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.Identify the correct procedure (CPT-4) code(s) for the above scenario:

CPT-4: __________ Modifier: __________

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? __________________

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? _____________________

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: __________

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? _____________________

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: __________

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? _____________________

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? __________

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: __________

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? ____________________

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? _____________

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: __________

A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC).

Identify the correct procedure (CPT-4) code for this service:
CPT-4: __________

An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct diagnosis (ICD-9-CM) code for the above scenario.
ICD-9-CM: __________

An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct procedure (CPT-4) code for the above scenario:
CPT-4: __________
CPT-4: __________

A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario:
ICD-9-CM: __________

A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct procedure (CPT-4) code(s) for the above scenario.
CPT-4: __________

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 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: __________

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: __________

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__________

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? ___________________

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? _____________

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:___________________

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: __________

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? ___________________

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:_________

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? __________________________________

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 _________

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: __________

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?
__________

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?
______________

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

In this scenario, which physician are you coding for?
_________________________________

HEMODIALYSIS PROGRESS NOTE

LOCATION:Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

Identify the correct (ICD-9-CM) diagnosis code(s) for the above scenario:

ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________,
ICD-9-CM __________.

HEMODIALYSIS PROGRESS NOTE

LOCATION:Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.
Identify the correct procedure code (CPT-4) for the above scenario:

CPT-4 __________

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

Should a modifier be added to the CPT code in order to submit the insurance claim?
______________

HEMODIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Sandra Amada
ATTENDING PHYSICIAN: George Orbitz, 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

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: _____

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: _____

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: ______________

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): _______

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): _______

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: ___

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: __________

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: __________

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: __________

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: __________

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: __________

urticaria

keloid

boil

melanin

epidermis and dermis

hyodermis

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?

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: __________

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)
____________________

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)
____________________, ____________________

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: __________

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? ____________________

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?____________________

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: _________

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? ____________________

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: _____________________

An excision of the left great toe nail and matrix, complete for permanent removal:
CPT Code: ___

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.

Mastectomy that is done for gynecomastia:

Removal of 37 skin tags by electrosurgical destruction:

Destruction of 7 actinic keratoses:

T/F Free skin grafts are coded according to the site, size and type of repair to the recipient site.

Fine needle aspiration of the breast without imaging:

When coding 3 biopsies of the skin, performed at the same visit, the reporting would be:

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.

Excision of a pilonidal cyst that was a complicated procedure:

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.

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.

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.

The repaired wound should be measured or converted to:

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.

Dermabrasion of the segmental face:

Using the “Rule of Nines,” each adult leg is what percentage of the human body?

T/F A debridement is the cleaning of a surface area and the removal of necrotic tissue by washing or cutting.

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.

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.

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: __________

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: __________

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: __________

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: __________

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: __________

Hidr/o

Onych/o

Trich/o

Burs/o

chondr/o

erg/o

my/o

myel/o

ton/o

phren/o

phleb/o

angi/o

bucc/o

cholecyst/o

labi/o

stoma, stomat/o

basal

Os

ec-, ecto

end/o

mes/o

dextr/o

sinister/o

Ab

Ad

dia

per

-gram

-graph

scope

scopy

-desis

-ectomy

-pexy

-traphy

-stomy

-tomy

-tripsy

blepharoplasty

salpingo-oophorectomy

tracheostomy

leukocytosis

proximal

distal

superior/ cranial

inferior/caudal

superficial/external

deep/internal

sagittal

transverse(horizontal)

epithelial tissue

mucous membrane

stratum lucidum

long bones

tubular bones

synovial

root meaning of joint

example of a long bone

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? __________

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?

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? ____________________

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? _____________

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?

A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC).

Identify the correct procedure (CPT-4) code for this service:

An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct diagnosis (ICD-9-CM) code for the above scenario.

An 80-year-old female patient with cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.
Identify the correct procedure (CPT-4) code for the above scenario:CPT-4: __________
CPT-4: __________

A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario:

ICD-9-CM: __________

A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct procedure (CPT-4) code(s) for the above scenario.

CPT-4: __________

T/F The postmortem codes 88000-88099 represent physician services only.

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?

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?

What is the name given to grouped laboratory work that represents those tests commonly performed together?

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?

Pathologic analysis of sample taken from Patient’s right kidney during a biopsy. What are the correct CPT-4 code(s) for these services?

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.

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?

T/F Pathologists have specific codes for clinical pathology consultations.

According to the CPT Index, in what section would you locate codes to report venipunctures and arterial punctures?

T/F There are four subheadings in the radiology section.

T/F According to the CPT manual there are different codes for Helicobacter pylori (H. pylori) depending on the source of the specimen.

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.

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?

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?

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?

What is the modifier used to identify the technical component of a radiologic procedure?

T/F The phrase “with contrast” represents contrast material administered intravascularly, intra-articularly, or intrathecally.

T/F For repeat laboratory tests performed on the same day, the correct modifier is -51.

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.

According to the guidelines for Radiation oncology, these codes include normal follow-up care during the course of treatment and ________ following its completion.

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? __________________________________

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 _________

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: __________

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?

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?

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

In this scenario, which physician are you coding for?

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

Identify the correct (ICD-9-CM) diagnosis code(s) for the above scenario:

ICD-9-CM __________,

ICD-9-CM __________,

ICD-9-CM __________,

ICD-9-CM __________.

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

Identify the correct procedure code (CPT-4) for the above scenario:

CPT-4 __________

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

Should a modifier be added to the CPT code in order to submit the insurance claim?

HEMODIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Sandra Amada

ATTENDING PHYSICIAN: George Orbitz, MD

HEMODIALYSIS PROGRESS NOTE: The patient is seen and examined during hemodialysis. The patient appears to be hemodynamically stable, not in any form of respiratory distress or compromise.

LABORATORY STUDIES: Latest labs were performed 4 weeks ago. Hemogram shows an H&H (hematocrit and hemoglobin) of 8.6/26.2. WBC (white blood count) is 9.9, normochromic/normocytic indices. Platelets are 143. There is left shift of 81.1% neutrophils. Sodium is 139, potassium 4, chloride 98, CO2 (carbon dioxide) is 30.7, BUN (blood urea nitrogen) and creatinine 31/3.4, glucose 121, and calcium 8.2. Today, we will dialyze her for a total of 4 hours using an HP-150 dialyzer via her right-sided Perm-A-Cath. We will use a 2.0 potassium bath, and we will not give her any heparin loading dose during this treatment.

PHYSICAL EXAM: At present time, vital signs are stable. Blood pressure is 128/57. Heart rate is 80, and she is tolerating a blood flow rate of 500 ml (milliliter) per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae, anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy. Symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 (first heart sound) and S2 (second heart sound) distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

ASSESSMENT/PLAN:
I. End-stage renal disease (on maintenance hemodialysis, Monday, Wednesday, and Friday), most likely secondary to the following:Hypertension. Continue same antihypertensive regimen as ordered.
B. Type 2 diabetes mellitus. Continue oral antidiabetic agents. Continue the same dialysis orders as above.
C. Previous chronic use of NSAID (nonsteroidal antiinflammatory drug)/COX-2 inhibitors.
II. Anemia due to chronic renal disease.
III. Questionable diverticulosis; status post multiple herniorrhaphies; status post- cholecystectomy.
IV. Discharge planning: The plan is to discharge the patient to rehabilitation medicine.
At this time, the patient appears to be stable and is tolerating hemodialysis. We will continue to follow this patient from the renal/hemodialysis standpoint. She will get erythropoietin 10,000 units IV (intravenous) after hemodialysis today.

What claim form will be submitted for the physician?s services? ________________

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 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:

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

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:

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? _______________

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? ___

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:___________________

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: __________

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? ______

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:_________

-opia

-omia

-tropia

-algesia

-algia

-cele

-esthesia

-iatry

-ictal

-kines/o

-paresis

-plegia

-agon

-drome

-emia

-in

-ine

-tropin

-uria

-ectomy

-edema

-itis

-megaly

-oid

-oma

-penia

-pexy

-phylaxis

-poiesis

-ase

-chezia

-iasis

-phagia

-prandial

-eal

-lithiasis

-lysis

-plasty

-rrhaphy

-tripsy

-one

-stomy

-arche

-cyesis

-gravida

-rrhexis

-parous

-para

-rrhea

-salphinx

-tocia

-version

-dilation

-emia

-graphy

-osis

-sclerosis

-stenosis

-tomy

-ar

-ary

-capnia

-centesis

-dynia

-ectasis

-gram

-graph

-meter

-metry

-osmia

-oxia

-phonia

-pnea

-ptysis

-rrhage

-rrhagia

-scopy

-spasm

-sphyxia

-thorax

-asthenia

-blast

-clast

-clasia

-clasis

-desis

-listhesia

-malacia

-physis

-porosis

-schisis

-tome

-coccus

-ia

-opsy

Abstractor

Abuse

Accreditation

Accredited

Act/ Law/ Statute

Actual Charge

Additional Benefits

Adjudication

Adjusted Average Per Capita Cost (AAPCC)

Administrative Code Sets

Administrative Costs

Administrative Data

Administrative Law Judge (ALJ)

Administrative Simplification

Administrative Simplification Act

Admission Date

Admitting Diagnosis

Admitting Physician

Advance Beneficiary Notification (ABN)

Advanced Directive

Allowed Charge

Ambulatory Care

Ambulatory Care Sensitive Conditions (ACSC)

Ambulatory Payment Classification (APC)

Ambulatory Surgery Center (ASC)

American Hospital Association (AHA)

American Medical Association (AMA)

ASHIM

Ancillary Services

Appeal

Approved Amount

Assigned Claim

Assignment

Attending Physician

Automated Claim Review

Basic Benefit

Beneficiary

Benefit Payment

Benefit Period

Benefits

Board Certified

Business Associate

Capitation

Care Plan

Caregiver

Case Management

Case Mix

Case Mix Index

Catastrophic Illness

Catastrophic Limit

Center for Disease Control and Prevention (CDC)

Center for Medicare & Medicaid Services (CMS)

Certification

Civilian Health and Medical Program (CHAMPUS)

Charge Description Master (CDM)

Claim

Claim Adjustment Reason Codes

Claim Status Code

CMS Agent

UB-04

CMS1500

Code of Federal Regulations

Code Set

Coinsurance

Community Mental Health Services

Comprehensive Inpatient Rehabilitation Facility

Comprehensive Outpatient Rehabilitation Facility (CORF)

Conditional Payment

Consolidated Omnibus Budget Recondiliation Act (COBRA)

Coordination of Benefits

Coordination Period

Cost Rate

Cost Report

Cost Sharing

Covered Benefit

Covered Charges

Covered Entity

Covered Services

Critical Access Hospital

Current Dental Terminology (CDT)

Current Procedural Terminology (CPT)

Custodial Care

Custodial Care Facility

Date of Service

Deductible

Deductible (Medicare)

Demographic Data

Demonstrations

Department of Health and Human Services (DHHS)

Descriptor

Designated Code Set

Diagnosis

Diagnosis Code

Diagnosis Related Groups (DRG’s)

Disability

Discharge Planning

Disproportionate Share Hospital

Downcode

DRG Coding

Dual Eligibility

Durable Medical Equipment (DME)

Durable Medical Equipment Regional Carrier (DMERC)

Electronic Data Interchange (EDI)

EDI Translator

Edit

Emergency Care

Emergency Room (Hospital)

Emergency Medical Treatment and Active Labor Act (EMTALA)

Encounter Data

Enrollment Period

Episode of Care

Explanation of Benefits EOB(Remittance Advise (RA)- Medicare)

Exclusions

Facility Charge

Federal Register

Fee Schedule

Fiscal Intermediary

Fixed Capital Assets

Formulary Drugs

Fraud and Abuse

Freedom of Information Act (FOIA)

Fully Accredited

Group Health Plan

Guidelines

Health Care Clearinghouse

Health Care Code Maintenance Committee

Health Care Prepayment Plan (HCPPP)

Health Care Provider

Health Care Quality Improvement Program (HCQIP)

Health Employer Data and Information Set (HEDIS)

Health Insurance Association of America (HIAA)

Health Insurance Claim Number (HICN)

Health Plan

Health Common Procedural Coding System (HCPCS)

Precedence

Section I

Section II

Section III

Section IV

E&M

New Patient

Established Patient

Chief Complaint

Volume 1

Volume 2

Volume 3

Volume 1 & Volume 2

V codes

E codes

ICD updates

Tabular List

Alphabetic Index

Chapters

Sections

Categories

Subcategories

Subclassification

nonessential modifiers

essential modifiers

Malignant hypertension

Benign Hypertension

Unspecified Hypertension

Malignant Neoplasm

Primary malignancy

Secondary malignancy

Carcinoma in situ

Benign Neoplasm

Uncertain behavior

Unspecified Nature

Table of Drugs and Chemicals

NEC

NOS

Other codes

unspecified

AND

WITH

SEE

SEE ALSO

Guidelines

when can you code 388.xx first

How do you code hypertension with heart disease?

How do you code hypertension with ESRD.

How do you code poisonings?

trephination

tentorium cerebelli

F wave

H reflex

slanted brackets

Adren/o ; Adrenal/o

Adrenocortic

Endocrin/o

Hypophys/o

Insul/o

Parathyr/o ; Parathyroid/o

Pituitar/o

Thyr/o ; Thyroid/o

Cerebr/o

Cortic

Encephal/o

Gangli/o ; Ganglion

Gil

Medull/o

Mening/o ; Menige/o

Myel/o

Narc/o

Neur/o ; Neur/i

Psych/o

Radicul/o

Somn/o ; Somn/i

Colp/o

Episi

Gyn/o ; Gynec/o

Hyster/o

Mast/o

Men/o ; Mens

Metr/o : Metr/i

O/o

Oophor/o

Ov/o ; Ovul/o

Salping/o

insurance claim form

Claim forms contain

provider

reimbursement

manual claim submission

electronic media claim (EMC)

electric data interchange (EDI)

optical character recognition (OCR)

optical scanning

non compliance

The purpose of claim forms is to submit charges for medical services and supplies to various third-party payers for reimbursement.

Third-party reimbursement for medical services and/or supplies is determined based on the information reported on the claim.

A computer template defines all the information required on the claim for the payer, and specific payer edits can also be programmed.

Manual submission of claims results in reduced processing time. Reimbursement for manual claims may be generally received within 7 to 14 days.

The CMS-1450 (UB-04) is used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.

Claim forms can be submitted to third-party payers _______ on paper or by _______.

Two claim forms that are used for submission of claims to payers are the _________and the _____________.

The electronic claims process can be accomplished by ______ transmission or transmission through a ____________.

A ________ is an organization that reformats claim data received from various providers to meet compatibility specifications for various payers.

The standard transaction format for the CMS-1500 is the ______ and the format for the CMS-1450 (UB-04) is the ______.

Claim form used by institutional providers to submit hospital facility charges for services, procedures, and items to payers for reimbursement.

The process of sending data from one computer to another by telephone line or cable.

A group of claims that is prepared and transmitted together.

A claim that is transmitted through electronic data interchange (EDI).

Claim for used by non-institutional providers to submit professional charges for physician and outpatient services to payers for reimbursement.

An individual or entity, such as a doctor or hospital, that provides medical services and/or supplies to patients.

A process whereby the claim form is scanned and data on the claim are transferred into a computer system.

Provisions outlined under this legislation require the electronic transmission of most health care transactions.

An organization that reformats claim data received from providers to meet compatibility specifications for submission to various payers.

A claim that is typed or computer generated on paper and sent by mail.

The CMS-1500 and the CMS-1450 (UB-04) are the claim forms used to submit charges to payers for reimbursement.

The CMS-1500 consists of 33 blocks and the CMS-1450 consists of 33 fields referred to as form locators (FL).

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)

The HIAA and the AMA developed the CMS-1450.

The SUBC are responsible for the oversight of state-specific CMS-1450 billing requirements.

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.

The _____ _______ ______ is a unique number assigned by the hospital to identify the patient account for the claim.

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.

The ________ _______ _________ is a number assigned to a patient’s medical record by the facility (hospital).

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.

Information regarding the patient’s condition is recorded in what fields on the cms-1500.

The fields on the CMS-1450 that are used to report two-digit alphanumeric value codes and the dollar amount associated with the code.

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?

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.

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.

The four-digit type of bill number is recorded in this field on the CMS-1450 to provide information about the facility bill type.

The two-digit number that represents the admission and discharge hour is recorded in these fields on the CMS-1450.

Information about the patient such as name, address, zip code, phone, sex, and employer is recorded in these fields on the CMS-1500.

The fields on the CMS-1450 used to record the patient control number and the medical or health record number.

This field on the CMS-1450 is used to report the name and address of the individual who is responsible for paying the claim.

The acronym HCPCS in FL 44 stands for Health Care Procedure Coding System.

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.

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.

A revenue code and the standard abbreviated description are recorded in FL 50.

The external cause of injury codes are used to describe the procedure performed.

______ ________ are four numeric digits and they were developed by the NUBC to categorize like services and items.

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.

The ______ ______ is the provider who is responsible for the patient’s care during the inpatient hospital stay.

Written authorization from a patient for the payer to forward benefits to the provider is called an ________ _______ _________.

The standard unique health identifier for health care providers, for use in filing and processing health care claims and other transactions, is called _________ ________ ________.

Fields used to record charge information including revenue code, standard description, HCPCS, unit, charge, and non-covered charge.

Field used to record HCPCS level l CPT and HCPCS level ll medicare national procedure codes.

Group name and number for each payer are recorded in

Admitting diagnosis is recorded in

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?

Field used to provide additional information required by the payer for the claim to be processed.

Principle diagnosis and other diagnoses are recorded in these fields.

Fields used to record the insured’s name for each payer recorded on the claim form.

The patient reason for visit is recorded in this field on outpatient claims.

Treatment authorization codes obtained from the primary, secondary or tertiary payer is recorded in these fields.

The purpose of a claim form is to submit charges to a patient.

Manual claim submission is more efficient than electronic claim submission.

CMS-1500 is used to submit non-institutional charges to a payer for reimbursement.

The CMS-1450 (UB-04) has 33 fields.

Claim form completion instructions vary by payer.

The _________ ______ ________ _________ _________ ______ ________ coding system
is used to record services, procedures, and items in FL 44.

. A patient’s written permission for the payer to send payment to the provider is called the
_______________._______________._______________..

The condition determined after study is the __________________ diagnosis.

. 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.

The procedure performed for definitive treatment of the principal diagnosis is called the
_____________ procedure

The __________________ claim form is utilized by institutional providers to submit
hospital facility charges for services, procedures, and items to payers for reimbursement.

The ____________ acronym represents the coding system used today to report patient
conditions and significant procedures.

In accordance with HIPAA provisions, the ________________________ coding system will
replace the ICD-9-CM coding system effective________________________.

Inpatient claims require the reporting of a __________ ____ ___________ ____ indicator
for principal and other conditions.

The CMS-1450 (UB-04) contains 81 fields referred to as _______________.

The field used to record four-digit codes used to categorize services, procedures, and items.

The field used to record the principal procedure.

The field used to report the standard abbreviated description of revenue codes.

The fields used to report the principal and other diagnoses.

The field used to record the HCPCS Level I and HCPCS Level II Medicare National code.

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.

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)

The CMS-1450 (UB-04) is used to submit facility charges for ambulatory surgery and inpatient services.

Which section of the CMS-1450 (UB-04) is used to provide information about charges submitted on the claim form?

ALVEOLUS

BRONCHIAL

CAVITY

EPIGLOTTIS

ESOPHAGUS

EUPNEIC

INTERCOSTAL

LARYNX

LOBE

MEDIASTINUM

NASOPHARYNX

PARIETAL PLEURA

STERNUM

THORAX

TRACHEA

What are three factors of E/M codes?

Place or setting in which the service was provided is called?

There are different codes for outpatient and inpatient settings.

Kind of service provided is called?

Codes are divides based on the types of service.

How many types of patients statuses are there?

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.

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.

Has not been formally admitted to a health care facility.

Has been formally admitted to a health care facility.

The three key components are the history, examination,and a medical decision-making complexity.

Is the subjective (patient provided) information that the physician elicits regarding to the chief complaint

There are four elements of history.

What are the four elements of history?

CC

HPI

ROS

PFSH

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

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

Location means

Quality means

Severity means

Duration means

Timing means

Context means

Modifying factors means

Associated signs and symptoms means

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.

What are the two levels of HPI

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.

The detailed and comprehensive levels of history contain an extended review of the HPI elements.

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.

A review of the patient’s past experience with illnesses, injuries, and treatment .

A review of medical events in the patient’s family

An age appropriate review of past and current activities

is a review that is focused on the organ system involved in the chief complaint

Includes a review of the system directly involved in the chief complaint, plus related (up to nine) systems.

Includes at least 10 of the 14 Organ Systems

is a review of the pas, family,and social history of the patient

What are the two levels of PFSH?

What are the four levels of history?

When the physician focuses on the CC and a brief history of the present problem of a patient.

When the physician focuses on a CC, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.

When the physician focuses on a CC and obtains an extended history of the present problem.

When the physician documents the CC, obtains an extended history of the present problem, does a complete ROS, and obtains a complete PFSH

Is the subjective information the patient provides the physician

Objective information that the physician gathers.

Head (Including face)

Neck

Chest (Including Breast and axillae)

Abdomen

Genitalia, groin,and buttocks

Back

Each extremity

Ophthalmologic (eyes)

Otolaryngologic (ears,nose,mouth, and throat)

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Muscoskeletal

Integumentary (Skin)

Neurologic

Psychiatric

Hematologic/ Lymphatic/ Immunologic

What are the four levels of examination?

Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA

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

An extended examination of the affected BAs or related OSs. It involves an extended examination of 2-7 BAs or OSs

Encompasses at least 8 OSs without counting BAs

The levels of examination include both body areas (BA) and organ systems (OS), with the exception of the comprehensive examination.

When abstracting a medical record count both the

Constitutional on the exam count as 1 OS and that OS counts when calculating the examination.

the key component of MDM is based on the__________ of the decision the physician must make regarding the patient’s diagnosis and care.

Complexity of decision making is based on three elements.

What are the three elements of decision making?

What are the four types of MDM complexity?

Blood pressure, sitting

Blood pressure, lying

Pulse

Respiration

Temperature

Height

Weight

General appearance

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.

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

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.

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.

____________ factors are those conditions that help the physician to determine the extent of history, examination, and decision making necessary to treat the patient

What are the three contributory factors?

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.

A physician might arrange for other services to be provided to the patient, such as arrangements for admittance to a long- term nursing facility.

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

How many types of presenting problems are there?

What are the five types of presenting problems?

A _______ problem is a blood pressure reading, a dressing change,or another service that can be performed without the physician being immediately present.

also called a minor presenting problem

The risk of complete sickness without treatment is low, there is no risk of death without treatment, and full recovery without impairment is expected.

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,

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.

What are two measurements of 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.

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.

_______ services are based on time

More than one physician can use the subsequent care codes on the same day. This is called

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.

These codes are reported for either inpatients or outpatients who are admitted and discharged on the same day.

______________ are reported on the final day of services for a multiple-day-stay in a hospital setting.

Findings that were not the reason for the test.

WHAT ACT REQUIRED THE USE OF ICD-9-CM CODES FOR OUTPT CLAIMS?

HOW ARE ICD-9-CM CODES USED FOR RESEARCH?

WHAT IS THE PURPOSE OF ICD-9-CM CODES? (3 REASONS TO USE)

ICD-9-CM CODES ON INSURANCE FORMS

ICD-9-CM CONVENTION: NEC

NOS

BRACKETS [ ]

PARENTHESES ( )

COLON :

} BRACE

LOZENGE

SECTION MARK

BOLD TYPE

ITALICIZED TYPE

SLANTED BRACKETS

INCLUDES NOTES

EXCLUDES NOTES

AND

WITH

CODE, IF APPLICABLE, ANY CAUSAL CONDITION FIRST

CROSS REFERENCES

NOTES

EPONYMS

ETIOLOGY

MANIFESTATION OF DISEASE

COMBINATION CODE

SECTIONS

SUBTERMS ARE INDENTED___SPACES.

MAJOR DIVISIONS OF VOL 1 TABULAR

MAIN PORTION OF ICD-9-CM

ICD-9-CM QUIDELINES WERE DEVELOPED BY THESE PARTIES.

AHA

AHIMA

CMS

NCHS

APPENDIX A

MULTIPLE CODING FOR SINGLE CONDITION.

burns to multiple sites in the same anatomic area

highest degree

burns

late effect

treatment for malignacy

Assignment of benefits

Attending physician

Batch

Clearinghouse

Electronic data interchange (EDI)

Electronic media claim (EMC)

Form locator (FL)

Insurance claim form

Medical record number (MRN)

National Provider Identifier (NPI)

National Uniform Billing Committee (NUBC)

North American Industry Classification System (NAIC) code

Optical scanning

Paper claim

Provider

Reimbursement

Revenue codes

State Uniform Billing Committees (SUBC)

Tertiary payer

Timely filing

Unique Provider Identification Number (UPIN)

AMA

CMS

CMS-1450 (UB-04)

EDI

EIN

EMC

ER/ED

FL

HCPCS

HIAA

HIPAA

HIPPS

HRN

ICD-9-CM
Modification

MRN

NAIC

NPI

NUBC

OCR

PoA

RA

SUBC

UB-04

UPIN

Medical Billing & Coding as a Career

What are Medical Ethics?

What does acting within ethical behavior boundaries mean?

Legal Aspects of of Medical Billing & Coding:

Compliance regulations:

Health Insurance Portability & Accountability Act (HIPPA)

What are the 2 provisions of HIPPA?

What is Title I of HIPPA?

What is Title II of HIPPA?

What is the False Claims Act (FCA)?

What is the National Correct Coding Initiative (NCCI)?

How many edits does NCCI include?

Column 1/Column 2 edits (NCCI)

Mutually Exclusive Edits (NCCI)

What are the possible consequences of inaccurate coding and incorrect billing?

Who has the task of investigate and prosecuting health care fraud & abuse?

Fraud

Who audits claims?

What are common forms of fraud?

Abuse

What are examples of Abuse?

What is a method use to minimize danger, hazards, & liabilities associated w/ abuse?

Patient Confidentiality

When may providers use PHI (Protected Health Information) w/o specific authorization under the HIPPA Privacy Rule?

What is Employer Liability?

What is Employee Liability?

What is a Medical Record & what is it comprised of?

What is a medical report?

Reasons for Documentation

Retention Of Medical Records

Med Term

Diagnosis suffixes:

-algia

-emia

-itis

-megaly

-meter

-oma

-osis

-pathy

-rrhagia

-rrhea

-sclerosis

-scopy

Procedural Suffixes:

-centesis

-ectomy

-gram

-graphy

-lysis

-pexy

-plasty

-rrhapy

-scopy

-stomy

-therapy

-tomy

Common Prefixes:

a, an

ante

anti

brady

dys

endo

epi

ex

hemi

hypo

infra

inter

neo

oligo

pan

para

per

poly

pre

pseudo

sub

supra

tetra

Common Root Words

arth

cephal

cardi

cholecyst

chondro

colp

derm

enter

episi

gastro

gloss

hepato

hyster

lapar

lact

lith

mast

myo

nat

oophor

oste

pneum

rhin

salping

stomat

Directional Terms:

Anterior, Ventral

Posterior, Dorsal

Superior

Inferior

Proximal

Distal

Medial

Lateral

Frontal, Coronal

Sagittal

Transverse, Cross-sectional

Anatomy & Physiology

What is the 1st body system for which medical procedures are described in the CPT manual?

How much area does the skin cover?

What is the main function of the skin?

SEBACEOUS (OIL) GLANDS & SUDDORIFERIOUS (SWEAT GLANDS)

How many layers to the skin?

Hair, Nail & Glands

Hair

Nails

What is the moon like white area of the nail called?

What is the eponychium?

SEBACEOUS GLANDS

SUDDORIFEROUS GLANDS

How many types of sweat glands?

What organ secretes hormones?

Integumentery Vocabulary

Albino

Collagen

Melanin

Lipocyte

Macule

Polyp

Fissure-

Nodule

Ulcer

Vesicle

Wheal

Alopecia

Gangrene

Impetigo

Multigravida

The Musculoskeletal System

What are bones connected to one another by?

What are muscles attached to the bone by?

What is the fibrous covering of muscles called?

Bones

How are bones categorized?

Axial Skeleton

Appendicular Skeleton

Long Bones

Short Bones

Flat Bones

Sesamoid Bones

The Axial Skeleton-Skull, Rib Cage, Spine

Skull

Cranium

Facial Bones

Zygoma

Lacrimal Bones

Maxilla

Mandible

Vomer

Palatine bones

Spinal/Vertebral Column

Cervical

Thoracle

Lumbar

Sacral

Coccygeal

Rib Cage

The Appendicular Skeleton

Upper Appendicular Skeleton

Scapula

Clavicle

Upper Extremities

Humerus

Ulna

Radius

Carpals

Metacarpals

Phalanges

Lower Appendicular

Pelvis

Ischium

Pubic Bone

Lower Extremeties

Femur

Patella

Tibia

Fibula

Malleolus

Tarsal

Metatarsal

Phalanx

Joints

No ROM

Limited ROM

Full ROM

Synovial Joints

Muscles

What are the 3 different functions of the human muscles?

How are muscles attached to bones?

Muscle Actions

Extension

Flexion

Abduction

Adduction

Supination

Pronation

Dorsiflexion

Plantar Flexion

Eversion

Inversion

Protraction

Retraction

Rotation

Fractures

Communicated Fracture

Compression Fracture

Colles Fracture

Complicated Fracture

Hairline Fracture

Greenstick Fracture

Pathologic Fracture

Salter-Harris Fracture

Sprains, strains and dislocation/subluxation

Strain

Dislocation

Subluxation

Evaluations & Management Review

Basic Format of the levels of E&M services

New Patient

Established Patient

Chief Complaint

How many Volumes to ICD manual?

Volume 1-Index to Diseases, Tabular List

Volume 2-Index to Diseases, Alphabetic Index

Volume 3-Procedures

Which volume(s) are used in the inpatient and outpatient settings (physician office)?

How to ensure you have chosen the correct code?

Supplementary Classification Codes

What are V codes?

What are circumstances when V codes are used?

What are E codes?

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?

/When is the ICD manual updated

How many chapters does the Tabular List(Volume 1) contain?

What do the codes range from? (ICD-Volume 1)

Chapters

Sections

Categories

Subcategories

Subclassification

Level of detail in coding

Sequencing the diagnosis

Alphabetic Index (Volume 2)

Nonessential Modifers

Essential Modifiers

Hypertension table

Neoplasm Table

Describe the 6 columns of the neoplasm table

Malignant

Primary Malignancy

Secondary Malignancy

Carcinoma (Ca) in Situ

Benign

Uncertain Behavior

Unspecified Nature

Choose the code that represents the current status of the neoplasm

3 sections to Alphabetic Index

Section 1: Index to diseases

Section 2: Table of Drugs and Chemicals

Section 3: Index to External Cause of Injury (E codes)

Health Care Financing Administration Common Procedure Coding System

Who assigns NPI#’s & what are they?

Who developed HCPCS & What is it?

Level I Codes

Level II Codes (National Codes)

Level III Codes

CPT

Who publishes CPT and updates it?

Category I Codes

Category II Codes

Category III Codes

How many sections to the CPT Manual?

What format does CPT coding system use and why?

2 types of CPT Codes

Other CPT Codes

How do you know if an update has been made to the CPT manual?

How many parts to CPT Manual?

Evaluation & Management

Anesthesia

Surgery

Radiology (including nuclear medicine and diagnostic ultrasound)

Pathology and Laboratory

Medicine (except anesthesiology)

Add-on codes

Location Methods

CPT Modifiers

-24 Unrelated E/M Service by the same physician during a postoperative period

-26 Professional Component

-32 Mandated Services

-50 Bilateral Procedure

-51 Mulitple Procedure

-58 Staged or Related Procedure or Service by the same Physician during the Postoperative Period

-78 Return to Operating Room for a Related Procedure During the Postoperative Period

79 Unrelated Procedure or Service by the same physician during the postoperative period

-90 reference (outside) laboratory

-99 Multiple Modifiers

Evaluation and Management (E/M Codes)

What are the key components of E/M?

Unlisted Procedures

Surgical Package

What is Health Insurance?

What 3 ways can an individual obtain health insurance?

Indemnity Insurance

HMO

PPO

POS

Preferred Provider Plan

How is a fee schedule determined?

Relative Value Payment Schedule Method

Medicare’s Resource Based Relative Vale Scale (RBRVS) Payment Schedule

How are payments determined under Medicare’s RBRVS?

A geographic practice cost index is applied to account for the economic variation across the different area of the country

What % does Medicare pay?

What portion of services do the beneficiary pay?

The St. Anthony Relative Value for Physicians (RVP)

Contracted Rates w/ MCO’s

Capitated Rates

Medicare

Who is Medicare available to?

What are Medicare Health Insurance Claim Numbers (HCIN’a)?

Common Suffixes used by Medicare:

Medicare Part A

How do individuals that are not eligible for Social Security Obtain Medicare Part A?

Medicare Part B

What out of pocket costs for beneficiaries are associated w/ Medicare part B?

How are services paid to physicians associated w/ Medicare Part B?

Medicare Part C

Medicare Part D

Claim Status

Clean Claim

Dirty Claim

Invalid Claim

Rejected Claim

What is an Advance Beneficiary Notice?

What is Medigap?

Medicaid

How is eligibility for Medicaid classified?

Medicaid is the payer of last resort

Medicaid and Medicare (dual coverage)

Some of the Services covered by Medicaid

Workers Compensation

Who covers cost of Workers Compensations?

What are the 5 types of benefits offered?

Disability Insurance

Liability Insurance

TRICARE

What are the 3 types of plans covered under TRICARE?

How are co-payments determined with TRICARE?

CHAMPVA

Commercial Carriers

Gender rule

Birthday rule

Blue Cross/Blue Shield Plans

Blue Cross

Blue Shield

What are BC/BS plans reimbursement methodologies?

Paper Claim

Electronic Claim

What is a clearinghouse?

What are the 2 major sections of a claims form?

What should be done in absences of payer provided instructions for completing claim form?

Basic Billing & Reimbursement Steps:

Life cycle of Insurance Claims

Non-covered benefit

Unauthorized Benefit

What does Medical Necessity edit check for?

VI. Payment

Assignment of Benefits

Accept Assignment

New Patient

Established Patient

Inpatient

Outpatient

Consultation

Fee-for-service

Fiscal Intermediary

Explanation of Benefits (EOB)

Premium

Deductible

co-payment

Coinsurance

Coding

Medical Neccessity

Exclusion and Limitations

Pre-certification

Pre-determination

Pre-authorization

Qualified diagnosis

Eligibility

Coordination of benefits (COB)

encounter form

Itemized statement

Peer Review Organization (PRO)

Health Insurance Portability And Accountability Act (HIPPA)

Civil Monetary Penalties Law (CMPL)

The Good Samaritan Act

Remittance Advice

The Patient Care Partnership (Patients Bill of Rights)

Physician

Health Practitioner

Group Practice

Physician’s Identification Numbers

epidermis

skin or accessory organs

para-

trich/o

lunula

hypodermis

eosin/o; juand/o; cyan/o

escharotomy

-plasty

paronychium

pustule

Stage III pressure ulcer

atopic

papulosquamous

pityriasis

erysipelas

herpes simplex

verrucae

keratoacanthoma

squamous cell

tubular

sesamoid

zygoma

diaphysis

cranium parts

ear bones

epiphyseal

acetabulum

olecranon

synarthrosis

compound fractue

osteoporosis

ankylosing spondylitis

osteogenic

multiple myoma

dermatomyositis

chondrosarcoma

reduction

sprain

primary osteoarthritis

lower respiratory tract

larynx

trachea

septum

atel/o

spir/o

pan-

ARDS

FEV1

-pnea

adult respiratory distress syndrome

empyema

most common types of atelectasis

pneumoconiosis

COPD

bronchiectasis

emphysema

chronic cough

hypercapnia

bronchiolitis

veins

diastole

sinoatrial

atrioventricular