AAPC Chapter 19 A & B Questions & Answers

An established patient presents to the office with a recurrence of bursitis in both shoulders. Previous injections have been given which provided relief. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit?

20610-50

NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear. HEART: Regular. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history and by physical examination that he has a rather small indirect inguinal hernia. His cord and testicles are normal. NEURO: Grossly intact to motor and sensory examination. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation. What E/M code is reported?

99203 K40.90

Case 9 Hospital Admission Chief Complaint: Nausea and vomiting, weakness HPI: The patient is a 78-year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None. Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: Morphine. Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. Family History: Mother deceased after childbirth. Father deceased from asphyxia. ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. Eyes: Negative for vision changes. Pulmonary: Negative for dyspnea. Cardiovascular: Negative for angina. Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. Neurologic: Negative for headaches. Negative for seizures. Psychiatric: Negative for anxiety. Negative for depression. Integumentary: Positive for rash for which she takes Benadryl. Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. Objective: Vital Signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. Generally: No apparent distress, alert and oriented x 3, pleasant Spanish speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus. Neck: Supple, full range of motion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy's sign. Back: Costovertebral angle tenderness. Extremities: No clubbing, cyanosis or edema. Laboratory Studies Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. Assessment 1.Nausea, vomiting, diarrhea, likely gastroenteritis 2.Cystitis 3.Hypokalemia 4.Hyponatremia 5.Cholelithiasis 6.Diabetes mellitus type 2 7.Hypertension Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff toxin and fecal stool culture and sensitivity. What are the CPT® and ICD-10-CM code(s) reported?

99222 R11.2 R19.7 N30.90 E87.6 E87.1 K80.20 E11.9 Z79.84 I10

Case 1: Emergency Department Visit Chief complaint: Dizziness, nausea, vomiting. History of Present Illness A 43-year-old very pleasant gentleman with history of hypertension who presents to the emergency department with chief complaint of abrupt onset |1| of nausea, vomiting, and dizziness. |2| The patient said that while he was sitting, |3| he felt like the room was spinning and felt very unstable, |4| and had severe nausea. Denies any abdominal pain, |5| fever, chills, |6| headache, |7| or shortness of breath. |8| Symptoms are exacerbated by certain movements. |9| Denies any sick contacts. This is the first time this has ever happened. The patient arrived via EMS. After receiving 12.5 mg of Phenergan® |10| intravenously, he feels better at this time. The patient said that he has some mild nausea. |11| He has had one episode of nonbloody, nonbilious emesis in the emergency room. Past Medical History: Hypertension. |12| Past Surgical History: Negative. |12| Social History: Occasional alcohol use, nonsmoker, no drug use. |13| Family History: Negative for hypertension |14| Review of Systems All pertinent positives and negatives as above, all 10 systems |15| reviewed and the remaining are negative. Physical Examination Temperature 97, heart rate 66, blood pressure 169/92, respiratory rate 20, O2 sat 97% on room air. General examination: The patient in no acute distress. |16| HEENT: Normocephalic, atraumatic. |17| Pupils are 4 and reactive. |18| There is a slight horizontal nystagmus with left lateral gaze. |19| Mucous membranes are moist. |20| Neck is supple. There is no Kernig's, no Brudzinskj's. Hallpike maneuver was negative. The patient was symptomatic with both directions. |21| Lungs are clear auscultation bilaterally. Chest symmetric. |22| Cardiovascular: S1, S2, regular rate and rhythm. |23| Abdomen is soft, nontender, |24| no CVA tenderness. |25| Neurologically, the patient is alert and oriented x3. Cranial nerves II-XII are grossly intact. Strength is 5/5. Reflexes are symmetric. Cerebellum is intact with good finger-to-nose. Sensation is grossly intact. |26| Lymph: No appreciable cervical, axilla, inguinal lymphadenopathy. |27| Diagnostics CBC: White blood cell count of 14, hemoglobin 15, hematocrit 45, platelets are 179.Chem-7 identifies glucose of 202, BUN of 13, creatinine 0.8. |28| ED Course The patient underwent an MRI of the brain, |29| which was interpreted as negative per the attending radiologist. He was treated with intravenous Zofran® |30| and oral Antivert®, |31| feels better at this time. Plan: The patient will be discharged at this time. Advised to follow up with his primary care physician. Return if increased symptoms. Diagnosis: Vertigo. |32| Disposition: Discharged stable condition. |1| HPI: Timing |2| HPI: Associated signs and symptoms |3| HPI: Context |4| HPI: Quality |5| ROS: Gastrointestinal |6| ROS: Constitutional |7| ROS: Neurological |8| ROS: Respiratory |9| HPI: Modifying factors |10| HPI: Modifying factors |11| HPI: Severity |12| PFSH: Past Medical History |13| PFSH: Social History |14| PFSH: Family History |15| ROS: Complete |16| Organ System: Constitutional |17| Body Area: Head |18| Organ System: Eyes |19| Organ System: Neurologic |20| Organ System: Mouth |21| Organ System: Neurologic |22| Organ System: Respiratory |23| Organ System: Cardiovascular |24| Body Area: Abdomen |25| Organ System: Genitourinary |26| Organ System: Neurologic |27| Organ System: Lymphatic |28| Labs reviewed |29| MRI ordered |30| IV Zofran |31| Oral meds |32| Definitive diagnosis What are the CPT® and ICD-10-CM codes reported?

CPT Code: 99284 ICD-10-CM Code: R42

Case 1: Established Patient Office Visit Chief Complaint: Right shoulder pain |1| This is a 47-year-old, otherwise healthy, right-hand-dominant male toolmaker with a 6-8 week history of gradual insidious onset of right shoulder pain. He has noted popping along the medial aspect of the scapula but this is not particularly associated with the pain. The pain seems to be localized more laterally. He has been taking Naprosyn® for some low back discomfort, which also helps his shoulder. ROS: No HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, or nerve complaints. MS is positive for joint pain, muscle tenderness, and weakness. Past History: Medications: Naprosyn®, Allergic to Penicillin. Prior surgery on lower back (1994). Family History: None Social History: Positive for tobacco and alcohol use. Physical Examination: Right shoulder is non-swollen. No deformity. No muscular atrophy. He does have crepitus that localizes to his scapulothoracic articulation medially and posteriorly, but there is no tenderness or apparent pain. He has full active range of motion. No instability. Negative impingement. He does have some pain primarily with resisted supraspinatus function, but no distinct weakness. X-ray: X-rays, three views of the right shoulder viewed in office, |3| show normal anatomic relationships. No soft tissue calcifications. Acromial humeral interval maintained. The X-ray will be officially read by the radiologist. Assessment and Plan: Right rotator cuff tendonitis. |2| After discussion of treatment options, he wished to proceed with shoulder injection done with 2 cc of Xylocaine® under a sterile technique from a posterior approach. |4| He is started on a rotator cuff exercise program. Return in 3-4 weeks for follow up. |1| Chief complaint |2| Number and Complexity of Problems: Acute uncomplicated injury/illness |3|Amount and Complexity of Data: X-rays independently reviewed by physician. Will be reported by the radiologist. 4| Risk of Complications: Joint injection; shoulder Wat are the CPT® and ICD-10-CM codes reported?

CPT Codes: 99213-25, 20610 ICD-10-CM Code: M75.81

Case 1: Established Patient Office Visit Chief Complaint: Right shoulder pain |1| This is a 47-year-old, otherwise healthy, right-hand-dominant male toolmaker with a 6-8 week history of gradual insidious onset of right shoulder pain. He has noted popping along the medial aspect of the scapula but this is not particularly associated with the pain. The pain seems to be localized more laterally. He has been taking Naprosyn® for some low back discomfort, which also helps his shoulder. ROS: No HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, or nerve complaints. MS is positive for joint pain, muscle tenderness, and weakness. Past History: Medications: Naprosyn®, Allergic to Penicillin. Prior surgery on lower back (1994). Family History: None Social History: Positive for tobacco and alcohol use. Physical Examination: Right shoulder is non-swollen. No deformity. No muscular atrophy. He does have crepitus that localizes to his scapulothoracic articulation medially and posteriorly, but there is no tenderness or apparent pain. He has full active range of motion. No instability. Negative impingement. He does have some pain primarily with resisted supraspinatus function, but no distinct weakness. X-ray: X-rays, three views of the right shoulder viewed in office, |3| show normal anatomic relationships. No soft tissue calcifications. Acromial humeral interval maintained. The X-ray will be officially read by the radiologist. Assessment and Plan: Right rotator cuff tendonitis. |2| After discussion of treatment options, he wished to proceed with shoulder injection done with 2 cc of Xylocaine® under a sterile technique from a posterior approach. |4| He is started on a rotator cuff exercise program. Return in 3-4 weeks for follow up. |1| Chief complaint |2| Number and Complexity of Problems: Acute uncomplicated injury/illness |3| Amount and Complexity of Data: X-rays independently reviewed by physician. Will be reported by the radiologist. 4| Risk of Complications: Joint injection; shoulder What are the CPT® and ICD-10-CM codes reported?

CPT Codes: 99213-25, 20610 ICD-10-CM Code: M75.81

Physical Exam: General/Constitutional: No apparent distress. Well nourished and well developed. Ears: TMs gray. Landmarks normal. Positive light reflex. Nose/Throat: Nose and throat clear; palate intact; no lesions. Lymphatic: No palpable cervical, supraclavicular, or axillary adenopathy. Respiratory: Normal to inspection. Lungs clear to auscultation. Cardiovascular: RRR without murmurs. Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses. Integumentary: No unusual rashes or lesions. Musculoskeletal: Good strength; no deformities. Full ROM all extremities. Extremities: Extremities appear normal. What is the level of exam?

Comprehensive

Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He is evaluated by the ED provider. This is the first time he has been to this hospital. What subsection is used to report the ED visit?

Emergency Department Services

Subsequent Hospital Visit Labs: BUN 56, creatinine 2.1, K 5.2, HGB 12. Impression: 1.Severe exacerbation of CHF 2.Poorly controlled HTN 3.Worsening ARF due to cardio-renal syndrome Plan: 1.Increase BUMEX to 2 mg IV Q6. 2.Give 500 mg IV DIURIL times one. 3.Re-check usual labs in a.m. Total time: 20 minutes. What is the level of medical decision making?

High

What ICD-10-CM code is reported for angina pectoris with a documented spasm?

I20.1

Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.

Location, quality and duration

A patient is seen in consultation by endocrinologist at the request of her PCP for uncontrolled DM2. HPI: DM is uncontrolled. Recent A1C was 8.5. She is on oral meds. She has had eye exam two months ago. Her wellness exam was three months ago. She is under a lot of stress. No other new problems or complaints. HTN is controlled. Constitutional: WDWN female Heart: RRR, no edema Respiratory: Clear to auscultation Extremities: Normal pedal pulses, no edema A/P: DM type 2 uncontrolled, essential hypertension Plan for A1C before next visit. Return to office in three months for follow up. If A1C is still high, we will consider insulin. What is the level of medical decision making?

Moderate

A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive checkup and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam?

Preventative medicine, established patient

A provider admits Mrs. Smith to the hospital. She is there for five days. The provider sees her each day she's in the hospital. What subcategory of E/M codes would be used for days two, three and four?

Subsequent Hospital Care

A 65-year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening. CHIEF COMPLAINT: CHFINTERVAL HISTORY: CHF symptoms worsened since yesterday.Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins.PHYSICAL EXAMINATION:GENERAL: Mild respiratory distress at restVITAL SIGNS: BP 168/84, HR 58, temperature 98.1.LUNGS: Worsening bibasilar cracklesCARDIOVASCULAR: RRR, no MRGs.EXTREMITIES: Show worsening lower extremity edema.LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.IMPRESSION:1. Severe exacerbation of CHF2. Poorly controlled HTN3. Worsening ARF due to cardio-renal syndromePLAN:1. Increase BUMEX to 2 mg IV Q6.2. Give 500 mg IV DIURIL times one.3. Re-check usual labs in a.m. Total time: 20 minutes.What E/M Category is used for this visit?

Subsequent Hospital Visit (99231-99233)

ED Visit: Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the chest X-ray, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD, which is stable, and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ED to go directly to the unit. What is the level of medical decision making?

high

Physical Exam: General: Alert, smiling child. HEENT: There is clear rhinorrhea. Pharynx is without inflammation. Neck: Supple. Chest: Lungs are clear without wheeze or rhonchi. Abdomen: Soft, nontender. What is the level of exam?

expanded problem focused

ESTABLISHED PATIENT OFFICE VISIT DOS: 05/09/X1 CHIEF COMPLAINT: Left tibia fracture. HISTORY OF PRESENT ILLNESS: Patient is a 13-year-old male we first saw on 04/24/X1. He was noted to have been injured when he jumped and fell while running down a hill. He sustained a Salter-Harris II physeal fracture of the distal tibia. He is currently non-weight bearing in a short-leg cast. He has been compliant with his activity modifications. PHYSICAL EXAMINATION: He is intact to sensation. His capillary refill of the toes remains stable. There is no skin breakdown at the proximal or distal aspect of the cast. The cast is intact. ANCILLARY STUDIES: Radiographs ordered, performed, and billed in our office of the left ankle May 08, 20XX show good alignment and positioning of the fracture. Growth plate is stable. IMPRESSION: Left distal tibia fracture. PLAN: He will continue with the use of his cast, maintain non-weight bearing status. Return for reassessment with X-ray in two weeks. Cast care instructions are once again being reviewed. What E/M code is reported?

***

NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Low back pain with radiating pain into the legs. HISTORY OF PRESENT ILLNESS: A 78-year-old female with long-standing back pain. She is noted to have undergone previous epidurals. She has been diagnosed with spinal stenosis for approximately 10 years. She denies bowel or bladder dysfunction or saddle anesthesia. She offers a weakness of the extremity and numbness. She offers no unexpected weight loss, no recent trauma. She denies previous back surgery. She is a new patient to our office. CURRENT MEDICATIONS: Lisinopril, Lovastatin, glipizide, Arimidex, Naproxen, Neurontin, Xalatan, multivitamin. ALLERGIES: Codeine. PAST MEDICAL HISTORY: Breast cancer, hypertension, diabetes, prior history of spinal stenosis. REVIEW OF SYSTEMS: Denies any cardiac arrhythmia or unstable angina. No pulmonary disorders. Denies thyroid disease. No renal dysfunction. No history of stroke or seizure. She is without any unexpected weight loss or constitutional signs of infection. SOCIAL HISTORY: She is ambulatory without assist device. Denies tobacco and alcohol use. FAMILY HISTORY: Diabetes and cancer. PHYSICAL EXAMINATION: Side-to-side comparison shows no asymmetry, no pronounced atrophy. She has a pronounced straight leg raise on the right and also a contralateral straight leg raise on the left, but her discomfort is to a lesser degree. Reflexes are symmetric. Motor strength is noted to be 5/5 with ankle dorsi and plantar flexion, great toe extension, knee flexion/extension, hip abduction. She has 4/5 motor strength with hip flexion. Her hips are supple on examination. She has decreased sensation to L4-L5 level. ANCILLARY STUDIES: Independent interpretation of previous MRI from November 20XX shows evidence of spinal stenosis at L3-4, L4-5, and 5-S1. There is neural foramenal narrowing at these levels. Findings are most noted at L4-5. In addition, there is facet hypertrophy and ligamentous thickening. Cord maintained a normal signal. IMPRESSION: Spinal stenosis with radicular leg pain. PLAN: A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another course of epidural steroids. I have also recommended physical therapy. Further recommendations are pending her MRI. What E/M code is reported?

***

Patient is seen in the ED for a migraine. She is experiencing nausea with vomiting and decreased appetite. Blurry vision. Has had a low-grade fever. The pain is rated 9 out of 10 and is not responding to oral medication. Physical exam: General appearance: Mild distress. 99.6 BP 110/60 Resp 18 Skin: Warm. Dry. No pallor. No rash. Good skin turgor. Facial: No bruises, no swelling, no tenderness. Scalp: No swelling, no deformity, no tenderness. Neck: Trachea midline. Cognitive function: Within normal limits. Best response: Within normal limits. Speech: Within normal limits. Sensation: Within normal limits. Motor strength: Within normal limits. Extinction-neglect: Negative. Reflexes: Within normal limits. Cerebellar test: Within normal limits. Assessment: Migraine headache - intractable, R/O viral infection, meningitis Plan: She will be admitted. Order CT of head and lumbar puncture. What E/M code is reported?

***

ESTABLISHED PATIENT OFFICE VISIT HISTORY OF PRESENT ILLNESS: Patient follows up today after a CT scan of her abdomen for abdominal pain. She continues to have the same symptoms that she was having at her last clinic visit. I have interpreted the CT scan and went over the images with her. The only very subtle abnormality in her right inguinal region is that of a slight bowing of her transversalis fascia. Otherwise, I do not notice any abnormality. Trying to correlate this with where her symptoms are located on her abdominal wall, these are in two separate locations. Her abdominal wall pain is approximately 3 cm above her inguinal canal. ASSESSMENT/PLAN: She will continue to hold off on any significant core activities. I have told her to try and avoid activities that reproduce her pain. If this is an abdominal wall injury, it is going to take several weeks for it to heal and she will need to hold off on those activities for the next six to eight weeks. She will contact my office in three weeks to let me know how she is doing with her conservative management. If she continues to have symptoms at that time, then she may require an MRI scan of her abdomen and pelvis to try and identify an etiology for her pain. What E/M code is reported?

*****

Case 3 Susan is a 67-year-old female and is referred by Dr. R with a suspicious neoplasm of her left arm. She has had it for about a year, but it has grown a lot these last few months. I had the privilege of taking a skin cancer off her forearm in the past. Past Medical History: Hypertension, arthritis. Allergies: None. Medications: Benicar and Vytorin. Social History: Cigarettes: None. Physical Examination: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. Medical Decision Making: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, performed a 3 mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene. We will see her back next week to go over the results. What are the CPT® and ICD-10-CM code(s) reported?

11300 D49.2 Z85.828

What modifier is used to report an evaluation and management service mandated by a court order?

32

Mr. Yates loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Yates. When EMS reached the hospital Emergency Department, Mr. Yates is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour in critical care stabilizing the patient and performing CPR. The time the provider spent on CPR was 15 minutes (the CPR time was included in the one-hour critical care time). What are the appropriate procedure codes for this encounter?

92950, 99291, 99288

A 60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Total time spent with the patient was 32 minutes. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

99203

Case 2 The patient is a 32-year-old male here for the first time. Chief Complaint: Left knee area is bothersome, painful, moderate severity. The patient also notes swelling in the knee area, limited ambulation, and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. Problem occurred spontaneously. Problem is sporadic. Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems, so patient has avoided using it. Past Medical History: Patient denies any past medical problems. Surgeries: Patient has undergone surgery on the appendix. Hospitalizations: Patient denies any past hospitalizations that are noteworthy. Medications: Hydrocodone. Allergies: Patient denies having allergies. Family History: Mother: No serious medical problems; Father: No serious medical problems. Social History: Patient is married. Occupation: Patient is a chef. Review of Systems: Constitutional: Denies fevers. Denies chills. Denies rapid weight loss. Eyes: Denies vision problems. Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems. Cardiovascular: Denies chest pains. Denies an irregular heartbeat. Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath. Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool. Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination. Integumentary: Denies any rashes. Denies having any insect bites. Neurological: Denies numbness. Denies tremors. Denies loss of consciousness. Hematologic/Lymphatic: Denies easy bruising. Denies blood clots. Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite. Review of Previous Studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No varicosities. Reflexes are normal patellar. No clonus. Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. Neck: Neck is supple. No JVD. Impression: 1.Infective synovitis of the left knee 2.Contracture of the left knee 3.Possible medial meniscal tear of right knee Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day, discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy. We will obtain an MRI to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. What are the CPT® and ICD-10-CM code(s) reported?

99203 M65.162 M24.562

Case 5 NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Right lower quadrant abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old who presents with diffuse right lower abdominal pain. The pain tends to be located near his right groin. He states that it has been present since the summer of 20XX. He was doing some significant activity at that time, including significant manual labor in his yard. It was at that time that he began to notice the symptoms. He continued to work in construction throughout the summer and fall. His symptoms continued through this time and only recently, as he has limited his activity, has the pain improved. He does not have any obstructive symptoms. He has not had previous inguinal hernia repair. He was seen by his primary care provider who thought he may have a spigelian type hernia and thus he has been sent to my clinic for evaluation of this problem. PAST MEDICAL HISTORY: Low back pain, osteoarthritis, hypertension, and anxiety. PAST SURGICAL HISTORY: Anal fistulotomy, appendectomy, patent foramen ovale closure, multiple arthroscopies, carpal tunnel release bilaterally, hand surgery for tendon releases, and bilateral cataract extraction. ALLERGIES: He gets nausea and vomiting with narcotics, but otherwise has no true medication allergies. CURRENT MEDICATIONS: Clonazepam, AndroGel, multivitamins. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is retired. He tries to exercise regularly. He does not smoke or drink. REVIEW OF SYSTEMS: An 11-point review of systems was undertaken and, except for some mild upper respiratory tract infection type symptoms and some low back pain, was essentially negative. PHYSICAL EXAMINATION: Vital Signs: Temperature is 96.4. Heart rate is 72. Blood pressure is 164/92. Respiratory rate is 15. Height is 5 feet 0 inches. Weight is 199 pounds. HEENT: The sclerae are anicteric and the oropharynx is clear. Neck: No jugular venous distension or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate without murmurs. Abdomen: Soft, nontender, and nondistended with no palpable intraabdominal abnormalities of note. Specifically, there are no palpable anterior abdominal wall fascial abnormalities of note. Back: No CVA tenderness and no spinal abnormalities. Groin: Both the right and left inguinal regions are intact with no evidence of hernia. There are no spermatic cord or testicular abnormalities. Extremities: No clubbing, cyanosis, or edema. ASSESSMENT: Right groin pain, improving with limitation of activity. PLAN: This patient most likely has one of two issues that are responsible for his symptoms. One would be an occult hernia on the right side. This would present with pain without a palpable hernia on examination. This is where the posterior wall is disrupted and can lead to the same symptoms as an inguinal hernia, but without a palpable hernia. In this situation, patients typically do not get very much relief of their symptoms by decreasing their activity as one is continually utilizing the abdominal wall musculature and remain symptomatic from the hernia. Treatment would require laparoscopic surgery. The other possible pathology would be an abdominal wall injury such as a muscle pull or strain. This typically would get better with rest and since the patient is stating that his symptoms have improved over the last month or so with decreasing his activity then I would expect that he would continue to improve with conservative management. The patient agrees with the plan of continued decreased activity for the next four to eight weeks. He has not had any projects planned around his house and is not going to participate in construction at this time. He will get back to his normal activity in March. He will pay attention to his symptoms and if he does have recurrence of his symptoms with increasing physical activity, he will contact my office to arrange follow up. What are the CPT® and ICD-10-CM code(s) reported?

99203 R10.31

New Patient History & PhysicalCHIEF COMPLAINT: Right chronic inguinal hernia.HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country.PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.MEDICATIONS: Advair.ALLERGIES: None.REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.GENERAL APPEARANCE: He is a very muscular well-built man in no distress.SKIN: Normal.LYMPH NODES: None.HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.CHEST: Clear to auscultation.HEART: Regular rhythm with no murmur.ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal.IMPRESSION: Right chronic indirect inguinal hernia.PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. He was cautioned on the fact this could become an emergent situation if this becomes incarcerated. I gave him the scheduling number, and he will call and arrange the operation.What CPT® and ICD-10-CM codes are reported?

99204, K40.90

An established 47-year-old patient presents to the provider's office after falling last night in her apartment when she slipped on water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no prescription medication. It is recommended to use heat, such as a hot water bottle. Take Ibuprofen as needed for pain. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service?

99213, S39.012A, W01.0XXA, Y92.030

Case 10 Established Patient Chief Complaint: Thoracic spine pain Problem List: 1.Rheumatoid arthritis, right and left hands. 2.Compression fracture of the thoracic spine T11. 3.Alcoholism. 4.Depression/anxiety. Review of Systems: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. Current Medications: Vasotec 20 mg a day, Folic Acid 1mg a day, Norvasc 5 mg a day, Pravachol 40 mg a day, Plaquenil 400 mg a day, Humira 40 mg every other week, Celexa 20 mg, a day, Klonopin .5 mg as needed, aspirin 81 mg a day, Ambien 10 mg as needed, Hydrocodone as needed. Physical Exam: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular. Musculoskeletal Exam: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis. Review of DEXA (Dual Energy X-ray Absorptiometry) Scan: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward's triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from last year. Assessment: 1.Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated. 2.Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective. Plan: 1.Continue current therapy. 2.Aspirate the synovial cyst in the left second finger. 3.Follow up in about 6-8 weeks. 4.Repeat labs prior to visit. Procedure Note: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1 cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20 mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know. What are the CPT® and ICD-10-CM code(s) reported?

99213-2520612-F177080J1020M06.041M06.042M71.342M80.08XD

ESTABLISHED PATIENT OFFICE VISIT HISTORY: This is a 28-year-old lady who presents today for follow up. She went to the emergency room for lower abdominal pain on 03/24/X1. Urine pregnancy test was negative. Her last menstrual period was on 02/24/X1. She has not had a period. She is using condoms for contraception. She quit taking birth control pills in February. She also has slight vaginal discharge. She is para 1+3, had two miscarriages and one abortion in the past. She had a Pap smear in January of this year and it showed abnormal atypical squamous cells, ASCUS. She also had an HIV test which was negative. PHYSICAL EXAMINATION: No acute distress. Vital signs: Stable. No pallor. Chest: Clear. Heart: No murmur. Abdomen: Soft. Pelvic examination: Minimal vaginal discharge. Uterus is normal size and mobile. Positive slight adnexal tenderness. ASSESSMENT/PLAN: I have ordered urine pregnancy test, UA, and also GC/chlamydia were obtained. I have arranged pelvic ultrasound to rule out ovarian cyst. It seems that she may have pelvic inflammatory disease. I have given her Rocephin 500 mg in the office, followed by azithromycin two a day for three days, GC/chlamydia result, UA and pregnancy test, and we will re-evaluate after this. What E/M code is reported?

99214

Case 1 Identification: The patient is a 37-year-old Caucasian lady. Chief Complaint: The patient is here today for follow up of lower extremity swelling. History of Present Illness: A 37-year-old with a history of dyslipidemia and chronic pain. The patient is here for follow up of bilateral lower extremity swelling. The patient tells me the swelling responded to hydrochlorothiazide. Exam: Very pleasant, no acute distress (NAD). Vitals: P: 67, R: 18, Temp 98.6, BP: 130/85. Data Review: I did review her labs and echocardiogram. The patient does have moderate pulmonary hypertension. Assessment: 1.Bilateral lower extremity swelling: Improved with diuretics; this may be secondary to problem #2. 2.Pulmonary hypertension: Etiology is not clear at this time, will do a workup and possible referral to a pulmonologist. Plan: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD-10-CM code(s) reported?

99214 M79.89 I27.20

A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PMDetailed History, Detailed Exam, Low MDMDischarge date/time: 01/22/20XX 8:15 AMDischarge time: 20 minutesWhat CPT® code(s) is/are reported for the admission and discharge to Observation Care?

99218, 99217

A patient is admitted to the hospital for a lung transplant. The admitting physician performs a comprehensive history, a comprehensive exam, and a high level of medical decision making. What is the appropriate E/M code for this visit?

99223

Case 6 Hospital Progress Note Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain. The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date. Objective: Vital signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98. General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). Laboratory Data: Shows C Diff toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. Assessment: 1.Cholelithiasis 2.Cystitis 3.Conjunctivitis 4.Hyponatremia 5.Hypokalemia 6.Diabetes mellitus type 2 7.Hypertension If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest X-ray PA and lateral this morning to evaluate that. What are the CPT® and ICD-10-CM code(s) reported?

99232 K80.20 N30.90 H10.9 E87.1 E87.6 E11.9 I10

A 90-year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

99235

A 33-year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?

99238

Case 7 Discharge Summary Hospital Course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Ciloxan eye ointment for that. Discharge Diagnoses: 1.Cholelithiasis 2.Cystitis 3.Conjunctivitis 4.Hyponatremia 5.Diabetes mellitus type 2 6.Hypertension Discharge Medications: 1.Levaquin 500 mg p.o. daily x2 days 2.Ciloxan ointment, apply b.i.d.to left eye x 4 days/ 3.Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20 4.Benadryl 25 mg p.o. daily p.r.n. rash 5.Diovan 320 p.o. daily 6.Calcium 600 mg p.o. daily 7.Vitamin C 500 mg p.o. daily. 8.Metformin 1000 mg p.o. daily 9.Lipitor 20 mg p.o. at bedtime 10.Coreg CR 20 mg p.o. daily. Discharge Diet: Cardiac Activities: ad lib Discharge instructions: Patient to be NPO after midnight Sunday. Dismiss: Home Condition: Good Follow-up: Follow up with me in 1 week. Follow up on Monday morning for cholecystectomy. NPO after midnight on Sunday. What are the CPT® and ICD-10-CM code(s) reported?

99238 K80.20 N30.90 H10.9 E87.1 E11.9 Z79.84 I10

A 32-year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

99242

A 45-year-old patient is seeing the neurologist, Dr. Williams, at the request of his family physician to evaluate complaints of weakness, numbness, and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain. His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He has a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day. A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck. After performing an EMG and nerve conduction study, Dr. Williams determines the patient has left ulnar neuropathy at the cubital tunnel region, as well as an ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult. What is the appropriate E/M consultation code for this visit?

99243

Subjective: 6-year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist.Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normalAssessment: Wrist sprainPlan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement.What is the E/M code for this visit?

99281

A 25-year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient's altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported?

99285

Mrs. Standerfer's family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction at the nursing home. She has not experienced any chest pain, dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physician takes her BP both supine and standing, and notes her pulse and temperature. A detailed exam of the eyes, ears, nose, and throat is performed along with a detailed neurological exam. The physician orders blood work to determine if her electrolytes are out of balance again. What is the appropriate E/M code for this visit?

99309

Case 8 XYZ Nursing Home Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious. Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts everywhere. Ancillary Studies: A.M. labs—none new this morning. X-ray shows no evidence of fracture with definitive arthritis. Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias. Assessment & Plan: 1.Patient is an 84-year-old Caucasian male who presented after a fall with rib contusion, right shoulder pain and uncontrolled pain since. He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient's mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning. 2.Patient with elevated blood pressures upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently. 3.Very advanced dementia, will follow, continue on home medications. 4.Coronary artery disease and congestive heart failure. These appear stable at this time. 5.History of atrial fibrillation, sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control. 6.Type 2 diabetes mellitus. Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia. 7.We will follow the patient closely and adjust medications as necessary. What are the CPT® and ICD-10-CM code(s) reported?

99309 S20.211A M25.511 R03.0 F03.90 I25.10 I50.9 I48.91 E11.9 Z79.84

A provider makes a home care visit to a 63-year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this provider was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The provider speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported?

99348

A provider visits Mr. Smith's home monthly. Today, the provider performs a problem focused history, an expanded problem focused examination and a medical decision making of low complexity. What CPT® code is reported?

99348

A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported?

99367

Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk, but her mother has returned to work and is using a breast pump but has not seemed to produce enough milk.PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week.ASSESSMENTFour-month-old well checkColdMild thrushDiaper rashPLAN:Okay to advance to baby foodsOkay to supplement with SimilacNystatin suspension for the thrush and creams for the diaper rash if it recursMother will bring child back after the cold symptoms resolve for her DPT, HIB and polioWhat E/M code(s) is/are reported?

99391

A 10-year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs a history and exam and treats the patient for a URI with low medical decision making. What CPT® coding is reported for this visit?

99393, 99213-25

Case 4 Age: 33-year-old —Established patient Vital Signs: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98%, WEIGHT: 161 lbs. Current Allergy List: Lortab Current Medication List: Lunesta Oral Tablet 3 Mg, 1 Every Day at Bedtime, As Needed Prozac Oral Capsule Conventional 40 Mg, 1 Every Day Levothyroxine Sodium Oral Tablet 100 Mcg, 1 Every Day for Thyroid Meloxicam Oral Tablet 15 Mg, 1 Every Day for Joint Pain Imitrex Oral Tablet 100 Mg, 1 Tab Po as Directed, Can Repeat After 2 Hours for migraines, Max 2 Per Day Phenergan 25 Mg, 1 Every 4-6 Hours, As Needed for Nausea Chief Complaint: Here for a comprehensive annual physical and pelvic examinations. History of Present Illness: Pt here for routine Pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. Past Medical History: Depression. Family History: No cancer or heart disease, mother has hypertension. Social History: Tobacco Use: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. Review of Systems: Patient denies any symptoms in all systems except for HPI. Physical Exam: Constitutional: Well developed, well-nourished individual in no acute distress. Eyes: Conjunctivae appear normal. PERRLA ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx. Neck: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted. Respiratory: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. Cardiovascular: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema. Chest/Breast: Breasts normal to inspection with no deformity, no breast tenderness or masses. GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all four quadrants. GU: External/Vaginal: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal. Cervix: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep Pap smear. Uterus: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal. Adnexa/Parametria: No masses or tenderness noted. Lymphatics: No lymphadenopathy in the neck, axillae, or groin. Musculoskeletal exam: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability. Extremities: Bilateral Lower: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone. Skin: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers. Neurologic: CNS II-XII grossly intact. Psychiatric: Mood and affect appropriate. Labs/Radiology/Tests: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, Pap smear. Assessment/Plan: Unspecified acquired hypothyroidism. What are the CPT® and ICD-10-CM code(s) reported?

99395 Z00.00 Z01.419 E03.9

A 75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?

99397

Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He acted as a co-surgeon working with an orthopedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. From what category or subcategory of evaluation and management services would Dr. Hedrick's follow-up visit be reported?

non-billable

Mr. Andrews, a 34-year-old male, visits Dr. Parker's office at the request of Dr. Smith for a neurological consultation. He presents with complaints of weakness, numbness, and pain in his left hand and arm. Dr. Parker examines the patient and sends his recommendations and a written report back to Dr. Smith for the care of the patient. Which category or subcategory of evaluation and management codes would be selected for the visit to Dr. Parker?

Outpatient consultation

Hospital visit Chief Complaint: Gallstones and reflux. History of Present Illness: This is a 61-year-old woman who was seen in the ER and subsequently admitted in observation status. She has a two-year history of severe gallbladder attacks. Also, of note, she has had ongoing reflux problems for many years. Within the last few months, her reflux has worsened. Assessment/Plan: This is a 61-year-old woman with symptomatic cholelithiasis and reflux. Her number one concern right now is the gallbladder pain. This sounds like symptomatic cholelithiasis. As a result, we will schedule her for laparoscopic cholecystectomy with intraoperative cholangiogram. The risks and benefits were explained to the patient who understood and agrees for us to proceed. With regard to her reflux, it is partially controlled by her medication. She also is overweight and might have symptom improvement after weight loss. She is also very hesitant to proceed with the Nissan fundoplication because her husband had the surgery done before and had some problems with vomiting afterward. She does have objective evidence of reflux as well and is a good candidate for surgery. However, we will let her decide whether she wants to proceed with this procedure. What is the level of medical decision making?

Moderate

Physical Exam: General: His physical exam shows an intubated male. He is at times somewhat combative. There is a brace on the right shoulder. Skin: His skin is warm and dry. No rashes, ulcers, or lesions. Lungs: The lungs are diminished breath sounds, though no crackles are noted. Cardiac: Cardiac exam is tachycardic, no distinct murmurs appreciated. Extremities show no significant edema. Abdomen: Abdominal exam is soft. No masses or tenderness. No hepatosplenomegaly. Extremities: No clubbing or cyanosis. Bilateral lower: No misalignment or tenderness. Based on the 1995 Documentation Guidelines, what is the level of exam?

detailed

What ICD-10-CM code is reported for nausea and vomiting?

R11.2

Chief Complaint: Fever. Present Illness: The patient is a 2-year, 3-month-old female placed in observation status with less than one day of a high fever with decreased appetite. There has been no vomiting or diarrhea. Parents are unaware of any cough. Tylenol has been given which reduced the fever. Past Medical History: Otherwise negative. Current Medications: Tylenol® 160 mg q.4 h. per infant Tylenol® drops. Allergies: NONE. Immunizations: Up to date. Review of Systems: As per HPI. Rest of review of systems reviewed and negative. Personal, Family, Social History: The patient is not exposed to secondhand cigarette smoke. What is the level of history?

comprehensive

Physical Exam: Constitutional: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90 percent General Appearance: The patient reveals profound intellectual disability. Tracheostomy is in place. Eyes: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. Neck: The neck is supple, and the trachea is midline. Range of motion is normal. There are no masses, crepitus, or tenderness of the neck. The thyroid gland has no appreciable goiter. Respiratory: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes, and rhonchi. Cardiovascular: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs, or gallops are noted. There is no significant edema to the lower extremities. Gastrointestinal: The abdomen is soft and nondistended. There is no tenderness, rebound, or guarding noted. There are no masses. No organomegaly is appreciated. Skin: The skin is pale and slightly diaphoretic. Neurologic: Cranial nerves appear intact. The patient moves all four extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. Lymphatic: There are no palpable pathologic lymph nodes in the neck or axilla. Musculoskeletal: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing, or edema to the digits. What is the level of exam?

comprehensive

Physical Exam: General Appearance: Healthy appearing individual in no distress. Abdomen: Soft, non-tender, without masses. No CVA tenderness. Female Exam: Vulva/Labia Majora: No erythema, ulcerations, swelling, or lesions seen. Bartholin Glands: No cysts, abscesses, induration, discharge, masses, or inflammation noted. Skene's: No cysts, abscesses, induration, discharge, masses, or inflammation noted. Clitoris/Labia Minora: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable. Urethral Meatus: Meatus appears normal in size and location. No masses, lesions, or prolapse. Urethra: No masses, tenderness, or scarring. Bladder: Without fullness, masses, or tenderness. Vagina: Mucosa clear without lesions, Pelvic support normal. No discharge. Cervix: The cervix is clear, firm, and closed. No visible lesions. No abnormal discharge. Uterus: Uterus non-tender and of normal size, shape, and consistency. Position and mobility are normal. Adnexa/Parametria: No masses or tenderness noted. Based on the 1995 Documentation Guidelines, what is the level of exam?

comprehensive

Emergency Department A 47-year-old white male presents to the emergency department after the four-wheeler he was operating struck a ditch and rapidly came to a halt. This threw him against the windshield where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations. He is evaluated by Dr. Jones and a CT scan suggests a hyper dense abnormality within the brain. A bleed could not be ruled out and an inpatient hospital admission is recommended. His past history includes previous tonsillectomy, previous hospital admission for a syncopal episode associated with pain in the groin area, and hypercholesterolemia. He has no known allergies. His current medications are Zocor® and Accutane®. He is a nonsmoker and a moderate drinker of alcohol. The review of systems is negative for nausea, vomiting, blurred vision, or headache. What is the level of history?

expanded problem focused

History of Present Illness A 53-year-old man who is a veterinarian is seen for the first time today for a consultation. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple, both in January 20XX. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is and thinks it may be another skin cancer. He is also concerned about another lesion that has been present for a while, just lateral to his right eye. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past. Review of Systems: Otherwise well, no other skin complaints. Past Medical History Coronary artery disease status post bypass surgery, history of squamous and basal cell carcinomas as noted above, hay fever, and hyperlipidemia. He has had lipomas removed. Medications: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec®, 5 percent saline in eyes. Allergies: No known drug allergies. Family History: No family history of skin cancer or other skin problems. Social History: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married. What is the level of history?

expanded problem focused

John, a 16-year-old male, is admitted by the emergency department physician for observation after an ATV accident. The patient is discharged from observation by another provider the next day. What category or subcategory of evaluation and management codes would be selected for the emergency department physician?

initial observation care

IMPRESSION: Right recurrent gynecomastia. PLAN: The patient is sent for consultation re: right breast ultrasound initially performed by her primary care physician (PCP). The PCP requests a consultation for a gynecologist to recommend treatment. The gynecologist reviews the films showing a hypoechoic area measuring 1.7 x 0.7 x 1.2 cm in the 11 o'clock position of the right breast. There was no Doppler flow, and the transmission suggested that this was a cystic lesion. Because of this ultrasound and because this is symptomatic, I have recommended a simple mastectomy under general anesthesia. The patient agrees. I described the operation to the patient. What is the level of medical decision making?

low

A PCP transfers a patient to a cardiologist for management of the patient's congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?

new patient office visit

During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee. Her knee has been unstable since the incident and she decided to consult an orthopedist. She visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr. Howard's diagnosis is a torn ACL. What category and subcategory of evaluation and management code would be selected for the visit to Dr. Howard?

office visit, new patient