
result of accumulation of dust particles in lung
COPD
an irreversible airway obstructive disease in which symptoms are bronchial spasm, dyspnea, wheezing
bronchiectasis
examples are cylindrical, varicose, and secular/cystic
emphysema
condition in which there is a loss of elasticity and enlargement of alveoli
chronic cough
defined as cough that lasts for over 3 weeks
hypercapnia
condition marked by an increase in carbon dioxide in arterial blood and decreased ability to breathe that can result in respiratory acidosis
bronchiolitis
condition often follows a viral infection and occurs on children under 2 years of age. Examples of various types of this condition are constrictive, proliferating, and obliterative
veins
carry blood to the heart
diastole
relaxation phase of heartbeat
sinoatrial
nature’s pacemaker
atrioventricular
located on the interatrial septum
three layers of chamber walls of the heart
endocardium, myocardium, epicardium
interatrial
septum that divides upper two chambers of heart
tricuspid
valve between right atrium and right ventricle
pericardium
outer two-layer covering of the heart
right and left atria
receive blood
ather/o
plaque
stroke
may be caused by a lesion of carotid artery
140/90
hypertension
infective endocarditis
inflammation of the interior of the lining of the heart and when caused by streptococci or staphlococci, the infection is bacterial
angina pectoris
chest pain
mitral
regurgitation backflow of blood from left ventricle into left atrium
constrictive pericarditis
heart wall disorder, fibrous lesions form and encase heart
idiopathic
unknown cause
dilated
condition also known as congestive cardiomyopathy
Buerger’s
peripheral arterial disease most often occuring in young men who are heavy smokers
hypertrophic
cardiomyopathy resulting in a thickened interventricular septum
three layers of the uterus
perimetrium, endometrium, myometrium
cervix
located at the lower end of the uterus
266 days
approximate gestation of a human fetus
LMP
last menstrual period
prenatal
stage that describes development of fetus from fertilization to birth
three trimesters of gestation
LMP-12 wks, 13-27 weeks, 28-EDD
olig/o
few; scant
crypt/o
hidden
-arche
beginning
endo-
within
saline
most common solution used for intra-amniotic injections
primary
type of dysmenorrhea treated with nonsteriodal antiinflammatory agents and progesterone
secondary
in this type of amenorrhea there is a cessation of menstruation
oligomenorrhea
in excess of 6 weeks
metrorrhagia
bleeding between cycles
menorrhagia
increased amount and duration of flow
endometriosis
condition with increased risks of breast cancer, ovarian cancer, and non-Hodgkin lymphoma
leiomyoma
benign lesion also known as uterine fibriods
placenta previa
types of this condition are marginal, partial, and total
malposition of fetus
breech, shoulder, brow, face, and vertex
prostate gland
activates sperm and produces some seminal fluid
vas deferens
carries sperm from testes to ejaculatory duct
erectile tissues of the penis
two corpora cavernosa and one spongiosum
bulbourethral gland
AKA Cowper’s gland
male genital accessory organs
seminal vesicles, prostate, ducts, bulbourethral gland, penis, and scrotum
andr/o
male
balan/o
glans penis
tunica albuginea
cover the testes
TURP
transurethral resection of prostate; describes a surgical resection of prostate that is accomplished by means of an endoscope inserted into urethra
BPH
benign prostatic hypertrophy; describes a condition of prostate in which there is an enlargement that is benign
cryptorchidism
condition in which the testes do not descend
orchitis
most often caused by a virus
torsion
condition that can be either congenital or aquired through trauma and tht involves twisting of testes
testes cancer
divided into two main groups of germ cell tumors and sex stromal cord tumors
Mohs
surgical technique involves excision of a lesion in layers until no further evidence of abnormality is seen
epispadias
a disorder of uretra in which urethral meatus in located on dorsal (back) side of penis
balanitis
inflammation of glans
Peyronie’s
disease aka as bent nail syndrome
benign prostatic hypertrophy
condition in which multiple fibroadenomatous nodules form and lead to decreased urine flow. Condition is thought to be related to increased levels of estrogen/androgen
adenocarcinoma
cancer of prostate is predominately this type of cancer
cortex
outer covering of the kidney
kidney structure
cortex, medulla, hilum, pyramids, papilla, pelvis, calyces, and nephrons
trigone
smooth area inside the bladder
ureter
narrow tube connecting kidney and bladder
three surfaces of urinary bladder
posterior (base), anterior (neck), and superior (peritoneum)
lith/o
stone
dysuria
painful urination
medulla
inner portion of kidneys
olig/o
scant; few
ARF
acute renal failure
three types of renal failure
prerenal, intrarenal, and postrenal
90%
loss of nephron function in end-stage renal disease
E. coli
usually the cause of bacterial cystitis
antibiotics
primary treatment for acute pyelonephritis
APSGN
acute poststreptococcal glomerulonephritis
obstuctive uropathy
urinary tract obstruction
ESWL
extracorporeal shock wave lithotripsy; treatment for kidney stones
treatment for hydornephrosis
treatment of underlying condition
polycystic kidney
congenital condition in which numerous cysts form in the kidney
treatment of Wilm’s tumor
excision, radiation therapy, and chemotherapy. Usually a combination of all
parts of the small intestine
duodenum, jejunum, and ileum
sphincter
ring of muscles
pharynx
throat
three parts of the stomach
fundus, body, and antrum
uvula
projectin at the back of the mouth
rugae
mucosal membrane that lines the stomach
the parts of the colon
ascending, transverse, descending, and sigmoid
celi/o
abdomen
anastomosis
connecting two ends of a tube
EGD
espohagogastroduidenoscopy; scope placed through the esophagus into the stomach and to the duodenum
posthepatic
type of hyperbilirubinemia hallmarked by excess bile flow into the blood
hepatitis A
type of hepatitis transmitted by the oral-fecal route
posticteric
recovery stage of hepatitis
alcohol liver cirrhosis
aka portal cirrhosis
cholangitis
inflammation of the bile ducts
smoking
primary factor that increases the risk of pancreatic cancer
pancreatitis
potential complication of this condition is ARDS
cholesterol and bile salts
high levels can form gallstones
removal of cause
primary treatment for jaundice
cirrhosis
has as the largest group who abuse alcohol
LUQ
left upper quadrant; location of spleen
bone marrow
produces RBCs and platelets
lymph organs
spleen, thymus, and tonsils
lymph
transports fluids and protiens that have leaked from the blood system back to viens
thymus
largest in infants and shrinks with age
aden/o
gland
hyper-
excess
-megaly
enlargement
jugular
lymph node located on neck
stem cells
originate in the bone marrow
mediastinum
NOT an organ system
division of mediastinum
superior, anterior, posterior, and middle
flattens out
the diaphragm does during inspiration
median
partition
dome
the shape of the diaphragm
diaphragm
separates the abdominal cavity from the thoracic cavity
mediastinum
area between the lungs
diaphragmatic
esophageal hernia
esophageal
aka diaphragmatic hernia
breathing
the diaphragm assists in
anemia
reduced number of erythrocytes and decreased quality of hemoglobin
hemolytic anemia
condition hallmarked by a shortened survival or mature erythrocytes and inability of bone marrow to compensate for decreased survival
infectious mononucleosis
most common cause is Epstein-Barr virus
lymphangitis
inflammation of the lymphatic vessel
Reed-Sternberg
giant cell present in Hodgkin’s disease
multiple myeloma
increases plasma cells, which replace bone marrow
pernicious
type of anemia for which vitamin B injection may be prescribed
megaloblasts
large stem cells
infectious mononucleosis
kissing disease
Burkitt’s
lymphoma usually found in Africa
progesterone
not affected by the endocrine system
thyroid
gland that overlies the trachea
adrenal
gland that is located on the top of each kidney
outer region of the adrenal gland that secretes corticosteriods
cortex
parathyroid
located on the thyroid
pituitary
located at the base of the brain in a depression in the skull
oxytocin
stimulates contractions during childbirth
estrogen and progenterone
produced only during pregnancy by the placenta
crin/o
secrete
eu-
good
type 1 diabetes
typically occurs before 30
NIDDM
non-insulin-dependant diabetes mellitus
tumor
the most common cause of pituitary disorder
somaatotrophin
hormone can cause giantism
goiter
can be caused by hypothyroidism or hyperthyroidism
Hashimoto’s
type of hypothyroidism that is an autoimmune disorder
hypoparathyroidism
can cause tetany
Conn’s syndrome
aka primary hyperaldosteronism
virilization
development of male characteristics
hormone replacement
treatment for Addison’s disease
peripheral
portion of nervous system that contains cranial and spinal nerves
dendrite
part of neuron that receives signals
monocytes
not associated with glia
cerebrum
largest part of the brain
divied into two hemispheres
cerebrum
12
number of pairs of cranial nerves
left cerebrum
controls right side of body
encephal/o
brain
tetra-
four
phas/o
speech
Alzheimer’s disease
most common dementia
MND
motor neuron disease
Parkinson’s disease
dopamine replacement is useful
myasthenia gravis
primary symptoms are muscle weakness and fatigability
Guillain-Barre syndrome
aka idiopathic polyneuritis
schizophrenia
thought to be caused by genetic factors and possibly fetal brain damage
Reye’s syndrome
associated with viral infection, especially when aspirin has been administered
concussion
mild blow to head in which recovery is expected within 24 hours
ICP
intracranial pressure
subarachnoid hematoma
blood mixes with cerebrospinal fluid
choriod
middle layer of the eye
conjunctiva
covering of the front of sclera and lining of eyelid
CN1
cranial nerve controls the sense of smell
parts of the inner ear
vestibule, semicircular canals, and cochlea
mechanoreceptors
receptors that react to touch
bones of the middle ear
stapes, malleus, and incus
proprioceptors
receptors that react to postition and orientation
blephar/o
eyelid
phak/o
eye lens
PERRLA
pupils are equal, round, and reactive to light and accomodation
astigmatism
irregular curvature of the refractive surfaces of the eye
hyperopia
eyeball is shorter than normal and results in being able to see objects in the distance but not close up
nystagmus
rapid, involuntary eye movement is the predominant symptom
presbyopia
age-related farsightedness
hordeolum
stye
keratitis
inflammation of the cornea that is caused by herpes simplex virus
macular degeneration
destructin of the fovea centralis
otitis media
infection that occurs in the middle ear cavity
sensorineural
hearing loss that can be due to a lesion on the cochlea
perceptive deafness
sensorineural
incision of the perineum during childbirth:
episiotomy
fingerlike ends of the fallopian tubes are called:
Fimbriae
the study and treatment of newborns is called:
Neonatology
a woman who has had 3 miscarriages and 2 live births:
gravida 5 para 2
hormone produced by an endocrine gland located below the brain:
follicle-stimulating hormons (FSH)
removal of the fallopian tubes and ovaries:
Bilateral salpingo-oophorectomy
sac containing the egg is the:
ovarian follicle
painful labor and delivery:
dystocia
physician’s effort to turn the fetus during delivery:
cephalic version
excessive flow of blood from the uterus between menstrual periods:
menometrorragia
amniocentesis
needle puncture of the amniotic sac to withdraw amniotic fluid for analysis
amniotic fluid
fluid within the amniotic sac that surrounds and protects the fetus
endocervicitis
an inflammation of the mucous membrane lining of the cervix, inflammation of the inner (lining) of the cervix
chorionic
pertaining to the chorion
colposcopy
visual examination of the vagina and cervix using a colposcope
culdocentesis
surgical puncture to remove fluid from the cul-de-sac
episiotomy
A surgical procedure in which an incision is made to enlarge the vaginal (vulva) opening for delivery
galactorrhea
Abnormal production and secretion of milk from the breasts or any white discharge from the nipple.
gynecomastia
Abnormal development of breast tissue in males
lactation
the period following birth during which milk is secreted, the secretion of milk
colpotomy is an incision into the vagina
true
diagnostic amniocentesis includes radiologic supervision and interpretation
false
a radical vulvectomy is the removal of greater than 80% of the vulvar area
false
loop electrode excision procedures are also referred to as:
leep, or letz
hysterectomy codes are first divided in the CPT manual based on the __?__ and then on any secondary procedures that were done.
approach
in which category would you locate a code for the removal of an IUD?
introduction
lysis of adhesions os performed on either the fallopian tubes or the:
ovary, oviduct
the code 59400 doesn’t include?
medical problems complicating labor ordelivery, E/M codes
if a patient has had a previous cesarran delivery and then has a vaginal delivery, the correct code would be:
59612
a fetal non-stress test is completed on a 36-week pregnancy. the correct code would be?
59025
biopsy of the vaginal mucosa code is?
57100
what surgery subheading has only two codes?
intersex surgery
salpingectomy
the surgical remoal of the fallopian tube
disp/o
the combining form that means thirst
allograft
is also known as homograft
mechanorecptor, proprioceptor, thermoreceptor
are all receptors within the body
gustatory
means taste
-ectomy
the suffix meaning removal;
pachyderma
means abnormal thickening of the skin
diastole
the relaxation phase of the heartbeat
duodenum
the first portion of the small intestines
vestibule
this is part of the inner ear
anterior chamber
this is the area behind the cornea
clavicle
this is the collar bone
supination
the act of turning upward, such as teh hand turned palm upward
dermis
this is known as the middle layer of skin, also known as the corium or true skin.
diaphysis
the shaft of the long bone
endocardium, myocardium, epicardium
are coverings of the chamber walls of the heart.
straight forward MDM
one self limited or minor problem (minimal) {amount or complexity of data to review-minimal/none}
Low Complexity MDM
2 or more self limited or minor problem, 1 stable chronic or acute uncomplicated illness or injury. Acute uncomplicated illness or injury.(# of diagonioses or management options, limited) {amount or complexity of data to review-limited} RISK-Minimal
Moderate Complexity MDM
1 or more chronic illnesses with mild exerbation, progression or side effects of treatment-2 or more stable chronic illnesses. Undiagonised new problem with uncertain prognosis, acute illness with systemic symptoms, acute complicated injury.(# of diagonioses or management options, multiple) {amount or complexity of data to review-moderate}RISK-low
High Complexity MDM
1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Acute or chronic illnesses or injuries that pose a threat to life or bodily functions. Phychiatric illness with potential threat to self or others. Peritonitis. Acute Renal failure, or a abrupt change in neurologic status..(# of diagonioses or management options, extensive) {amount or complexity of data to review-extensive}RISK-high
Cleft lip & cleft palate (orofacial cleft)
congential defect, causes feeding problems, danger of aspirating food, & results in speech defects. TREATMENT: surgical repair
Ulceration
canker sore-caused by herpes simplex virus. ulceration of the oral mucosa. Also known as Aphthous ulcer (aphtha: small ulcer) Aphthous stomatitis. Heals spontaneously.
Canidida
this is naturally found in the mouth. Thrush (oral candidiasis) is overarching infection. Causes: antibotic regimen, chemotherapy, glucocorticoids. Common in diabetics and Aids patients. Treatment- Nystatin(tropical fungal agent)
Herpes simplex type 1
Herpetic stomatitis, viral cold sores and blisters. Associated with herpes simplex virus type 1 (HSV-1) Treatment, NO CURE. Maybe alleviated somewhat by antiviral medications.
Cancer of Oral Cavity
Most common type is squamous cell carcinoma, Kaposi’s sarcoma is type seen in AIDS patients. Increased in smokers. Lip cancer also increased in smokers, particulary pipe. Poor prognosis. Usually asymptomatic until later stages. Metastasis through lymph nodes.
Scleroderma
Also known as progressive systemic sclerosis. Atrophy of smooth muscles of the lower esophagus. Lower esophageal sphincter (LES) does not close properly. Leads to esophageal reflux. Strictures form. Predominantly dysphagia.
Esophagitis
Inflammation of esophagus. Types, acute- most common type that is caused by hiatal hernia. Infectious esophagitis is common in patients with AIDS. Ingestion of strong alksline or acid substances, such as those found in household cleaners. Inflamation leads to scaring. CHRONIC: Most common type is caused by LES Reflux
Cancer of Esophagus
Most common type is squamous cell or secondary adenocarcinoma. Usually caused by continued irritation, smoking, alcohol, hiatal hernia, chronic esophagitis/GERD, poor prognosis.
Hiatal Hernia (diaphragmatic hernia)
diaphragm goes over stomach. esophagus passes through diaphragm at natural opening (hiatus), part of the stomach protrudes (herniates) through opening of diaphragm into throat. Types: sliding-stomach and gastroesophageal junction protrude through the hiatus paraesophageal/rolling hiatal. Part of fundus protrudes. SYMPTOMS: heartburn, reflux, belching, lying causes discomfort, dysphagia, substernal pain after eating.
Gastroesopageal Reflux Disease (GERD)
Associated with hiatal hernias. Reflux of gastric contents, Lower esopageal sphincter does not constrict properly. TREATMENT: Reduce irritants, such as smoking, spicy foods, alcohol. Antacids, elevate head of bed, avoid tight clothing.
Gastritis
Inflamation of the stomach mucosa. Acute superfical gastritis, Mild transient irrtation. Causes: Excessive alcohol, infection, food allergies, spicy foods, asprin, H.pylori (Helicobacter pylori). Symptoms: Nausea, vomiting, anorexia, bleeding in more severe cases, espigastric pain. TREATMENT: usually spontaneous remission in 2 to 3 days. removal of underlaying irritation, antibiotics for infection
Chronic atropic gastritis
progressive atrophy of epithelium. Types; Type A-atrophic or fundal. Involves fundus of stomach, autoimmune disease, decreases acid secreation, results in high gastrin levels. Type B-antral, involves antrum region of stomach, often assoicated with elderly, maybe associated with pernicious anemia, low gatrin levels, usually caused by infection, irritated by alcohol, drugs, & tobacco. Symptom debatement; bland diet, alcohol avoidance, ASA avoidance, antibiotics for H. pylori.
Peptic Ulcers
Erosive area of mucosa. Extends below epithelium, chronic ulcers have scar tissue at base of erosive area. Can occur anyplace on gastrointestinal tract but typically are found on the: Lower esophagus, stomach, proxmal duodenum. Some causes; alcohol, smoking, aspirin, severe stress, bacterial infections caused by Helicobacter pylori (H.pylori), 90% of the time, genetic factor, constant use of anti-inflammatory drugs. Symptoms; epigastric pain when stomach is empty, relieved by food or antacid, burning. May include; vomiting blood, nausea, weight loss, anorexia, Severe cases may include; obstruction, hemorrhage, perforation. TREATMENT: Surgical intervention, antacids, dietary restrictions, rest, antibiotics.
Gastric Cancer(malignant tumor of stomach)
Most often in men over 40-cause id unknown, but is often associated with Helicobacter pylori (bacterial infection). Predisposing factors; atrophic gastritis, pernicious anemia, history of nonhealing gastric ulcer, Blood type A, goegraphic factors, environmental factors, carcinogenic foods, smoked meats, nitrates, pickeled foods. Symptoms; usually asymptomatic in early stages. TREATMENT: excision, chemotherapy, radiation(poor response), prognosis.
Pyloric Stenosis
Narrowing of the pyloric sphincter. Signs appear soon after birth, failure to thrive, projectile vomiting. TREATMENT: surgery to relieve stenosis (pyloromyotomy)
Celiac disease
most important malabsorption condition. Villia atrophy in to response to food containing glutten and lose the ability to absorb, Glutten is a protein found in wheat, rye, oats, & barley. Symptoms; Malnutrition, muscle wasting, distended abdomen, diarrhea, fatigue, weakness. TREATMENT: Glutten free diet, steroids when necessary.
Lactase deficiency
Enxyme deficiency. Secondary to gastrointestinal damage, such as regional enteritis, infection, common in blacks, occuring in adulthood. Symptoms; intolerance to milk, intestinal cramping, diarrhea, flatulence. TREATMENT: Elimination of milk products.
Crohn’s Disease (regional enteritis)
Inflammatory bowel disease-affects terminal ileum and colon. Unknown cause. Symptoms; vary greatly/inflammatory disease of the GI tract.diarrhea, gas, fever, abdominal pain, malaise, anorexia, weight loss. TREATMENT: no specific treatment. Palloative medications to control symptoms, pesection of the intestine with anastomosis, diet modification
Duodenal ulcers
most common ulcers. Develope in younger population, common in Type O blood types.
Appendicitis
Inflammation of vermiform appendix that projects from the cecum. Obstruction of the lumen leads to inffection. Appendix becomes hypoxic (decreased oxygen levels), may cause gangrene, may rupture, causing peritonitis. Symptoms; periumbilical (around umbilicus) pain, initially right lower quadrant pain as inflammation progresses, nausea, vomiting, possible diarrhea. TREATMENT: appendectomy, management of any perforation of abscess.
Meckel’s Diverticulum
an appendage of the ileum near cecum derived from an unobliterated yolk stalk in fetal development. Symptoms can mimic appeddicitis.
Peritonitis
Inflammation of the peritoneum(membrane that lines abdominal cavity) Usually results of spread of infection from the abdominal organ, puncture wound to abdomen, rupture of the gastrointestinal tract-appedicitis or Meckel’s diverticulum, abcesses form, resulting in adhesions, may result in obstruction. Types; Acute, Chronic. Symptoms; abdominal pain, vomiting, rigid abdomen, fever, leukocyrosis (increased white blood cells in blood). TREATMENT: antibotics, suction of stomach & intestines, if possible surgical removal of orgin of infection, such as appedix, fluid placement, bed rest.
Obstruction
any interference with passage of intestinal contents. Maybe; acute, chronic, partial, total. Types; Nonmechanical, Paralytic ileus, result of trama or toxins. Mechanical; results of tumors, adhesions, hernias, Simple mechanical obstruction, one point of obstruction. Closed loop obstruction, at least 2 points of obstruction. Diverticulosis, twisted bowel (volvulus) Telescoping bowel (intussception). Symptoms; abdominal distension, pain, vomiting, total constipation. TREATMENT: surgical intervention, symptomatic treatment
Diverticulosis
Herniation of intestinal mucosa, forms sacs inlining, called diverticula. Sacs fill & become inflamed, common in aged. Symptoms; diarrhea or constipation, gas, abdominal discomfort. Complications; perforation, bleeding, peritonitis, abscess, obstruction. TREATMENT: Antimicrobials as necessary, high fiber diet, stool softener, dietary restrictions of solid foods, surgical intervention.
Ulcerative colitis
Inflammation of rectum that progresses to the sigmoid colon. Intermitten exacerbations and remissions. May develop in megacolon. Leads to obstruction & dilation of colon, increased risk of colorectal cancer. Symptoms; Diarrhea, blood & mucus may be present, cramping, fever, weight loss. TREATMENT: Remove physical or emotional stressors, anti-inflamatory medications, antimobility agents, nutritional supplements, surgical intervention.
Colorectal Cancer
Usually develops from polyp in those 55 & older. Increased risks, genetic factors, 40 years of age and older, diets high in fat, sugar, red meats, low fiber diets. Symptoms; asymptomatic until advanced, some mayt experience, cramping, ribbon stools, feeling of incomplete evacuation, fatigue, weight loss, change in bowel habits, blood in stool. TREATMENT: surgical excision, radiation, chemotherapy, combination of previous,
Jaundice
a symptom of biliary disease, not a disease itself. Results in yellow eyes (sclera) and skin. Types, Prehepatic- escess of destruction of red blood cells, results in hemolytic anemia or reaction to tranfusion. Interhepatic- impaired uptake of bilirubin and decreased blending of bilirubin by hepatic cells, results of liver disease, such as cirrhosis, or hepatitis. Posthepatic- excess of bile flows into blood, results in obstruction, due to condition such as inflammation of liver, tumors, cholelithiasis. TREATMENT: removal of cause.
Cancer of liver
Most commonly a metastasis; primary CA rare. Risk of primary lliver CA-hepatitis B, C, & D, cirrhosis, myotoxins, heavy smoking & alcohol use. TREATMENT: Surgical resection if localized, survival typically 3 or 4 months.
Viral Hepatitis
Liver cells damaged, results in inflammtion and necrosis. Damage can be mild or severe, scar tissue forms in liver, leads to ischemia.
Hepatitis A (HAV)
Infectious hepatitis- caused by hepatitis A virus. Transmission- mostly oral-fecal route-contaminated foodor water, does not have a chronic state. Slow onset-complete recovery characteristic. Vaccine availiable for those that are traveling, gamma globulin may be administered to those exposed.
Hepatitis B (HBV)
Serum hepatitis, carrier state is common, caused by hepatitis B virus, asymptomatic but contagious, long incubation period. Transmission-intravenous drug users, transfussion, expossure to blood and bodily fluids, sexual transmission, mother-to-fetus transmission, immune globulin is temporary prophylactic, vaccine is now routine for children & is given to those at risk. Severe forms cause liver cell destruction, cirrhosis, & death.
Hepatitis C (HCV)
Transmission of virus. Most commonly by transfussion, IV drug users, half of cases develop into chronic hepatitis, increase risk of hepatocellular cancer, carrier state may develop.
Hepatitis D (HDV)
Transmission of Hepatitis D virus. Blood, intravenous drug users, Hepatitis B is present for this type to develop.
Hepatitis E (HEV)
Transmission of hepatitis E virus. Oral-fecal route, does not develop into chronic or carrier.
Hepatitis G
Transmission of hepatitis G virus, IV drug use, sexual transmission. Symptoms of hepatitis. Stages, Preicteric; anorexia, nausea and vomiting, liver enzymes may be elevated-indication of liver cell damage; fatigue, malaise, generalized pain & low grade fever, cough. Icteric jaundice, hepatomegaly (enlarged liver), biliary obstruction, light colored stools and dark urine, prutitus, abdominal pain. Posticteric (recovery) Reduction of symptoms. TREATMENT: None. In early stages gamma globulins may be used. Interferon may be used for cases of chronic hepatitis B & C.
Non-Viral Hepatitis
Hepatitis that results from hepatotoxins. Symptoms; similiar to viral hepatitis. TREATMENT: removal of hepatotoxins.
Cirrhosis
profuse liver damage. Extensive fibrosis, results in inflammation, progressive disorder, leads to liver failure. Types-Alcoholic liver known as Laennec’s cirrhosis or portal, largest group. Biliary; associated with immune disorders, obstructions (intrahepatic blood vessels) occur and disrupt normal function. Postnecrotic-associated with chronic hepatitis (A or C) and exposure to toxins. Symptoms; Asymptomatic in early stages, nausea, vomiting, fatigue, weightloss, pruritus, jaundice, edema. TREATMENT: Symptomatic, dietary restrictions, reduced protein & sodium, increased vitamins & carbohydrates, diuretics, antibotics, liver transplant.
Cholecystitis
inflammation of gallbladder & cystic duct.
cholangitis
inflammation of the bile duct.
cholelithiasis
Formation of gallstones. Consists of cholesterol or bilirubin. Occurs most often in those with high levels of cholesterol, calcium, or bile salts. Stones cause irritation and inflamation, may lead to infection, obstruction, may result in pancreatitis, rupture may be possible. Symptoms; often asymptomatic, dietary intolerance to particularly fat, right upper quadrant pain, pain in back and or shoulder,epigastric discomfort, bloating heartburn, flatulence. TREATMENT: Surgical intervention (laparoscopic cholecystectomy), lithotripsy, medical management by use of drugs that break down stone.
Pancreatiitis
Inflammation of pancreas resulting from digestive enzyme attackto pancreas. Acute and chronic forms. Commonly associated with alcoholism/biliary tract obstruction, drug toxicity, gallstone obstruction of common bile duct and viral infections. Symptoms; severe pain, acute form is medically emergency, neurogenic shock, septicemia, general sepsis. Complications; adult respiratory distress syndrome (ARDS), renel failure. TREATMENT: no oral intake, IV fluids given and carefully monitored, analgesics, stop process of autodigestion, prevent systemic shutdown.
Pancreatic Cancer
Increased risk, cigarette smoking, diet high in fat and protein. Symptoms; weight loss, jaundice, anorexia, most types of pancreatic cancer are asymptomatic until well advanced. TREATMENT: palliative, pain management.

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