Coding Scenarios

11042, 12002-51

A woman was screaming in a parking lot and calling for help. She had accidentally locked her keys in the car, along with her infant son. It was a hot day, and she was quite concerned about her child. Alex Franklin came along and used a rock to break a window on the other side of the car, reached in through the broken glass, and unlocked the door. Without question, Alex is a hero, but he also cut his wrist on the broken glass. At the ED, Dr. Sander discovered that the subcutaneous tissue at the laceration site was littered with tiny shards of glass. Dr. Sander administered a local anesthetic. It took Dr. Sander quite a long time to debride the 5.3 by 1.6 cm wound of all the glass before he was able to suture it. What codes would be reported for this procedure?

D12.2

Aaron Docker, a 65 year old male, returns to see Dr. Cabrera. The results of his colonoscopy and laboratory tests on the biopsy have come back. Dr. Cabrera confirms Aaron has a benign neoplasm of the ascending colon. What diagnosis code(s) should be reported for this encounter?

32854

Abbey Reason, a 15 year old female, was diagnosed 3 years ago with idiopathic pulmonary fibrosis, a chronic intersitial pulmonary disease. Corticosteroid therapy has not improved her condition, so Dr. Flemming admitted her today for a double-lung transplantation. The harvesting of the allograft and the preparation of the cadaver donor double-lung allograft were done by Dr. Orenge. Dr. Flemming only performed the actual lung transplant, en bloc, along with a cardiopulmonary bypass. Abbey tolerated the procedure well and has an excellent prognosis. Determine the procedure code(s) that Dr. Flemmings coder would need to submit on the claims forms for Abbey's surgery.

D13.7

Abby Shantner, a 41 year old female, comes to see Dr. Branson to get the results of her biopsy. Dr. Branson explains that Abby has an alpha ell adenoma of the pancreas. Dr. Branson spends 30 minutes discussing treatment options. What diagnosis code(s) should be reported for this encounter?

90847-95

Adam has been acting out, often losing his temper and getting violent, since his parents divorced. After individual sessions, Dr. Eisenberg holds a family psychotherapy session with Adam and his parents. As Adam's mother had moved about 1 hour away, and Adam's father was at work, Dr. Eisenberg used Skype to connect the whole family for the 50-minutes session. Dr. Eisenberg's notes indicate good progress was made. Determine the appropriate code for the services provided by Dr. Eisenberg.

Z43.3

Adeline Plenner, a 43 year old female, came in to see Dr. Buldar, her gastroenterologist. She had a colostomy 6 weeks ago, and this is a standard post-procedural follow-up. He noted that there was some irritation and he applied some ointment and gave Adelina a prescription for more ointment. Dr. Buldar examined the area and told Adelina to return prn.

120013-23-47

Aden Carrington, a 9 year old boy, had a superficial cut, about 3.3 cm, on his left cheek, after being in a car accident and hit by broken glass. Dr. Kern is ready to perform a simple repair of the wound, but she is very concerned. Aden has Tourette's syndrome, which causes him to jerk or move abruptly, especially when nervous. Although anesthesia is not typically used for a simple repair of a superficial sound, Dr. Kern administers general anesthesia. Sharon Haverty, a CRNA, assists Dr. Kern with monitoring Aden during the procedure. What procedure code(s) should be reported for this encounter?

E53.8, F02.81, Z91.83

Eboni O'Neal, a 37 year old female, came with her husband, Carl, to see Dr. Annikah, a psychiatrist, on a referral from her regular physician. She complains about unusual fatigue and problems remembering things. Her husband has complained about unusual fatigue and problems remembering things. Her husband has complained that she has been unusually irritable. Carl states that he has found Eboni wandering the neighborhood several time over the last few weeks. Eboni admitted to being on a new dairy-free, animal product-free diet. After a complete physical examination, Dr. Annikah performed a complete psychology exam and ordered bloodwork, which confirmed his diagnosis of dementia caused by vitamin B12 deficiency. What diagnosis code(s) should be reported for this encounter?

T23.261A, T22.391A, T31.0

Eli Glosyck, a 28 year old male, was trying to start a campfire when the flames flared and burned him on the back of his right hand, right forearm, and right elbow. He was rushed to the emergency room, where Dr. Compton determined that he had third-degree burns on his hand and forearm and second-degree burns on his elbow. What diagnosis code(s) should be reported for this encounter?

J05.0

Fawn Springwater, a 3 year old female, was brought to her pediatrician, Dr. Canterberg, with an odd sounding cough and chest congestion. She had the measles just a short time prior. After a complete PE and the appropriate tests, Dr. Canterberg diagnosed Fawn with the croup. What diagnosis code(s) should be reported for this encounter?

33533, 33517

Elias McGynty is a 54 year old male who has significant multivessel coronary artery disease. He has atypical anginal symptoms, which are probably secondary to his insulin-dependent (Type 1) diabetes mellitus. Nonetheless, he is at risk for ischemia, and in order to reduce this risk, surgical myocardial revascularization is recommended. Procedure: A coronary artery bypass graft operation utilizing the left internal mammary artery as conduit to the left anterior descending. The remaining conduit will come from the greater saphenous veins. The risks and benefits of this procedure were explained to the patient. He signed the informed consent. The patient tolerated the procedure well and was brought into recovery conscious and aware. Determine the correct procedure code(s) for this encounter.

98960

Eliot Sharpton is a Certified Diabetes Educator (CDE) and is meeting today with Robyn Wu. She was just diagnosed with type 2 diabetes mellitus. Eliot spends 30 minutes with her, using the standardized curriculum, to help Robyn adjust her diet, get some exercise in her routine, and answer questions about her medication. Determine the procedure code(s) for the encounter between Eliot Sharpton and Robyn Wu.

M77.02

Elliot Carlyle, a 17 year old male, is believed to be an up-and-coming star on the golf course. He explains to Dr. Carole that the pain in his left elbow has become severe and his ability to grasp the club is weakened. Physical exam included flexion and pronation, confirming medical epicondylitis. What diagnosis code(s) should be reported for this encounter?

L63.0

Ellyn Pacard, a 41 year old female, presents to Dr. Grall with what she believes to be nonscarring male-pattern alopecia. Examination reveals small patches of scalp, with some limited mild erythema. "Exclamation point" hairs are located on the periphery with some indication of new patches and regrowth. Explained to patient that complete regrowth is possible in this diagnosis. Diagnosis: alopecia capitis Treatment plan: intralesional corticosteroid injections followed by minoxidil applications. What diagnosis code(s) should be reported for this encounter?

50060

Ena Colby, a 41 year old female, is admitted today for the surgical removal of a kidney stone. The stone was too big for her to pass so Dr. Olympia decided to remove it surgically.The nephrolithotomy, with complete removal of the calculus went as planned, and Ena tolerated the entire procedure well. Determine the correct procedure code(s) for this encounter.

12044, 12002-59

Fiona Curtis, a 27 year old female, got into a bar fight and sustained multiple wounds to her hand and arm. Dr. Rockville performed intermediate repair of a 5 by 2 cm wound and 3.1 by 1 cm wound on Fiona's right hand and a simple repair to a 3.2-by 1-cm wound to her right forearm. Determine the correct procedure codes to report for this encounter.

31233

Epharim Habbati, a 41 year old male, had been diagnosed with chronic sinusitis many years ago and has tried everything. He told Dr. Tolber that no medication has worked and the inflammation just won't go away. Dr. Tolber performed a nasal/sinus diagnostic endoscopy via the inferior meatus, with a maxillary sinusoscopy. Determine the correct procedure code(s) for this encounter.

E86.0 C32.3

Eric Swanson is a 43 year old male with a malignant neoplasm of the laryngeal cartilage. He has become dehydrated due to the course of radiation therapy treatments. Dr. Leistner admitted Eric today to receive rehydration therapy. What diagnosis code(s) should be reported for this encounter?

76516

Eriq Taleni, a 57 year old male, was sent to the Kinsey Imaging Center by Dr. Rayman to have an ophthalmic biometry by ultrasound echography, A-scan. After performing the exam, Dr. Turner, the radiologist, wrote in his report that a second test using intraocular lens power calculation might be necessary to further clarify the condition of the eye. Dr. Rayman determined that Eriq should wait before having the second test. Determine the correct procedure code(s) for this encounter.

98942

Evan Lavella, a 37 year old male who is 6ft 6in. tall, has pain in his neck and spine. Dr. Eisenberg, a chiropractor, provided CMT to his cervical, thoracic, lumbar, sacral, and pelvic regions to alleviate Evan's pain. Determine the correct code(s) that should be reported for this CMT encounter.

J04.1, F17.210

Evan Pattison has been smoking cigarettes for more than 10 years. He has tried to quit several times, unsuccessfully. Evan tells the doctor that he has been very stressed and smoking much more than usual and now his throat hurts and his voice is hoarse. Dr. Dieter evaluates Evan and determines acute laryngitis due to tobacco dependence. What diagnosis code(s) should be reported for this encounter?

15004, 15135-58

Evan Riggs, an 11 year old male, had burn eschar on his face from an accident. Dr. Charne performed a surgical preparation of the area. Two days later, Dr. Charne applied a dermal autograft to the 30-sq.-cm. area. Based on the notes, find the best, most accurate procedure code(s) to report all of Dr. Charne's work for Evan's injury.

Z34.02, R03.0

Genesa Thurston, a 31 year old female, G1 P0, came to see Dr. Mallard for her routine 20 week prenatal checkup. Dr. Mallard noted that Genesa's blood pressure was elevated and told her to come back in 10 days for a recheck. What diagnosis code(s) should be reported for this encounter?

M51.26

George Cornelius came to see Dr. Rymer with complaints of sudden-onset, severe low back pain. He states that the pain is in the left side of his buttocks, his left leg, and sometimes his left foot. At times, he states that his leg seems weak as well. Dr. Rymer takes a complete patient history, including specific times and actions that intensify the pain. Then x-rays, followed by an MRI, are taken of George's spine, showing a herniated (intervertebral) disc at L3-L4. What diagnosis code(s) should be reported for this encounter?

99201

George Semple, a 57 year old male, was sen for the first time by Dr. Brieo in the office for a contusion of his hand. Dr. Brieo asked questions about the bruise on George's hand and examined his hand thoroughly. Determine the proper E/M code that should be reported for this encounter.

K62.0

Gerald Candahar, a 51 year old male, was brought into the procedure room so Dr. Avalino could remove his anal polyps. What diagnosis code(s) should be reported for this encounter?

01830-P1-AA

Gerald Chang, a healthy 19 year old male, was in a motorcycle accident. Today, Dr. Oliver, an anesthesiologist, was called in to administer general anesthesia so Dr. Joshua could insert internal fixation on Gerald's compound fracture of the right distal ulna and radius, as well as complete an arthroscopic repair of the right rotator cuff. Determine the correct code(s) to report Dr. Oliver's work during this surgical event.

61860

Gerald Rosen, a 63 year old male, was admitted for the implantation of a cerebral neurostimulator. Dr. Grumman performed a craniotomy and then successfully implanted the electrodes. Determine the correct procedure code(s) for this encounter.

87804

Gillian Morrison, RN, performs a rapid influenza test using a commercial test kit in the office to determine if Hester Childs has the virus. This way the results can be provided while Hester is still in with Dr. Alberts. When complete, Nurse Morrison visually reads the results as positive. Provide the correct procedure code(s) for this encounter.

11312, 99212-25

Gladys Topfer goes to see her dermatologist for a scheduled appointment to have a 1.5-cm mole removed from her cheek. Once Dr. Assanti completes the procedure, Glady's asks the doctor to look at a cyst that has developed under her arm. Dr. Assanti discusses the presence of the cyst with her (How long has it been there? Does it hurt? etc.) and then he examines her underarm area and determines that the best course of action is to wait and see what happens with the cyst. He advises Gladys to keep the area clean and to come back in 3 weeks if the cyst has not gone away. Determine the proper code(s) that should be reported for this encounter.

55120

Glenn-Hagger, a 15 year old male, came to see his regular physician, Dr. Carboni, to help. Glenn and his friends were fooling around at this father's construction company, and a staple gun went off, projecting a staple into his scrotum. Dr. Carboni carefully removed the staple and applied some antibiotic ointment to prevent infection until the two small wounds healed. Determine the correct procedure code(s) for this encounter.

99201

Gloria Merro, a 33 year old female, comes to see Dr. Feldner at his office with complaints of severe pain in her right wrist and forearm. She just moved to the area, and this is the first time Dr. Feldner has seen her. Gloria sees Dr. Feldner for a very specific concern. The doctor asks Gloria about any medical history she may have related to her arm. Next, Dr. Feldner examines Gloria's arm. He suspects that the arm is broken and orders an x-ray to be taken. Determine the proper E/M code that should be reported for this encounter.

90970x11

Glory Anders, a 61 year old female, was diagnosed with ESRD 6 months ago. She just moved to Springfield to be closer to her daughter and began her daily dialysis on June 20 at the Southside Dialysis Center. Prepare the claim for dialysis services for June.

0085T

Grace Emerson, a 55 year old female, had a heart transplant 2 months ago. She has not been feeling well, so Dr. Rasmussen performs a breath test for the heart transplant rejection. This test is experimental, but it is noninvasive. What procedure code(s) should be reported for this encounter?

B05.81

Gregg Espinoza brought his 3 year old son, Raymon, to his pediatrician, Dr. Nunez, with complaints of a 102 degree F fever for 3 days' duration. The boy was coughing, had signs of a runny nose, and had conjunctivitis in both eyes. Upon examination, Dr. Nunez notes Koplik's spots inside his cheeks and lips. Also noted are small, generalized, maculopapular erythematous rashes on his scalp. When asked, the father agreed that the boy had been scratching his head and he had been tugging at his ears. Dr. Nunez confirmed that Raymond had measles keratoconjunctivitis . What diagnosis code(s) should be reported for this encounter?

T81.4xxA, B95.8

Gregory Parrale, a 31 year old male, had his appendix taken out last week. He comes to Dr. Gorman's office for his post-surgical follow-up visit. Dr. Gorman finds the surgical wound is erythematous, swollen, and painful to the touch. He takes a swab of the fluid oozing from the site. The lab confirms a postoperative staph infection. What diagnosis code(s) should be reported for this encounter?

25270-47, 64450

Hallie Van Masters, a 27 year old female, came to see . Dr. Knowles for a repair of her extensor tendon in her right wrist. Dr. Knowles administered a regional nerve block and then performed the repair. Determine the correct anesthesia code for this encounter.

K08.421

Hannah Kim, a 49 year old female, comes in to see her dentist, Dr. Morrison. She knew that she had periodontitis for awhile, but now the teeth on her lower right side of her mouth are really bothering her. Dr. Morrison did a full evaluation and found that five teeth on the lower right were so loose that they came out with little encouragement. Dr. Morrison determined that Hannah has partial loss (edentulism) of teeth due to periodontal disease, Class I. What diagnosis code(s) should be reported for this encounter?

J84.112, J41.1

Hans Surgesson, a 47 year old male, has been suffering with chronic inflammation of his left bronchus. He admits to previous crack cocaine use but denies current use. He complains of a dry, hacking, paroxysmal cough and occasional dyspnea lasting at least 5 months. Chest x-ray and pulmonary function tests lead Dr. Mellville to diagnose Hans with idiopathic pulmonary fibrosis due to mucopurulent chronic bronchitis. Hans is placed on oxygen therapy immediately. What diagnosis code(s) should be reported for this encounter?

Z38.01, P07.03, P07.26

Harper Anne Glosick was born today at 27 weeks 2 day gestation by cesarean section at Hillside Hospital. She weighted 945 grams at birth, and her lungs are immature. Dr. McArthur admits Harper into the NICU with a diagnosis of extreme immaturity. What diagnosis code(s) should be reported for this encounter?

31238

Harrison Matthews, a 37 year old male, was having frequent nosebleeds. Finally, after all other methods failed to provide relief, Dr. French performed an endoscopic surgical procedure to control his nasal hemorrhages. Determine the correct procedure code(s) for this encounter.

88305

Hildy French, an 11 year old female, was taken to the OR to have her tonsils removed. However, due to additional symptoms, Dr. Anachino did a biopsy and sent a specimen of Hildy's tonsils to the lab for surgical pathologic examination. The report came back from the lab that Hildy had a malignant neoplasm of her tonsils. Dr. Anachino surgically removed additional sections to be certain that the entire tumor had been removed. Hildy tolerated the procedure well and was taken to the recovery room. Provide the correct pathology/lab code(s) that should be reported for this encounter.

Z52.811

IIani Marhefka, a 31 year old female, came in to donate her eggs. Her sister, Serita, had lesions on her ovaries and had to have them removed many years ago. Dr. Stark is going to harvest eggs from IIani to implant in Serita so she and her husband, Jude, can have children. IIani wanted to help her sister and brother-in-law by donating her eggs. What diagnosis code(s) should be reported for this encounter?

95808

Ian Ellington, a 47 year old male, was having a hard time staying awake during the day and asleep during the night. Dr. Bruse sent him down the hall to have a polysomnography, with three additional parameters, to rule out sleep apnea. Determine the correct procedure code(s) for the encounter between Marina and Dr. Yeager.

99070

Illea Beurus was prepped and ready for the procedure to begin. Dr. Hernandez performed the closed manipulation of the fracture. Instead of the usual plaster cast, fiberglass was used. Determine the correct code for this encounter.

L89.212, L89.222, S72.325D, S72.334D, S22.42XD

After attempting to jump his motorcycle over five barrels and crashing on the other side, Hunter Massler ended pup in the hospital for 6 weeks with a left, closed, transverse fractured femur, shaft; a right, closed oblique fracture femoral shaft; and three fractured ribs, left side. He was unable to move without extreme pain, so he lay in bed virtually motionless, except with the help from the nurse. After several weeks, while changing the sheets, Nurse Kenesson identified a pressure ulcer on each of his hips. Dr Weiner staged the ulcers bilaterally as stage 2 and ordered wound care immediately. While there, Dr. Weiner also checked Hunter's progress on the healing of his fractures. What diagnosis code(s) should be reported for this encounter?

K80.20

After struggling to deal with a sharp pain that went from his stomach area straight through to his back, Saul Braverman went to see Dr. Spiegel. After a full examination and an ultrasounds, Dr. Spiegel confirmed Saul's cholelithiasis and they discussed plans for surgery. What diagnosis code(s) should be reported for this encounter?

24516, 24400-58

Albert Rodgers, a 31 year old male, suffered a fracture to his upper arm that severely damaged the shaft of his right humerus. Dr. Curran decides to first do a bone graft to support the healing process of the fracture and to follow that with a second surgical procedure, an osteotomy, in about 4 weeks. This is a staged, or multipart, surgical procedure. What procedure codes would be reported for this scenario?

E11.9, Z79.4

Alec Kustra, a 37 year old male was diagnosed with type 2 diabetes a year ago. Dr. Lockhart had prescribed tolbutamide to stimulate his pancreatic insulin release. However, 6 months ago, he became concerned that the medication was not working and started Alec on a regime of insulin injections. Alec is here today for Dr. Lockhart to check his insulin levels. What diagnosis code(s) should be reported for this encounter?

99386-32

Alene Morgan, a 49 year old female, went to see Dr. Blume for a comprehensive physical assessment, as a requirement for her special coverage application. The insurance carrier would not consider the policy without the examination. She had never seen Dr. Blume before today's visit. Determine the proper code(s) that should be reported for this encounter.

36251

Alene Ransom, a 61 year old female, has had two mild heart attacks in the past 2 years. Today, Alene is at the Beyers Ambulatory Surgical Center for diagnostic angiography to quantify the degree of blockage suspected in her left renal artery. Dr. Black performs the procedure, which includes placing the catheter directly in the renal artery. Later that day, Dr. Black dictates a report indicating that Alene's left renal artery is 50% blocked.

H81.313

Alexis Acosta, a 33 year old female, was having a terrible time with dizziness. She states that she has also had a problem keeping her balance. A complete examination by Dr. McQuaig confirmed a diagnosis of bilateral aural vertigo. What diagnosis code(s) should be reported for this encounter?

V2623

Alfonzo Doyle, a 20 year old male, lost his eye in a skiing accident and has come to see Dr. Durran to receive his prosthetic eye. It is a custom-made plastic prosthesis. Code for the prosthesis only.

Z52.4

Alfredo "Al" Martinelli, a 43 year old male, was admitted to the hospital today because he is donating one of his kidneys to his son, Anthony. The surgery is scheduled for this afternoon. What diagnosis code(s) should be reported for this encounter?

B20, G04.81

Alfredo Zimoso has been HIV-positive for 10 years. He comes to see Dr. Chang because of severe headaches and vision problems. After a complete physical examination (PE) and appropriate tests, Dr. Chang diagnoses Alfredo with noninfectious acute disseminated encephalomyelitis, secondary to HIV. What diagnosis code(s) should be reported for this encounter?

22310

Allyssa Erickson, an 83 year old female, fell and sustained a fracture to the C4 vertebral body. Due to the position of the fracture, Dr. Rubbine was able to use a closed treatment without having to put her through a surgical procedure. Dr. Rubbine then put Allyssa into a brace. Determine the correct procedure code(s) for this encounter.

61645

Alvin Bartholemew, a 71 year old male, was admitted through the ED with signs of a stroke. He was taken into surgery immediately and Dr. Newton performed a percutaneous transluminal mechanical thrombectomy in the anterior parietal artery. Fluoroscopic guidance was used, and the thrombus was removed and Alteplase 0.9 mg/kg (a thrombolytic agent) was injected. Determine the correct procedure code(s) for this encounter.

J68.0, T54.91XA, Y92.232

Amanda Bleigh, a 33 year old female, works in a veterinary clinic. After a very sick stray animal was brought in, she was instructed by her boss to disinfect the floor of the clinic by mopping it with straight bleach. It was cold outside, so all the doors and windows were closed tightly. Amanda began to have trouble breathing. She went immediately to Dr. Litzkom's office, where, after examination and tests, he diagnosed her with acute chemical bronchitis. What diagnosis code(s) should be reported for this encounter?

90970-G6 x3

Amie Gander, a 39 year old female, was diagnosed with ESRD. Dr. Linnger prescribed her treatments to begin on May 29 at the Southside Dialysis Center (SDC). Code for the services provided at SDC for the month of may.

Q30.3

Baby boy Luciano was born vaginally at 33 weeks. Complete physical exam performed. No anomalies were noted with the exception of a perforated nasal septum. He is admitted into the NICU. Dr. Aronson, a pediatrician specializing in congenital respiratory disorders, was called in for a consultation. What diagnosis code(s) should be reported for this encounter?

A0130, S0209 Number of miles: 12

Barry Camacho, a 79 year old male, had a stroke 3 weeks ago. He has now improved sufficiently to be discharged from the hospital. However, he is not completely well. Barry is being transferred to a short-term rehabilitation facility to help him regain use of his legs and right arm. Ira Waxen, from Flomenhoff Ambulance Services, drove the wheelchair van to take Barry from McGraw Hospital to Flowers Nursing and Rehabilitation Center, a 12-mile ride. Determine the correct HCPCS Level II code(s) for the services provided by Ira Waxen to Barry Camacho.

28108-TA

Beatrice Burmuda, a 37 year old female, came to the Upton Ambulatory Surgery Center so that Dr. Thomas could excise a benign tumor from her left foot's big toe. She tolerated the procedure well. What procedure code(s) should be reported for this encounter?

K50.00

Bernadette Bowers, a 29 year old female, came to see Dr. Grandem with symptoms of persistent diarrhea and ongoing right lower quadrant (RLQ) abdominal pain. Lab work showed an increased white blood cell count and erythrocyte sedimentation rate. A barium enema showed string sign. A biopsy confirmed a diagnosis of Crohn's disease of the jejunum. What diagnosis code(s) should be reported for this encounter?

S91.332A, W45.0XXA, Y92.832, Y99.8

Bonnie Poggio, a 15 year old female, came into the clinic with her mother. While searching for seashells at the beach, she went up on the boardwalk barefooted to get ice cream and stepped on a nail, puncturing the sole of her left foot. After checking the puncture wound, cleaning it, and dressing it, Dr. Baldwin gave Bonnie a tetanus shot. What diagnosis code(s) should be reported for this encounter?

N20.0

Brandon Markinson, a 51 year old male, was in so much pain that he was doubled over. He went to the emergency department at the hospital near his house. Dr. Deitz took an x-ray and determined that Brandon had nephrolithiasis. She discussed treatment options with him. What diagnosis code(s) should be reported for this encounter?

I15.2, E24.0

Breanna Payne, a 67 year old female, came to see Dr. Lebonna in his office. She was having headaches and bouts of dizziness. After a physical examination, a urinalysis, and blood work, he diagnosed her with benign hypertension. Dr. Lebonna's notes stated that Breanna's hypertension was the result of her existing diagnosis of pituitary-dependent Cushing's disease. What diagnosis code(s) should be reported for this encounter?

M88.852

Everett Rotarine, a 43 year old male, was having pain his left thigh, which his orthopedist, Dr. Nixon, identified as excessive bone resorption, the osteoclastic phase of Paget's disease. X-rays and a urinalysis showing elevated levels of hydroxproline confirmed the osteoclastic hyperactivity. Everett comes in today to discuss the test findings and treatment options. What diagnosis code(s) should be reported for this encounter?

Z38.00, P05.16, Q86.0

Ines Nancy Mulle was borne, full term, vaginally at Barton Hospital. Her mother has been an alcoholic for many years and would not stop drinking during the pregnancy. Ines weighed only 1,575 grams, small for a full-term neonate. After testing, she was diagnosed with fetal alcohol syndrome and admitted into the NICU. What diagnosis code(s) should be reported for this encounter?

K11.5

Isaac McNealy, a 37 year old male, came in with complaints of pain in his face and mouth. He states that the pain becomes worse just before and during meals. He also claims that heh as trouble swallowing and when he went to the dentist, he couldn't open his mouth very wide at all. Dr. Randolph did an ultrasound of Isaac's face and neck and confirmed that he was suffering with calculus of the salivary duct. What diagnosis code(s) should be reported for this encounter?

90707, 90460, 90461, 90461

Isaac Nelson, a 5 year old male, came to Dr. Rubino for his MMR vaccine so that he can start kindergarten next month. Dr. Rubino administered an injection subcutaneously. Dr. Rubino met face-to-face with Isaac's mother and discussed the importance of the vaccine, as well as indications of a reaction that she should watch for. Isaac chose a red balloon as his prize for being a good patient. Determine the correct procedure code(s) for this encounter.

J44.1, J45.41

Isabella LaVelle, a 41 year old female, has a history of intermittent dyspnea and wheezing. She comes today to see Dr. Slater with complaints of Tachypnea, chest tightness, and a cough with thick mucus. The results of Dr. Slater's PE, the chest x-ray, sputum culture, EKG, pulmonary function tests, and an arterial blood gas analysis indicate moderate, persistent, asthma with COPD, with exacerbation. What diagnosis code(s) should be reported for this encounter?

F41.1

Brian B., a 52 year old divorced father of two teenagers, states he has had successful, financially rewarding career. He has been with this company for the last 15 years, the last 5 as vice president of his division. Even though his job performance evaluations are good, and he has been lauded by his boss, he is overwrought with worry constantly about losing his job and being unable to provide for his children. This worry has been troubling him for about the last 8 or 9 months. Despite really trying, he can't seem to shake the negative thoughts. Over these last months, he noticed that he feels restless, tired and stressed out. He often paces in his office when he's alone, especially when not deeply engaged in tasks. He's found difficulty in expressing himself and has been humiliated in a few meetings when this has occurred. At night, when attempting to sleep, he often finds that his brain won't shut off. Instead of resting, he finds himself obsessing over all the worst-case scenarios, including losing his job and ending up homeless. Dr. Burnett diagnoses Brian with generalized anxiety disorder and discusses a treatment plan with him. What diagnosis code(s) should be reported for this encounter?

E10.9

Brittany Hatthaway, a 53 year old female, came to see Dr. DeRupo for her annual checkup. She is type 1 insulin-dependent diabetic and has been feeling fine. There are no diabetic-related manifestations noted. What diagnosis code(s) should be reported for this encounter?

L02.436, B95.61

Carlos Monteverde, a 63 year old male, comes in to see Dr. Harris, complaining of an extremely painful spot on his thigh. He states he has been very tired lately, especially since he noticed this bump. Patient history reveals a preexistent furunculosis. Examination shows deep follicular abscess of several follicles with several draining points. CBC shows an elevated white blood cell count. Would culture identifies Staphylococcus aureus. Area is cleaned thoroughly. Instructions given to patient to apply warm, wet compresses at home. A.) Caruncle of the thigh, letf P.) Rx for erythromycin, q8h and mupirocin ointment What diagnosis code(s) should be reported for this encounter?

73501

Carly-Ann Price, an 18 month old female, is brought into the office of her pediatrician, Dr. Lattel. She fell off the couch onto a hard tile floor and it appears that her hip is painful to her. Dr. Lattel has his staff take an x-ray of the pelvis and hip to determine if there is a fracture. He orders only the anteroposterior view to be taken. He does not subject his patients to radiology exposure unnecessarily, and he believes that the one view will tell him what he needs to know. The x-ray confirms a hairline fracture, and he applies a cast. Determine the code(s) that should be reported for the radiologic service Dr. Lattel provided to Carly-Ann.

94660

Carmine Allen, a 2 day old male, was born at 35 weeks gestation, with a birth weight of 1,450g. After exhibiting hypotension, peripheral edema, and oliguria, Carmine was diagnosed by Dr. Yanger with respiratory distress syndrome. Dr. Yanger performed the initiation of continuous positive airway pressure ventilation (CPAP). Determine the code(s) that should be reported for this treatment provided to Carmine.

D86.1

Carol-Anne Nieman, a 41 year old female, came in complaining of discomfort and tenderness under her arms and in her neck. Dr. Rothenberg performed a physical exam, revealing swollen lymph nodes. Lab work showed she was suffering with sarcoidosis of her lymph nodes. What diagnosis code(s) should be reported for this encounter?

99202, 73620, L4387-LT

Carole Shelton, a 47 year old female, came to see Dr. Giardino, a podiatrist recommended by her primary care physician, complaining of acute pain in the ball of her left foot. She states that the pain has been ongoing for about 2 months. After examination, and an x-ray of the foot, two views, Dr. Giardino took a walking boot, non-pneumatic, from the storage room and placed it on her foot. He instructed Carole to wear the boot at all times, except while in bed, for 6 weeks, and return for a follow-up evaluation. Determine the correct CPT & HCPCS Level II code(s) reported for this encounter.

01130-P1

Carson Crosby, a healthy and fit 18 year old male, fell from a girder on a construction site, fracturing three ribs and two vertebrae, and sustaining a hairline fracture of his pelvis. Dr. Pollack, an anesthesiologist, was brought in to administer general anesthesia so the body cast could be applied by Dr. Abrams, an orthopedist. You are the professional coding specialist for Dr. Pollack, the anesthesiologist. Provide the correct procedure(s) code.

D56.1

Carter McMannus, an 18 month old male, was brought by his mother to Dr. Hampshire, a pediatrician specializing in hematologic disorders. Dr. Hampshire noticed jaundice, an enlarged spleen on palpation, and other signs of failure to thrive. Dr. Hampshire recognized these signs and symptoms and confirmed with blood tests a diagnosis of Cooley's anemia. What diagnosis code(s) should be reported for this encounter?

22612, 20930

Caryn Phillips, a 51 year old female, was diagnosed with degenerative disc disease 3 months ago. She s admitted today for Dr. Cheffer to perform a posterior arthrodesis of L5-S1 (transverse process), utilizing a morselized autogenous ilian bone graft harvested through a seperate fascial incision. Caryn tolerates the procedure well and is returned to her hospital room after 2 hours in recovery. Determine the correct procedure code(s) for this encounter.

46947, 99156, 99157

Caterina Zingler, a 41 year old female, came into the same day surgery center to have Dr. Freeman perform a hemorrhoidopexy by stapling. She was very nervous because she had never had this procedure before. Raymond Elvers, a CRNA, administered Versed, IV, a sedative to relieve her anxiety. The procedure is not really painful, so there was no need for a full anesthetic or painkiller. Raymond sat with Caterina throughout the procedure to ensure her safety and comfort level. Dr. Freeman accomplished the procedure in one stage, taking 30 minutes. Determine the proper codes for this encounter.

75820

Charles Baseman, a 55 year old male, flew in yesterday from Australia, a 26 hour flight. Since getting off the plane, he has been having pain in his right calf. Dr. Vernon performed a diagnostic venography to determine if Charles has deep vein thrombosis (DVT). After completing the procedure, he wrote a report with his interpretation, which was sent to Charles's internist. Determine the correct procedure code(s) for this encounter.

82947

Charles Endicott, a 31 year old male, is an up-and-coming stockbroker who does not pay much attention to a proper diet. He came to see his physician, Dr. Falacci, because he has been experiencing episodes of light-headedness. Dr. Falacci asks his assistant, Carla Falco, to do a quantitative blood glucose test. Carla takes a blood sample, goes to the back, and checks the specimen. The results indicate that Charles has hypoglycemia. Provide the correct procedure code(s) for this encounter.

O60.14x1, O60.14x2, Z3A.35, Z37.3

Charles Wallace drove his wife, Angela, a 30 year old female, to the hospital. She had gone into labor, but she was only at 35 weeks gestation. Dr. Callahan assisted in the delivery of her twin girls. However, there was a problem, and one of the twins was stillborn. What diagnosis code(s) should be reported for this encounter?

77065-GH-LT, 77067-52-RT

Cheryl Baxett, a 41 year old female, came into the hospital for her annual screening mammogram. Dr. Ogden ordered the screening to be completed with computer-aided detection, due to a prior history of breast cancer. Later that day, after the images were analyzed, Dr. Ogden diagnosed her with a considerable mass in her left breast. What procedure code(s) should be reported for this encounter?

I13.0, I50.21, N18.1

Clarissa Bennelli, a 71 year old female, is seen at Weston Hospital with a diagnosis of acute systolic congestive heart failure due to hypertensive heart disease. Ms. Bennelli responds positively to Lasix therapy. She is also diagnosed with stage 1 chronic renal disease. What diagnosis code(s) should be reported for this encounter?

N83.291

Clarisse Battle, a 31 year old female, came to see Dr. Legg with complaints of feeling bloated. She states that she has felt this way for over a month and cannot connect it to anything she has been eating. After taking a complete history, doing an exam, and performing an ultrasound, Dr. Legg explained that Clarisse had a simple cyst on her right ovary. What diagnosis code(s) should be reported for this encounter?

28292-73

Cole Dennali, a 59 year old male, was brought into Room 5 to be prepared for a bunionectomy. He changed into a gown, he got into bed, and the nurse took his vital signs. Cole's breathing was labored- it appeared he was having an asthma attack. Dr. Fraumann ordered respiratory therapy to come in and provide a nebulizer treatment. Because general anesthesia could not be administered, the bunionectomy was canceled. What procedure code(s) should be reported for this encounter?

I11.0, I50.32

Collin Fahey, a 53 year old male, was diagnosed with chronic congestive heart failure due to benign hypertension. Dr. Engman wrote a prescription for medication and scheduled follow-up tests. What diagnosis code(s) should be reported for this encounter?

80061, 84132

Concerned that Keisha Evans, a 51 year old female, might be suffering from hypercholesterolemia, Dr. Rawlins ordered blood work, including a total cholesterol serum test, lipoprotein, and triglycerides. He also added a potassium serum test to the order. Provide the correct procedure code(s) for this encounter.

N35.114, A52.75

Corneilus St. Augusteine contracted syphilis of his kidney, and now Dr. Acosta determines that an anterior urethral stricture has developed as a result. What diagnosis code(s) should be reported for this encounter?

J12.0

Craig Alaksar, a 13 year old male, came to see Dr. Winston with a complaint of a sore throat, fever, cough, chills, and malaise Dr. Winston examined Craig, took a chest X-Ray and did a WBC count. After reviewing the results of the exam and tests, Dr. Winston diagnosed Craig with adenovirus pneumonia. What diagnosis code(s) should be reported for this encounter?

36416, 82948

Cynthia Cardamen, a 33 year old female, was not feeling well, so she went to see her family physician, Dr. Slater. After talking with her and performing and exam, Dr. Slater began to suspect that Cynthia had diabetes mellitus, type 2. Reagan Dram, the nurse, obtained a specimen of capillary blood from Cynthia's left index finger and took it to Abbey Carmichael, who ran their in-house lab, for a glucose test to be performed. She used a reagent strip to perform the test and delivered the results to Dr. Slater. Determine the correct procedure code(s) for this interaction.

Z00.01, N40.2

Dallas Rossi, a 66 year old male, came in to see his regular physician, Dr. DeGusipe, for his annual physical. Dallas said he has been feeling great and working out about twice a week. During the digital rectal exam, Dr. DeGuisipe noted a palpable nodule on the posterior of Dallas's prostate. Dr. DeGuispe told Dallas that he appears in good health except for the nodule. They discussed this and scheduled an appointment for a biopsy. What diagnosis code(s) should be reported for this encounter?

T20.39xA

Damien Connell opened the cover of the bar-b-que to see how the coals were doing. He decided to add some lighter fluid to hurry it along, and the flames roared up into his face. Gina, his wife, rushed him to the emergency department. After an exam, Dr. Hawks diagnosed Damien with a third-degree burn on his chin and second-degree burns on his nose and cheek. What diagnosis code(s) should be reported for this encounter?

C73, E05.90

Daniel Coleman, a 41 year old male, came to see Dr. Lucano for a checkup. He was diagnosed with functioning thyroid carcinoma. Dr. Lucano reviews with Daniel the results of his latest thyroid scan, TSH and TRH stimulation tests, and an ultrasonogram. Dr Lucano informs Daniel that he has developed hyperthyroidism. What diagnosis code(s) should be reported for this encounter?

92511

Darlene Watson came with her husband; Albert, to see Dr. Hudman because of the problems Albert has been having sleeping. Darlene noticed that Albert snores terribly during the night and has, at time, abruptly stopped making noise. She is concerned that he may have actually stopped breathing during on of his episodes. Dr. Hudman performed a nasopharyngoscopy with an endoscope to check Albert's adenoids and lingual tonsils. The results of the exam indicated that Albert is suffering from sleep apnea. Determine the correct procedure code(s) for this encounter.

K0012-KH

Darryl Rosen, an 81 year old male, fell and broke his hip last winter. Even though it healed, Darryl is still experiencing difficulty walking long distances. Dr. Sorrel prescribed a power wheelchair for him. Darryl decided to purchase a lightweight, portable, motorized/power wheelchair from Hammermill Medical Supply Systems. What codes should be reported for the supply of Darryl Rosen's new equipment?

D05.12

Date of Consultation: 05/25/2018 Consulting Physician: Oliver Cannon, MD Requesting Physician: Theresa Calabressi, MD Thank you for referring the patient for medical oncology consultation. History of Present Illness: The patient is a 25 year old female with noninvasive left breast cancer. The patient had a screening mammogram 4 months ago, which revealed a left upper outer breast abnormality. Stereotactic biopsy previously confirmed ductal carcinoma in situ. The patient underwent needle localization excision with pathology confirming ductal carcinoma in situ grade 2, ER positive, PR positive. She received ipsilateral breast radiation. Her course has been complicated by apparent incision site infection, which has resulted in persistent low-grade oozing of blood and occasional extrusion of pus. She has been treated with several courses of antibiotics. However, the scant bloody discharge continues. Over the past 1 week, she has noted increasing tenderness at the site of bleeding and apparent infection. She otherwise offers no complaints. Past Medical History: Remarkable for anemia attributed to iron deficiency for which she takes iron supplements. Unremarkable for hypertension, diabetes, hypercholesterolemia, or prior cardiac pulmonary, or hepatic dysfunction. Normal monthly cycles; however the last cycle has been particularly prolonged at 9 days. Medications: She takes no regular prescription medications. Allergies: NKA Family History: Remarkable for sister with diagnosis of breast cancer at age 43, presently 51, in remission No other known family history of breast or ovary cancer. Father died at age 82 of cardiac disease, mother aged 79 with history of heart disease; 2 brothers, 3 sons, and 2 daughters are healthy. Social History: Married. Denies cigarettes, alcohol, drugs. Review of Systems: Denies fever, chills, sweats, headaches, seizures, syncope, blurred vision, dysphagia, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematoschezia, dysuria, hematuria, flank pain, back pain, abnormal bleeding, bruising, lymph nodes swelling, or focal paresthesias or weakness. Physical Examination General: The patient is well developed, well nourished, in no acute distress. Vital Signs: Temperature 98.8, HR 63, BP 110/81, Weight 135.4 pounds, height 57 inches. Skin: Skin clear. No visible rash, ecchymosis or petechia. HEENT: Normocephalic. No scleral icterus. No mucosal lesions. Neck: Supple without thyromegaly. Lymph Nodes: No secondary neck, axillary, or inguinal nodes. Breasts: Without dominant mass bilaterally. There is moderate induration of approximately 2.8 cm across, underlying the left upper outer quadrant incision. There is no flactuance or erythema and patient denies significant tenderness to the area. Chest: Clear to auscultation and percussion. Cardiac: Regular rate and rhythm. No murmur, rub, or gallop. Abdomen: Soft and nontender. No masses or hepatosplenomegaly. Rectal and Genital: Deferred. Extremities: No clubbing, cyanosis, or edema. Musculoskeletal: No back tenderness. No bony or joint deformity. Neurologic: Alert and oriented. Cranial nerves, sensory and motor system, and gait are normal. Impression: Ductal carcinoma in situ, left breast, stage 0 (Tis N0 M0), ER positive, PR positive, status post lumpectomy to negative surgical margins and has set up breast radiation. Overall prognosis is excellent with estimated risk of local recurrence in the 5% range. Risk of systemic metastasis is negligible. Thus, adjuvant systemic therapy is not warranted. She is, of course, at increased risk for second malignancy; thus tamoxifen chemoprevention would be a reasonable option. Recommendations and Plan: Diagnosis, prognosis, and management options were discussed in detail with the patient and questions were answered. Tamoxifen chemoprevention was discussed in detail and she, at this time, appears agreeable to initiation of therapy. I provided a prescription for tamoxifen 20 mg daily. On the assumption that she desires continuing oncologic follow-up, any follow-up appointment will be made in 6 months. Alternatively, if she should decline tamoxifen chemoprevention or if her gynecologic physician, Dr. Calabressi, would be willing to prescribe Tamoxifen and provide continuing follow-up, then medical oncology follow-up will on an as-needed basis. What diagnosis code(s) should be reported for this encounter?

77065, 77067-52

Every year, Donna Simmons, 47 year old female, came in for her annual well-woman exam, and then would go over to the Imaging Center for her screening mammogram. This year, Dr. Douglas felt a lump during Donna's manual exam, so he ordered a diagnostic mammogram for the left breast and a screening mammogram for the right. These mammograms were provided the next day at the Imaging Center. Determine the correct code or codes for Donna's encounter at the Imaging Center.

77067

Every year, Margarette Sanchez gets a mammogram the week before her birthday. She feels fine and no lumps were noted during her gynecologist's manual exam. Margarette arrives at the Women's Imaging Center for her annual exam. Determine the correct code or codes to report the provision of Margarette's annual mammogram.

90832-95

Dr. Lappin has been working with Louisa providing psychotherapy to help her deal with panic attacks. Today, Louisa is on a plane, traveling to visit her parents in another state. As she feels a panic attack coming on, she uses the airplanes WIFI system to skype with Dr. Lappin. They spend 30 minutes talking things through and helping Louisa get through. What procedure code(s) should be reported for this encounter?

99212-24

Dr. Marple removed Christen Ellison's gallbladder on February 28. The global period for this surgical procedure is 90 days. On March 15, Christen came to see Dr. Marple because he had been out in his garden and developed a rash on his arm. The physician examined Christen's arms and gave him an ointment for the rash. Determine the proper code(s) that should be reported for this encounter between Dr. Marple and Christen.

99242

Dr. Murphy, a general surgeon, saw Teena Harrison, a 46 year old female, in her office for a second opinion requested by Teena's gynecologist, Dr. Enterez, regarding a lump in her right breast. Dr. Murphy took a brief history of Teena's present illness and a personal and family medical history relating to her hematologic and lymphatic system, which was positive for breast cancer on her maternal side. After reviewing the mammogram and performing a limited physical exam of her breasts and chest area, the physician made the straightforward decision to advise a lumpectomy. Determine the proper E/M code that should be reported for this encounter.

28405

Dr. Philphot performed a closed realignment, manipulating the fractured calcaneal bone back together, and applied a foot-to-knee plaster cast. Determine the correct procedure code(s) for this encounter.

T80.310A

Dr. Prentiss ordered 1 pint of A+ to be transfused into Sami Yariz in the postoperative area. The nurse was in a hurry and did not read carefully when she grabbed the blood and hung it on the IV pole. A few hours later, the patient began to complain of feeling very hot (temperature 103F) and pain in his back. At that time, one of the assistants noticed that the patient was given AB+ blood. The patient was treated immediately for ABO incompatibility. Hemolytic transfusion reaction was confirmed. What diagnosis code(s) should be reported for this encounter?

L3410

Dr. Principe modified Miriam Collin's left orthopedic shoe by inserting a between-sole metatarsal bar wedge to accommodate Miriam's shrinking Achilles tendon. Determine the code(s) that should be reported for this product between Dr. Principe and Miriam Collins.

99204-57

Dr. Richards referred Timothy Dunne, a 67 year old male, to Dr. Elliot for a consultation to determine whether he needs a prostatectomy. After taking a comprehensive history, performing a comprehensive examination and reviewing all the previous test results, Dr. Eliot informs Timothy that he recommends the procedure. Timothy agrees, and they select a date the following week for the surgery to be performed. Determine the proper code(s) that should be reported for this encounter.

93926

Dr. Robbins was giving Teena Salazar her annual physical examination. She had a low-grade fever and swelling and cyanosis was evident on her lower right leg. Concerned that she might have deep-vein thrombophlebitis, he performed a duplex Doppler ultrasonogram to study the arteries in her leg. Determine the code(s) that should be reported for this test performed on Teena Salazar.

00500-P4

Dr. Rockenbach administers general anesthesia to Ethan Vox, a 71 year old male. Ethan has advanced esophageal cancer that has metastasized throughout his body. Dr. Glasser will be performing a partial esophagectomy. Determine the correct anesthesia code for this encounter.

11604, 13101

Dr. Samsune excised a lesion that measured 2.1 by 3.0 cm, with 0.5-cm margings on each side, from Sally Hardy's abdomen. Sally is diagnosed clinically obese and the excess fatty tissue around the lesion required a complex closure of the excision site. The pathology report confirmed that the lesion was malignant. What is the correct procedure code to report for this encounter between Dr. Samsune and Sally Hardy?

00406-P2

Dr. Steiner administered general anesthesia to Venice Binle, a 41 year old female with controlled type 1 diabetes mellitus, for her radical mastectomy with internal mammary node dissection, to be performed by Dr. Cabara. Determine the correct anesthesia code for this encounter.

99252

Dr. Sternan was asked by Dr. MacAndrews to provide a second opinion on Arthur Jankowski, a 17 year old male. Arthur's pulmonary specialist, Dr. MacAndrews, wants to perform a lung transplant because of his diagnosis of cystic fibrosis. Dr. Sternan examined Arthur's respiratory system in his hospital room, reviewed the x-rays ordered by Dr. MacAndrews, and wrote a report agreeing that Dr. MacAndrews should perform the surgery. Determine the E/M code that should be reported for this encounter between Dr. Sternan and Arthur Jankowski.

95807

Dr. Trenton documented performing a sleep study with simultaneous recording of vital signs for Kent Burlington. What procedure code(s) should be reported for this encounter?

01630-P1

Dr. Tristan administered general anesthesia to Austin Berger, a 15 year old otherwise healthy female gymnast, before Dr. Armaden performed an arthroscoptic extensive debridement of her shoulder joint. Determine the correct anesthesia code for this encounter.

27448-50-54-77

Dr. Tuders performed a bilateral osteotomy on the shaft of Arlis Richardson's femur. Another surgeon performed the same procedure on Arlis 2 weeks ago but was unsuccessful, so Dr. Tuders repeated the procedure. As an expert in this procedure, he was brought in to perform the surgery only and will not be involved in any preoperative or postoperative care of the patient. What procedure code(s) should be reported for this encounter?

R79.1

Dr. Victor ordered a coagulation profile, including a partial thromboplastin time (PTT) and prothrombin time (PT), to be done on Louis Langer prior to scheduling his surgery. The pathology report shows an abnormally prolonged PTT. The surgery will be delayed until Dr. Victor can confirm the cause. What diagnosis code(s) should be reported for this encounter?

I82.531

Dr. Victorlli examined Carter Franchez and diagnosed him with a chronic thrombosis of the right popliteal vein. What diagnosis code(s) should be reported for this encounter?

48554-53-66

Dr. Weaver, and his surgical team, began the pancreatic transplantation procedure on Kenneth. Once the incision had been made, the patient's heartbeat became erratic and could not be brought back under control, so the procedure was discontinued. What procedure code(s) should be reported for this encounter?

76801-26

Jalyssa Miland, a 35 year old female, is 10 weeks pregnant. This is her first pregnancy, and twins run in her family. In order to determine how many fetuses there are, Dr. Ruber orders a sonogram. Iona Appell is the technician at the imaging center next door to Dr. Ruber's office. The Kinsey Imaging Center performs Jalyssa's real-time transabdominal exam and sends the documentation to Dr. Ruber so that he can read and interpret the results. A single fetus was observed. You are Dr. Ruber's coder.

96413, J900x3

Janine Howell, a 55 year old female, came in for her chemotherapy treatment. She is given Myocet, 30 mg/m2 daily for 3 days, as treatment for metastatic breast neoplasms. This is day 2. The IV infusion takes 51 minutes. She tolerates the treatment well, and is discharged home. Provide the CPT and HCPCS Level II code(s) that should be reported.

34705

Jason Antone, a 54 year old, was admitted to the hospital by Dr. Sabrina Jordan, for treatment of a chronic, contained rupture of an aneurysm of the infrarenal aorta. Jason was prepped and draped in the usual manner, and the procedure to deploy an aorto-bi-iliac endograft was performed. Determine the correct procedure code(s) for this encounter.

A41.3

Pricilla Christopher, a 17 year old female, was brought by her mother to see Dr. Fasold. Pricilla claimed that her muscles ache, she has been sweating, and she has chills at the same time. She stated that she has been coughing and short of breath for several days. After running some tests, Dr. Fasold diagnoses Pricilla with sepsis due to Hemophilus influenza. What diagnosis code(s) should be reported for this encounter?

L60.2

Priscilla Alberts, an 83 year old female, was brought in with toenails that had grown out of normal shape. It had gotten to the point that she could no longer wear closed shoes, and her daughter was concerned. After examination, Dr. Terranzo diagnosed Priscilla with onychogryphosis. What diagnosis code(s) should be reported for this encounter?

A0424

Priscilla DeLucca, an emergency medical technician (EMT), was called in as an extra ambulance for attendant for the ALS ground transportation of Willow Lawarence, a 12 year old autistic female. Determine the correct HCPCS Level II code(s) for the services provided by Priscilla DeLucca.

Z30.430

Priscilla Sharp, a 25 year old female, came to see Dr. Trenton to have an intrauterine device (IUD) inserted. She and her husband, Eli, want to wait a while before having children. What diagnosis code(s) should be reported for this encounter?

99291, 99292 x 2

Rafael Soriano, a 17 year old male, was brought into the ED by ambulance after being involved in a motorcycle accident. He was not wearing a helmet, and his head hit a brick wall. After initial evaluation and testing by the ED physician, Rafael was sent to the CCU and Dr. Haung spent 2 hours reviewing test results, performing a complete physical exam of Rafael, and discussing a care management plan with the rest of the medical team. Determine the E/M code for Rafael's encounter with Dr. Haung.

92950

Ransom Sweeney was in Dr. Plenmen's office when Ransom went into cardiac arrest. Dr. Plenman immediately performed cardiopulmonary resuscitation (CPR). The nurse called 911, and Ransom was taken to the hospital after regaining consciousness and being stabilized. Determine the code(s) that should be reported for the service provided by Dr. Plenman for Ransom Sweeney.

H00.015

Raven Mercado, a 27 year old female, came in to see Dr. Garner complaining of swelling, pain, and redness on her left eyelid. She was pretty certain it was a stye, but it was so painful she had to ask for help. Dr. Garner examined her ad confirmed a diagnosis of hordeolum externum of the left lower eyelid (commonly known as a stye). What diagnosis code(s) should be reported for this encounter?

13101-77

Ray Devilldus, an 18 year old male, was stabbed in the chest during a fight. Dr. Swartz performed a complex repair of a 6-cm laceration of the chest. The next day, Dr. Swartz left for a medical conference. The guy who stabbed Ray showed up at the hospital, and Ray got out of bed, against the doctor's orders, and engaged in another fight, ripping open his stitches. Dr. Tyson, filling in for Dr. Swartz, had to take Ray back into the OR and redo the repair. Dr. Tyson will send the claim with the following code:

H73.011, B96.3

Rebekka Keith, a 9 year old female, was brought to her pediatrician, Dr. Granberry, because her right ear was very painful and inflamed, and there was a presence of both blood and fluid in her ear canal. She had suffered with the Flu (upper respiratory infection), which had resolved last week. Physical examination revealed blebs and evidence that one or two had ruptured spontaneously causing the presence of fluid and blood. Culture identified the pathogen as Haemophilus Influenzae. Dr. Granberry diagnosed Rebekka with acute infectious bullous myringitis of the right ear and prescribed antibiotic ear drops. What diagnosis code(s) should be reported for this encounter?

J15.212

Referring Physician: Audra Starch, MD Reason for Consultation: MRSA pneumonia, fever History of Present Illness: This 77 year old male has a history of recent stroke. Garden Nursing Home, where he is a resident, requested a consultation due to his increased cough, along with some pulmonary congestion. Dr. Starch prescribed an extended spectrum penicillin (Zosyn, 4.5g q 6hr IV bedside) for the patient's low-grade fever. Sputum cultures evidenced MRSA, leading to the request for this consultation. Patient is post-CVA aphasic. Daughter is present and serves as primary relator. Nurse's notes document that the patient has been aspirating in conjunction with the increasing frequency of cough. Overall status has decreased due to these situations. At this time, the patient appears to be resting comfortably without any complaints. Assessment and Plan: 1.) Pathology report shows: positive sputum cultures with methicillin-resistant Staphylococcus Aureus. 2.) Fever, most likely secondary to pneumonia. RX: Vancomycin, 500mg q 6hr IV x 10 days to treat MRSA ceftriazone, 2 g q 12, IM x 7 days to treat UTI/E.coli What diagnosis code(s) should be reported for this encounter?

99441

Renay Miller, a 47 year old female, had just seen the doctor during her annual physical 2 weeks earlier. Today she phoned Dr. Reese to ask if she could travel out of the country, due to her condition. They spoke for about 7 minutes regarding recommended precautions. Determine the proper E/M code that should be reported for this encounter.

E0619

Rita Warren came with her husband, Ryan, to see Dr. Capshaw because of the problems Ryan was having sleeping. Dr. Capshaw had performed a nasopharyngoscopy and diagnosed Ryan with sleep apnea. At this encounter, Dr. Capshaw provided Ryan with an apnea monitor, complete with a recording feature, so that more data could be collected and Dr. Capshaw could further evaluate his condition. Provide the correct HCPCS Level II codes that would be reported for this encounter.

73000-26

Roland Dellman, an 8 year old male, is brought into the emergency department by ambulance. He was skateboarding off a homemade ramp and fell on his neck and shoulder. Dr. Tyner suspects a broken clavicle and orders a complete radiologic exam of the area. This facility does not have a radiologist on staff at this time, so the facility took the x-ray and the digital images were electronically sent to Radiology Associates in another state. Dr. Neuman reads the films and sends a report to Dr. Tyner confirming the fracture. Code for Dr. Neuman.

65205

Ronald Jackson, a 49 year old male, was working in a metal shop. As he was trimming a steel bar, some metal splinters got into his eye. Fortunately, Dr. Draman found that the metal pieces presented superficial damage and had not embedded themselves in Ronald's conjunctiva. Dr. Draman removed all the metal pieces and placed a patch over Ronald's eye. Determine the correct procedure code(s) for this encounter.

88164

Rosalie Panesca, a 47 year old female, came to see Dr. Sizemore for her annual well-woman checkup. In addition to the examination, Dr. Sizemore took a Pap smear, to be examined using the Bethesda reporting system with manual screening. Rosalie's examination showed she was completely healthy. Provide the correct procedure code(s) for this encounter.

82565

Rosalyn Alvarez, an 84 year old female, complained to Dr. Files that she was having severe cramps in her legs and hands. She said it has been getting worse the last few months. In Rosalyn's chart, it notes that she has been on diuretics, so Dr. Files orders blood work to quantify her creatinine levels to check on her kidney function. Thelma Brooks, RN, performed the venipuncture and sent the blood specimen to the lab. Provide the correct procedure code(s) for this encounter.

Z00.129, Z13.850, W22.8xxA

Roseanna Glassman brought her 39 day old daughter, Marisol, to Dr. Granger for her routine health check. During the examination, Roseanna related that Marisol's head accidentally was banged into the table and she was worried about neurologic problems. Dr. Granger checked her head and found no bruise or laceration. To calm Roseanna, he took Marisol down the hall to have a special neurologic screening for traumatic brain injury. Fortunately, the scan was negative. What diagnosis code(s) should be reported for this encounter?

H01.021, H01.024

Rosemary Seaborn, a 25 year old female, came to see Dr. Spencer, an ophthalmologist, with complaints of itching and a burning sensation in both of her eyes. She stated her upper eyelids looked like they had "dandruff" with a crusty appearance, and she noted an increased sensitivity to light. After examinations and testing, Dr. Spencer documented a confirmed case of bilateral squamous blepharitis on her upper palpebrae. What diagnosis code(s) should be reported for this encounter?

E23.2

Roy Holvang, a 25 year old male, comes to see Dr. Fletcher with complaints of extreme thirst and muscle weakness. During examination, Dr. Fletcher identifies that Roy has poor tissue turgor, dry mucous membranes, and hypotension. UA results show urine of low osmolality at 75 mOsm/kg. Dr. Fletcher diagnoses Roy with diabetes insipidus and prescribes vasopressin IM qid. What diagnosis code(s) should be reported for this encounter?

I97.821 I62.01

Ruben Sackheim, a 55 year old male, was brought into the recovery room after having a craniectomy for the drainage of an intracranial abscess. Dr. Turner's notes indicate that Ruben had a postoperative cerebrovascular infarction with intracranial hemorrhage and an acute subdural hematoma. What diagnosis code(s) should be reported for this encounter?

99304

Sadie Adanson, an 89 year old female, was admitted today into McGraw Skilling Nursing Facility (SNF) by Dr. Domino for rehabilitation and care. She suffered a stroke 2 weeks ago and was just discharged from the hospital. Dr. Domino documented a comprehensive level of history. She performed a detailed level of physical exam. Due to the patient's advanced age, co-morbidities, and long list of current medications, as well as the late effects of the stroke, Dr. Domino's MDM was of high complexity. Determine the proper E/M code that should be reported for this encounter.

87335

Sally Tong, a 5 year old female, went to a picnic at the park with her playgroup and had a hamburger, cooked very rare. Later that evening, her parents rushed her to the hospital because she was vomiting and had severe diarrhea. Dr. Warner ordered an infectious agent antigen enzyme immunoassay for E. coli O157. Fortunately, the test was negative, and it turned out that she had just had eaten too much ice cream and milk. Provide the correct procedure code(s) for this encounter.

L5500-K2

Sam Tanner, a 29 year old male, returned home after being in a rehabilitation center for 3 months. He had a below-knee amputation (BKA) after he was hurt in a rescue mission following a major hurricane. Alice Conner fitted him for an initial, below-knee patellar tendon bearing (PTB) type socket prosthesis because he has the ability to walk on and even maneuver over such low obstacles as sidewalk curbs and stairs. Alice Conner ordered and supplied an initial, below-knee PTB type socket prosthesis. Code for this encounter.

99368

Scott Germain, an 81 year old male, is still having pain and swelling in his hands. Dr. Daniels, an orthopedist, came in to evaluate Scott 2 weeks ago, and Ira Hansrani's last physical therapy session with Scott was yesterday. Dr. Rubine, the gerontologist and primary care physician for Scott, reads the up-to-date notes and test results, and sets up a meeting in the conference room with Ira Hansrani, the physical therapist, and Dr. Daniels to discuss adjusting Scott's therapy plan, based on current test results. The meeting lasts 45 minutes. Determine the proper E/M code that should be reported for this encounter.

F10.24

Jason Hurst, a 63 year old male, has been a salesman for the last 30 years. He travels throughout the Midwest and has had a less-than-stellar career. Very often, he has become close to being fired for not making quota, but his supervisor takes pity on him because he has been with the company for so long. He is at the medical office today by court order after being arrested for his third DUI in the last 6 months. Seeking treatment if part of his plea deal so he doesn't lose his driver's license. He needs to be able to drive to see his customers. Jason states he has tried to stop drinking but can't because it is part of his job. He must take customers out for a drink. And when it is back at his office, all the guys go out for drinks after work. When he is on the road, he finds nothing to do in a motel at night, so he drinks away the loneliness. The one time he tried to quit drinking, he got really sick. The only that helped him feel better was a little "hair of the dog". He states that at times he is very sad and hopeless, while other times, especially when he is with clients, he is the life of the party and knowns some of the best jokes. He pleads for help and begins to cry. Dr. Walkowicz diagnoses Jason with alcohol dependence with alcohol-induced mood disorder. What diagnosis code(s) should be reported for this encounter?

G91.0

Jeffery Himes was referred to Dr. Jonas, a neurosurgeon, after his last brain MRI came back showing signs of an abundance of cerebrospinal fluid (CSF) in the ventricles of his brain. After taking a full history and examination, Dr. Jonas determined that there was malabsorption of CSF in the brain- an official diagnosis of communicating hydrocephalus. Dr. Jonas discussed the treatment options with Jeffrey and his family. What diagnosis code(s) should be reported for this encounter?

Q79.0

Jeffrey Gilberts, a 3 hours old male, is brought in for Dr. Gensin to surgically repair his diaphragmatic hernia. He was born with his abnormal fistula in the diaphragm, diagnosed at 28 weeks gestation, but it was determined that he was not a candidate for in utero surgery. What diagnosis code(s) should be reported for this encounter?

E16.1

Jessica Gundersen, a 61 year old female, has been feeling excessively tired and irritable. She tells Dr. Vickers that she has felt edgy and nervous while experiencing cold sweats and trembling. Dr. Vickers performs a glucose screening test using a reagent strip, resulting in a reading of less than 45 mg/dL. He orders a lab test to confirm a diagnosis of reactive hypoglycemia and provides Jessica with a diet to follow and a referral to a nutritionist. What diagnosis code(s) should be reported for this encounter?

H16.022

Jessica Harvey, a 41 year old female, came in to see Dr. Loughlin with complaints of pain in her left eye upon blinking, photophobia, and increased tearing. She has also noticed some blurring. She states she hasn't been able to put her contact lenses in for several days. Dr. Loughlin examined Jessica and dropped fluorescein dye into the conjunctival sac, which stained the outline of the ulcer, the entire outer rim of the cornea. Dr. Loughlin diagnosed Jessica with a ring corneal ulcer of the left eye. What diagnosis code(s) should be reported for this encounter?

97810, 97811

Josie Rossini, a 57 year old female, was having a problem with menopause. Because of the reported concerns about hormone replacement therapy (HRT), she decided to try acupuncture. After discussing her symptoms and a treatment plan, Dr. Kini inserted several needles. The needles were removed 20 minutes later. Dr. Kini reviewed the follow-up plan and made an appointment for Josie's next visit. Dr. Kini spent 30 minutes in total face-to-face with Josie, who reported marked improvement. Code for this encounter between Dr. Kini and Josie.

T23.342A, T23.362A, T74.12xA, X12.xxxA

Judah Messner, a 5 month old male, was brought into the ED with third-degree burns on all five fingers of his left hand and both second-degree and third-degree burns on the back of his left hand. His aunt brought him in after visiting the home and seeing her sister's boyfriend stick the baby's hand in a post of boiling water on the stove. She states she quickly grabbed the baby from this man and rushed him here. She stated that she did not want to risk staying on the premises awaiting in ambulance. When asked about the baby's mother, the aunt stated she just stood there, crying, and did not come with the child. The child was taken into treatment and the police were notified. What diagnosis code(s) should be reported for this encounter?

99396, 99215-25

Kensie Hamilton, a 47 year old female, comes to see her regular physician, Dr. Granger, for her annual physical. During the examination, Dr. Granger finds a mass in her abdomen that concerns him. After the exam, he sits and talks with Kensie about past or current problems with her abdomen, including pain, discomfort, and other details regarding her abdominal tissue. He asks whether any family members have had problems in that area, as well as about her alcohol consumption and sexual history as they related to his concern. Dr. Granger then goes into his office to analyze the multiple possibilities of diagnoses, evaluates the information in Kensie's chart, and reviews the moderate risk of copmlications that might occur due to her current list of medications. He orders an abdominal CT scan, blood work, and a UA for further input. Determine the proper E/M code that should be reported for this encounter.

13121, 13122

Kevin Kewly was in a fight with a member of his rival company's softball team. The other player took out a knife and stabbed him. When he arrived at the ED, Dr. Jarrenson repaired his 12cm laceration, including debridement and retention sutures, on his lower right arm. What procedure code(s) should be reported for this encounter?

J44.1, S62.102A

Kimberly Byner was admitted into the hospital because she was suffering acute exacerbation of her obstructive chronic bronchitis. After 2 days of treatment, while still in the hospital, she tried to get out of bed without help, fell, and broke her left wrist. What diagnosis code(s) should be reported for this encounter?

T52.1x1A, R06.03, Y92.59, Y99.0

Kurt Hershey found an unmarked barrel in the back of the warehouse where he works. He opened the top and leaned over to see what was inside. Vapors from the benzene solvent being stored in that barrel overcame Kurt. He had difficulty breathing because he accidentally inhaled the chemical. He was taken to the doctor immediately. Dr. Blanchard diagnosed Kurt with respiratory distress syndrome, a toxic effect from inhaling the benzene. What diagnosis code(s) should be reported for this encounter?

G00.8, B96.89

Lamonte Millwood went to see Dr. Vaughn after returning home from college on spring break. He stated that his new dorm room is a small suite and he has three roommates. He said that the last couple of days before he left to come home, two of his roommates were coughing and sneezing. Lamonte tells Dr. Vaughn that he has been nauseous and vomiting, he has become very sensitive to light, and he feels a bit confused, having trouble concentrated on his school work. Tests confirmed Dr. Vaughn's diagnosis of bacterial meningitis caused by Neisseria meningitidis. What diagnosis code(s) should be reported for this encounter?

M23.041, O98.712, Z21

Maureen Dunbar, a 27 year old female, 23 weeks pregnant, was playing tennis when she felt a pain in her right knee. She went to see her physician, Dr. Rummer who diagnosed her problem as derangement of the anterior horn of the lateral cystic meniscus. Maureen has been HIV-positive and asymptomatic for 5 years. What diagnosis code(s) should be reported for this encounter?

96374, 96367

Melissa Fusion, a 51 year old female, postmastectomy for malignant neoplasm of the breast, has been having chemotherapy treatments. She was seen today for nausea and vomiting as a result of this therapy. Dr. Saludo ordered an antiemetic 10 mg IV push and another antiemetic IV infusion over 30 minutes. Determine the correct procedure code(s) for this encounter.

T43.591A, T46.5x1A, I95.2

Meryl Brighton was prescribed Zyprexa (olanzapine), a psychotropic, by her psychiatrist, Dr. Cauldwell, for treatment of her bipolar disorder. Meryl mentioned that her family doctor, Dr. Wall, had her on Norvasc (amlodipine), an antihypertensive, for her high blood pressure. Dr. Cauldwell told Meryl to stop taking the Norvasc while on the Zyprexa. Meryl forgot and took both medicines at the same time. Meryl suffered a dangerous case of severe hypotension and was rushed to the ED by ambulance. What diagnosis code(s) should be reported for this encounter?

Z20.6

Michael Callahan got drunk and had unprotected intercourse last night. He comes to DR. Ansara's office to discuss his concerns about possible exposure to HIV. What diagnosis code(s) should be reported for this encounter?

99397, 1012F

Michael Catapano, a 71 year old male, come to see Dr. Sheridan, his primary care physician for the last 5 years, for his annual checkup. Michael has a family history of cardiac disease, so Dr. Sheridan takes extra care to examine Michael and speak with him about angina. Dr. Sheridan documents that angina is absent. What procedure code(s) should be reported for this encounter?

B85.0

Michael McCarthey brought his 6 year old daughter, Johannah, to see Dr. Benzzoni, complaining that his daughter keeps scratching her head. After a thorough exam, Dr. Benzzoni explains that Johannah has a case of head lice. He instructs Michael to buy Nix, an OTC permethrin, and provides an instruction sheet on how to rid his child and their household of the parasites. What diagnosis code(s) should be reported for this encounter?

H27.121

Nicholas McCord, a 45 year old male, was tightening the rope holding a load on the bed of his pickup truck when the rope broke suddenly. His fist, clenching the rope, snapped backward, hitting him in the right eye. The pain was difficult for him to deal with, so his friends brought him to the emergency department. After examination, Dr. Espinal diagnosed Nicholas with an anterior dislocation of his right eye lens. He was taken up to the procedure room. What diagnosis code(s) should be reported for this encounter?

86359

Nigel Winthrope, a 19 year old male, was diagnosed with hemophilia many years ago. As a result of a blood transfusion, he contracted HIV. He has come today for lab work to check on his T-cell count, an indicator of whether the HIV is progressing. Provide the correct procedure code(s) for this encounter.

N30.0, B96.20

Nila Taglia, a 33 year old female, just returned from her honeymoon in the islands. She is feeling a burning sensation and some pain on urination, so she came to see Dr. Slater. After exam and urinalysis, Nila was diagnosed with acute cystitis due to E. Coli. What diagnosis code(s) should be reported for this encounter?

K29.00, F10.188

Noel Cooper, a 43 year old male, came to see Dr. Briscow with complaints of epigastric discomfort, nausea, and indigestion, over the last several days. He admits to drinking alcohol at lunch and dinner daily. He states he often has a couple in the evening as well. A gastroscopy was performed, and Dr. Briscow confirmed a diagnosis of acute gastritis due to alcohol abuse. What diagnosis code(s) should be reported for this encounter?

96112

Oliver Gates, a 3 year old male, does not appear to be meeting certain milestones. Dr. Saunders performed a developmental test known as an Early Language Milestone Screening. Once the test was interpreted, he sent his report and contacted a speech therapist to consult on a treatment plan. Determine the code(s) that should be reported for this screening test performed on Oliver.

J45.52

Oliver Rockwell, a 61 year old male, was brought into the ED by ambulance because he was having a severe asthma attack. His wife, Karolyn, stated that he was diagnosed with asthma about 2 years prior. This attack began 5 days ago and has not responded to his inhaler, his regular asthma pills, or any other treatment. Dr. Pressman diagnosed Oliver with acute exacerbation of late-onset severe, persistent asthma with status asthmaticus. What diagnosis code(s) should be reported for this encounter?

E0600-RA

On January 5, a respiratory suction pump was provided to Teresa Christley, who was diagnosed with emphysema. On January 6, another suction pump was delivered to Teresa. The first unit had to be replaced because of a defective piece. What procedure code(s) should be reported for this encounter?

E0607-KS

Oscar Barkley, a 57 year old male, was diagnosed with type 2 diabetes mellitus. Dr. Habersham wants to try a new medication to control Oscar's blood glucose levels and delay, or avoid, putting him on insulin. Dr. Habersham gives Oscar the prescription for the medication and a second prescription for a home blood glucose monitor. What is the code you will report for the provision of the home glucose monitor?

81220

Parker Thomasini, a 4 year old male, has a cousin who has diagnosed with cystic fibrosis last year. Recently, he has been wheezing and has a dry, nonproductive cough. The fact that his cousin has cystic fibrosis means that Parker has a 25% chance of carrying the disease. Therefore, Dr. Preston ordered a molecular diagnostic test for the mutation of delta F 508 deletion in his DNA by sequencing, single segment. Provide the correct procedure code(s) for this encounter.

Procedure: 38220 Dr. Uker: 85097, 88313

Part 1: Danielle Lee, a 37 year old female, has a history of chronic myeloid leukemia (CML) and came to our facility today for a bone marrow aspiration, right side posterior iliac crest. Dr. Hansen used a 15-gauge needle to obtain the aspirate including an aspirate clot. The patient tolerated the procedure well. Determine the correct code for the procedure. Part 2: Dr. Uker, a certified pathologist, wrote this report after testing the bone marrow. Pathology Report: The following specimens were reviewed: -peripheral smear of bone marrow aspirate and clot section -iron stain Determine the code or codes that should be reported for Dr. Uker.

Z12.83, D22.5, L70.8

Patient Name: Christopher Flemming Subjective: The patient is a 54 year old male who presents for his annual preventive screening of moles. He has no particular lesions he is concerned about, although he states his wife has told him that he has a lot of moles on his back. e does not think any of them are changing. He did have an atypical nevus removed from one of the toes of his left foot about 3 years ago. He did not require re-excision after the biopsy. He was told to have annual skin exams and he just has not followed through with it. His other complaint is acne on his chest and back. Past Medical History: Negative for skin cancer. Medications: None. Allergies: NKDA Family History: Negative for melanoma. Social History: Moderate sun exposure. He does use sunscreen, when he remembers. Objective: Alert and oriented x3. Normal mood. Normal body habitus. Examined his face, neck, chest, abdomen, back, upper extremities and lower extremities, hands and feet bilaterally. There were no lesions anywhere worrisome for cutaneous malignancy; however, he does have an above-average number of pigmented macular nevi. These range from 2-6 mm in diameter. The lesions appear similar to each other and are widely distributed on his chest, abdomen, and back; few on his upper and lower extremities and face. On his upper back, there are scattered 2.5mm inflammatory papules and pustules. Assessment: 1.) Mild truncal acne 2.) Multiple nevi 3.) History of solitary atypical nevus Plan: 1.) Reviewed ABCD's of pigmented lesions, sun protection. Discussed self-exam. Advised he return to skin examination annually as the mole pattern he has does put him at a high lifetime risk of development of melanoma. 2.) He was given erythromycin solution to use b.i.d. for acne. 3.) Follow-up scheduled in 1 year. What diagnosis code(s) should be reported for this encounter?

G89.29, G44.229

Phillip is diagnosed with chronic tension headaches due to the extreme pressures of his job. He told the doctor he could not stand the pain anymore and he needed help. What diagnosis code(s) should be reported for this encounter?

S43.034A, Y93.31, Y92.39, Y99.8

Phyllis Bush, a 27 year old female, was learning to rock climb at her gym. As she was scaling the wall, her foot slipped and Phyllis grabbed on her right hand, pulling something in her shoulder. The severe pain caused her to stop by her physician's office on her way home. Dr. Dellin took x-rays and determined that she had an inferior dislocation of the humerus, right side. Dr. Dellin put Phyllis's arm into a sling and gave her a prescription for a pain reliever. What diagnosis code(s) should be reported for this encounter?

58285-62, 57288-62, 58285-80

Valerie Ferguson, a 43 year old female, has been diagnosed with endometriosis and is admitted to Midtown Hospital to have Dr. Lissard perform a vaginal, radical hysterectomy. While Valerie is in the operating room (OR) and under anesthesia, Dr. Rasmussen is going to perform an open sling operation for stress incontinence on her bladder, and Dr. Barlow is an assistant surgeon who is there to assist Dr. Lissard. She tolerates both procedures well and is taken back to her room. What procedure code(s) should be reported for this encounter?

J80, T51.2x1A

Vincent Perdimo, a 17 year old male, decided he wanted to audition for the State Fair. After watching some videos online, he decided that he could do a fire-eating act. As he was practicing in his backyard, he accidentally aspirated some of the isopropyl alcohol he poured in his mouth. After he began having problems breathing, his parents took him to the ED. Dr. Van Hooven documented that Vincent had severe pulmonary complications, and appeared to have pneumonitis with partially respiratory insufficiency. After a workup and testing, Vincent was admitted into the hospital with a diagnosis of acute respiratory distress syndrome. What diagnosis code(s) should be reported for this encounter?

O99.012

Vitalita Meadows, a 31 year old female, G2 P1, is 17 weeks pregnant. Dr. Kramer is meeting with her to discuss her lab test results, which indicate that Vitalita has anemia. Dr. Kramer is concerned about how the anemia will affect her pregnancy. What diagnosis code(s) should be reported for this encounter?

92081, 92100

Warren Preston, a 61 year old male, has been having a problem with blurred vision and pain in his eyes. His father has glaucoma, which makes Warren at high risk for the disease. Therefore, Dr. Coreley is going to perform a bilateral visual field examination and a serial tonometry with multiple measurements. None of these services is done as a part of a general ophthalmologic service provided to Warren. Provide the correct procedure codes for this encounter between Warren Preston and Dr. Coreley.

L94.0

Serena Brynner is a 19 year old female who came in to see Dr. Trenton with thickened, hardened skin and subcutaneous tissue on her forearms, bilaterally. Examination shows Addison's keloid present. She is given a referral to a plastic surgeon. What diagnosis code(s) should be reported for this encounter?

E10.21

Sergio Prisma, a 21 year old male, was diagnosed with type 1 diabetes mellitus when he was 7 years old. He has been lax about testing his glucose and giving himself his insulin shots because he has been so busy with his courses and activities at Hillgraw University. After a complete HPI and exam, Dr. Allenson performed a glucose test and a urinalysis. The results showed the early signs of type 1 diabetic nephrosis. What diagnosis code(s) should be reported for this encounter?

11200

Seth Berensen, a 69 year old male, came to see Dr. Tyner to get rid of some skin tags on his left cheek. After applying a local anesthetic, Dr. Tyner removed nine tags and sent them to the lab. What is the correct procedure code for this encounter between Seth Berensen and Dr. Tyner?

E44.0

Shakeia and Robert Malabwa just adopted Benjamin, a 3 year old male, from an orphanage in Africa. They brought him in to see Dr. D'Onofrio, a pediatrician, for his first American checkup. After reviewing what was available about his history, and a complete physical examination, Dr. D'Onofrio diagnosed Ben with moderate protein-energy malnutrition. They sat together and discussed a treatment plan and diet to help him improve. Lactose intolerance can manifest, so he suggested that they avoid foods with lactose. What diagnosis code(s) should be reported for this encounter?

N18.3

Shane Moyet, a 41 year old male, was tested as part of his annual physical. He came in today with his wife to get his test results. Dr. Contreras diagnosed him with moderate chronic kidney disease. She sat and discussed treatment options with Shane and his wife. What diagnosis code(s) should be reported for this encounter?

F32.1

Sherri L., a 23 year old female, came into see Dr. Keel, a psychiatrist. She has a very demanding and high stress life, being a second year law student. In addition, she is clerking for a judge, and she is planning her wedding for this coming summer. She states that she has always been highly motivated to achieve her goals. After graduating with top honors from college, she went on to achieve a 3.95 GPA in her first year in law school. She admits that she can be very self-critical when she is not able to achieve perfection, even though, intellectually, she knows that perfection is not necessary for success. Recently, she has been struggling with considerable feelings of worthlessness and shame due to her inability to perform as well as she has in the past. For the past few weeks, Sherri has noticed that she is constantly feeling fatigued, no matter how much she slept. She also states that it has been increasingly difficult to concentrate at work and pay attention in class. Her best friend, RaeAnn, who works with her at the courthouse, stated that, recently, Sherri is irritable and withdrawn, not at all her typical upbeat and friendly disposition. While she as always prided herself on perfect attendance at school and work, Sherri has called in sick on several occasions. On those days she stayed in bed all day, watching TV and sleeping. At hoe, Sherri's fiance has noticed changes in her as well. He states that, in the last 6 months, it seems that she has lost interest in sex despite a very healthy sex life during the previous 2 years they had been together. He also has noticed that she has had difficulties falling asleep at night. Her tossing and turning for an hour or two after they go to bed has been keeping him awake. He confesses that he overheard her having a tearful phone conversations with RaeAnn and her sister that have worried him. When he tries to get her to open up, she denies anything is wrong, emphatically stating "I'm fine," and walking away. Sherri states that she has found herself increasingly dissatisfied in her life. She admits to having frequent thoughts of wishing she was dead, yet denies ever considering suicide. She gets frustrated with herself because she feels that she has every reason to be happy yet can't seem to shake the sense of a heavy dark cloud enshrouding her. Dr. Keel diagnosed Sherri with major depressive disorder, single episode, moderate severity. What diagnosis code(s) should be reported for this encounter?

O44.13, Z3A.36, Z37.0

Shoshanna Betterman, a 29 year old female, had some third-trimester bleeding, so she went to her doctor. Dr. Patterson performed a pelvic examination and was concerned. A transvaginal ultrasound scan confirmed that she was suffering from total placenta previa. Because she is in her 36th week, Dr. Patterson arranged to do a C-Section immediately. Shoshanna's baby girl was born without further incident. What diagnosis code(s) should be reported for this encounter?

H74.42

Tatiana Clayton, a 39 year old female, felt something in her ear. She was having problems hearing in her left ear and felt very uncomfortable. When Dr. Silver asked her, she stated that it felt like something was inside her ear. Upon inspection with the otoscope, Dr. Silver diagnosed a polyp in her middle ear. What diagnosis code(s) should be reported for this encounter?

90834

Taylor Loeb, a 32 year old male, was sent to Dr. Panjab for psychotherapy to deal with anger management issues. Dr. Panjab spent 45 minutes with Taylor in her office. Determine the procedure code(s) that should be reported for this encounter between Dr. Panjab and Taylor Loeb.

16025-A4

Ted Kercher, a 33 year old male, is a firefighter who sustained partial-thickness burns the entire length of his right arm when something exploded. He comes in to see Dr. Taggert to have the dressings changed on four wounds. What procedure code(s) should be reported for this encounter?

99024

Ten days after Dr. Rollins performed a carpal tunnel revision on Nicole Letchin's left hand. Nicole, a 23 year old female, came to see him in his office, as instructed when he discharged her. He asked how she was feeling, checked the flexibility of the wrist, removed the stitches, and checked the healing of the incision. She was doing fine, so Dr. Rollins told her to come in only if she needed anything. Determine the proper code that should be reported for this encounter between Nicole and Dr. Rollins.

A9282

Teresa Baum, a 55 year old female, has been diagnosed with malignant neoplasm of the liver. She has lost all her hair because of chemotherapy and radiation treatments. Dr. Colter prescribed a wig to help lift her spirits and self-esteem. Determine the correct HCPCS Level II code(s) to report a claim for the wig.

G70.00

Theda Granddura, a 37 year old female, came to see Dr. Lyndon complaining of weakness in her arms and hands. She states that sometimes, she is unsteady on her feet and her right eyelid was droopy. Two days ago, she tried to pick up a glass and could not get her fingers to "work right". An EMG was performed in the office, confirming a diagnosis of myasthenia gravis. What diagnosis code(s) should be reported for this encounter?

S83.422A, V97.22xA, Y99.8

Theresa Flores experienced her first parachute jump with her boyfriend 3 months ago. She loved it and is now working on her certification for her parachute jumping. On her last jump, she sprained the lateral collateral ligament of her left knee after landing the wrong way. Dr. Hadden confirmed the injury and treated it. What diagnosis code(s) should be reported for this encounter?

43280

Thomas Mouldare, a 47 year old male, was diagnosed with a diaphragmatic (hiatal) hernia that required surgery. Dr. Wallabee performed a Nissen fundoplication, laparoscopically. The upper area of the stomach (gastric fundus) is plicated (wrapped) around the distal portion of the esophagus. This is done to support and reinforce the effectiveness of the lower esophageal sphincter. Then, the esophageal hiatus is sutured to narrow the opening back to the correct width. Determine the correct procedure code(s) for this encounter.

J43.1, Z87.891

Tiffany Burnstein, a 57 year old female, quit smoking 2 years ago after a two-pack-a-day habit that lasted 40 years. She came to see Dr. Mercado with an insidious onset of dyspnea, tachypnea, and malaise. PE showed use of her accessory muscles for respiration. Dr. Mercado took a chest x-ray, EKG, RBC count, and pulmonary function test. The results directed a diagnosis of panlobular emphysema. What diagnosis code(s) should be reported for this encounter?

N18.1, M10.352

Timothy Metrosky, a 55 year old male, came to see Dr. Weingard with complaints of acute pain in his left hip. He had been diagnosed with stage 1 chronic kidney disease about 1 year ago, but it has been under control with medication. Dr. Weingard aspirated synovial fluid from his hip, and the pathology report confirmed that Timothy had developed secondary gout in his hip. What diagnosis code(s) should be reported for this encounter?

E86.0, E10.9, T38.3x6A, Z91.138

Tori Anderson, a 19 year old female, was diagnosed with Type 1 Diabetes 2 years ago. Starting college, Tori kept forgetting to take her insulin as prescribed. She comes into the University Health Center because she feels dizzy, weak, and confused. Dr. Griffith, the on-call physician, finds her to have poor skin turgor and dry mucous membranes. He diagnoses her with dehydration caused by insulin deficiency and diabetes mellitus, type 1, uncontrolled. What diagnosis code(s) should be reported for this encounter?

Z04.2, S01.01xA, W01.198A, Y92.61, Y99.0

Tracey Morales, a 33 year old male, was brought into the ED after an accident on his construction job site. He tripped and his his head against a pile of bricks. There was a 3cm laceration on his temporal lobe scalp, but he did not lose consciousness. CT scan of his head was inconclusive. After the laceration was stitched up with a simple repair, Dr. Tribow placed Tracey into observation status so they could watch for signs of a concussion. After 20 hours with normal vital signs and a normal neurologic exam, he was determined to not have suffered a concussion and released. What diagnosis code(s) should be reported for this encounter?

Z38.1

Tristan Allen Montegro was born via vaginal delivery in the McGraw Birthing Center at 10:58 am on September 1. He weighted 8 pounds 5 ounces and was 21 inches long, with Apgar scores of 9 and 9. Dr. Grall, a pediatrician, performed a comprehensive examination immediately following Tristan's birth. Baby Tristan was sent home at 6:30 pm in the care of his mother, Arashala. What diagnosis code(s) should be reported for this encounter?

J09.X3

Andrea Ignitto, a 21 year old female, came into the University Clinic with complaints of nasal congestion, cough, sore throat, fatigue, and overall aches. She states that she has had bouts of mild diarrhea for the last 2 days. She indicates that her roommate and about five others on her dorm floor were sick with similar symptoms. She has a low grade fever, chills, and nausea but denies vomiting. She claims loss of appetite and feeling weak with generalized aches and pains. Her cough is mostly nonproductive. She denies chest pain or shortness of breath. Past Medical History: Right knee surgery. [She is a soccer captain.] Current Medications: Birth control pills Allergies: Sulfa Social History: The patient drinks a couple of beers per week. Review of Systems: Essentially as in the HPI. Objective: VITAL SIGNS: BP 116/82, pulse 100, temp. 100.4F, RR 18. Pain is 7/10. Saturation is 97% on room air. GENERAL: The patient is looking unwell but in no acute distress. HEENT: Atraumatic and normocephalic. PERRLA. Extraocular movements are intact. There is no icterus, cyanosis, or pallor of the conjunctiva. Tympanic membranes are dull but not inflamed bilaterally. Nasal turbinates are congested with clear exudates, Sinuses are uncomfortable to percussion. Posterior pharynx is minimally erythematous. No exudes are noted. CHEST: Air entry is adequate bilaterally with occasional scattered ronchi. No crackles are appreciated. HEART: Sounds 1 and 2 are heard and are normal. Regular rate and rhythm, somewhat tachycardic but no murmurs, gallops, or rubs. ABDOMEN: Soft and nontender. Bowel sounds are present but somewhat hyperactive. There is no hepatosplenomegaly. SKIN: Clear, sight pallow. EXTREMITIES: Without edema, cyanosis, or clubbing. Specimen taken and tested in our office lab. Novel A influenza virus is confirmed. Assessment: Influenza with gastrointestinal manifestations. Plan: 1.) The patient will be put on Phenergan with Codeine 5 mL p.o. t.i.d. for 7 days. 2.) Zyrtec 10 mg p.o. daily for 10 to 14 days. 3.) She is instructed to take Tylenol p.r.n. for aches and pains, to drink a lot of liquids, and to stay in the dorm, in bed if possible, and rest. 4.) She has been given a note for her coach and any professors. 5.) If she does not get any better, she will come back.

96413, 96415, 96415

Andrew Gitner is admitted today for his chemotherapy, which consists of an antineoplastic drug, 500 mg IV infusion over 3 hours. Dr. Munch is in attendance during Andrew's treatment. Determine the procedure code(s) that should be reported for this encounter between Dr. Munch and Andrew Gitner.

Z40.01, Z15.01, Z80.3

Angelina Constantine, a 27 year old female, was admitted today for the prophylactic removal of her breasts. Her grandmother, mother, and sister have all had breast cancer, so she had genetic testing performed. It indicated that she did have the gene susceptibility to breast cancer. She elected to have the surgery instead of taking chances with her health. What diagnosis code(s) should be reported for this encounter?

J15.3

Anna Carland, an 81 year old female, was admitted to the hospital with pneumonia. She was placed on oxygen to help her breathe while labs were done to determine the type of pneumonia. Dr. Premin diagnosed her with streptococcal pneumonia. The pathology report specifies Streptococcus pneumoniae group B. What diagnosis code(s) should be reported for this encounter?

I10

Anna Epstein, a 63 year old female, came to see Dr. Tanner. She was complaining of occasional dizziness and a headache. After a complete examination, Dr. Tanner diagnosed Anna with idiopathic systemic hypertension. What diagnosis code(s) should be reported for this encounter?

69930

Anna Mendoza, a 33 year old female, has been deaf since she was 11. She is admitted today for Dr. Eberhardt to put a cochlear implant in her left ear. It is expected that Anna will gain back much of her hearing. Determine the correct procedure code(s) for this encounter.

O69.0xx0

Annette Spearman, a 33 year old female, G1 P0, is in the birthing room and in full labor, ready to give birth to her baby vaginally. All of a sudden, Dr. Tatum tells her to stop pushing. The umbilical cord has prolapsed, and they cannot seem to move it. Dr. Tatum immediately orders Annette into the OR, where he performs a c-section. Annette's baby girl was born without further incident. What diagnosis code(s) should be reported for this encounter?

T23.352A

Anthony, a 15 year old male, was working on a school project in the basement and accidentally released the hot glue gun onto the palm of his left hand. Dr. Clermont treated him for third-degree burns of the palm of his hand. What diagnosis code(s) should be reported for this encounter?

01402-P1, 99100

Arlena Smithson, a 77 year old female, comes to see Dr. Beele for a total knee arthroplasty due to acute arthritis. Dr. Knight is called in to administer the general anesthesia for the procedure. Arlena is in otherwise good health. Determine the correct anesthesia code for this encounter.

I69.821

Arlene Williams goes to see Dr. McGovern. She was diagnosed with a cerebral embolism 3 months ago that has now resolved. She explains that she has been having difficulty putting words together to make a sentence and it seems to be getting worse. After examination, Dr. McGovern diagnoses her with post-cerebral embolic dysphasia. What diagnosis code(s) should be reported for this encounter?

A18.11

Audra Swenson was brought into the emergency department (ED) by ambulance because she was having suprapubic pain, pain in her lower back, and nocturia. Dr. Balthazar diagnosed Audra with renal tuberculosis, also known as urogenital TB, confirmed histologically with pyelonephritis. What diagnosis code(s) should be reported for this encounter between Dr. Balthazar and Audra Swenson?

97163

Date of Physical Therapy Evaluation: 05/31/2018 Date of Injury: 03/18/2018 History of Present Illness: The patient is a 19 year old male who was the driver in an MVA. He was struck from behind by a tractor trailer, causing his car to fishtail, landing beneath the truck's trailer. He is single and lives with his parents while he finishes college. His injuries have halted his education for now, but he is determined to reenroll at a future date. He depends, right now, on someone to transport him to our facility. Assessment and Plan: The patient is a 19 year old male, status post multiple trauma. For full assessment notes, including exam and clinical presentation of characteristics, see attached notes. 1.) Rehabilitation: Toe-touching weightbearing, left lower extremity. Weightbearing as tolerated, left upper extremity. PT, OT, speech language pathology, therapeutic recreation, and psychology to see and treat. 2.) Deep venous thrombosis prophylaxis: The patient is on Fragmin. The patient is to have his Dopplers repeated. 3.) Gastrointestinal prophylaxis: The patient is not on anything but complains of systemic nausea. We will start Pepcid 20 mg b.i.d. 4.) Bowel and bladder: Overflow urinary incontinence. We will place Foley and start Urecholine 12.5 mg p.o. t.i.d. 5.) Pain: Not well controlled. Start Oramorph 15 mg with Percocet for breakthrough and schedule before therapies. Disposition: The patient will likely be discharged to home with any equipment and modifications PRN. Dr. Gerald Foxglove was called in to perform a pre-discharge physical therapy evaluation. You are Dr. Foxglove's coder. Supply the correct code(s) for this encounter.

99282

David Emerson, a 17 year old male, presented at the ED with a painful, swollen wrist. The patient stated he had been hurt at a softball game. Dr. Lubner took a brief history and asked some key questions about David's arm/hand. He then examined David's wrist and arm, checked his musculoskeletal system, and ordered x-rays to be taken. It was rather simple to determine that David's diagnosis was a sprained wrist. Determine the proper E/M code that should be reported for this encounter.

B16.9

David Tranccione, a 55 year old white male, came into our office. He complains that he feels tired all the time, no matter how much he sleeps. His muscles are sore, his stomach is upset, and he has experienced frequent bouts of diarrhea. He made an appointment with his regular physician, Dr. Cameron, when he noticed his urine was dark. Dr. Cameron ordered blood tests, and the pathology report confirmed the diagnosis of acute hepatitis B virus. What diagnosis code(s) should be reported for this encounter?

M84,551A, C79.51, Z85.3

Deliah Livingston, a 49 year old female, was diagnosed with breast cancer a year ago. She had a double mastectomy 6 months ago. She came to see Dr. Wells for a checkup and he discovered that Deliah's malignancy had mestasized to the proximal portion of her right femur. Dr. Wells suggested surgery to insert a metal rod to support the bone. She told him she would think about it. Yesterday, she was walking down her driveway and all of a sudden her thighbone splintered and she fell. In the ED, Dr. Travers diagnosed Deliah with a pathological fracture of the proximal femur, just below the hips joint, due to metastatic malignancy. What diagnosis code(s) should be reported for this encounter?

68110

Delores Leon was diagnosed with a herniated orbital mass, OD (right inferior orbit). Dr. Marconi performed an excision of the mass and repair. From his notes; "The lower lid was everted and the inferior fornix examined. The herniating mass was viewed and measured at 0.81 cm in diameter. Westcott scissors were used to incise the conjunctival fornices. The herniating mass was then clamped, excised, and cauterized. It appeared to contain mostly fat tissue, which was sent to pathology. The inferior fornix was repaired using running suture of 6-0 plain gut. Bacitracin ointment was applied to the eye followed by an eye pad." Determine the correct procedure code(s) for this encounter.

I67.4, I10

Denise Argudin, a 53 year old female, came to see Dr. Fenwick because she was experiencing headaches and problems with her vision. Denise was diagnosed with essential benign hypertension 3 years ago. After a thorough physical examination and further questioning about her visual disturbances, Dr. Fenwick ordered a CT scan of her head and a few other tests. The test results indicate that Denise has hypertensive encephalopathy. What diagnosis code(s) should be reported for this encounter?

17110

Derrick Franks, a 54 year old male, came to see Dr. Johnston, his podiatrist, for the removal of a benign plantar wart from the sole of his left foot. Dr. Johnston administered a local anesthetic and then destroyed the wart using a chemosurgical technique. A protective bandage was applied to the foot, and Frank was sent home with an appointment to return in 1 week for a follow-up checkup. Determine the procedure code(s) that would be reported for this encounter.

A40.3, R65.20, N17.9

Dr. Kahanni admitted Burton Chapel with acute renal failure due to severe sepsis resulting from pneumonia. What diagnosis code(s) should be reported for this encounter?

11423

Dr. Lanahan excised a lesion that measured 2.0 cm by 1.0 cm, with 0.2 cm margins all around, from Anson Hillam's neck. The pathology report confirmed that the lesion was benign. What is the correct procedure code to report for this encounter between Dr. Lanahan and Anson Hillam's?

13121, 12041-59

Dinah Chen, a 21 year old female, came into the emergency clinic with two lacerations: one on her right hand and the second on her right arm. Dr. Padmore debrided and provided a complicated repair of the 3.1 cm laceration on her upper right arm and a layered closure a 2.5 cm laceration on her right hand, proximal to the second digit. What procedure code(s) should be reported for this encounter?

99202

Doman Cordero, a 41 year old male, came to see Dr. Decklin in her office for the first time because of a cough, fever, excessive sputum production, and difficulty in breathing. He had been reasonably well until now. Dr. Decklin did an expanded problem-focused exam of the patients respiratory system and took Daman's personal, family, and social history in detail. After a chest x-ray was taken to rule out pneumonia, Dr. Decklin's straight forward MDM led her to diagnose him with bronchitis and prescribe an antibiotic and a steroid.

T55.1x1A

Dr. Barry, a pediatrician, was called in to see Abigail Scanter, a 3 year old female, brought in by her mother after she discovered Abigail on the floor with part of a detergent pod in her mouth, half empty. Abigail was having difficulty breathing; she had vomited; and her mouth, throat, and esophagus were erythmatous, swollen, and irritated. Dr. Barry ordered blood tests and immediately began to pump Abigails stomach based on his diagnosis of a toxic effect of the accidental ingestion of detergent. What diagnosis code(s) should be reported for this encounter?

E0105, A4636

Dr. Bettesh provided Lauren Martins, a 79 year old female, with a quad cane, after putting on a new handgrip. Code for the supply only.

26010-FA, 26010-F1-59

Dr. Cabbot drained an abscess on Mark Swanson's left thumb and another on his second finger. Both were simple procedures. What procedure code(s) should be reported for this encounter?

28202

Dr. Capella performed a repair of the secondary tenon flexor in Bruce Roden's right foot. He first performed an open tenotomy and then did the repair with a free graft. Determine the correct procedure code(s) that should be reported.

00522-QX

Dr. Charleston, an anesthesiologist, was asked to provide anesthesia care while Dr. Ablione performed a needle for biopsy of the pleura of Rosalind Bowman's left lung. Gerald Mathinson, a CRNA, will administer the anesthesia for this procedure, with Dr. Charleston's supervision. What procedure code(s) should be reported for this anesthesia service?

99218

Dr. Fein performed an initial observation at the hospital of Lois Martin, a 31 year old female. After asking about her personal medical history, including pertinent history of stomach problems, digestive problems, and pertinent family and social history directly related to her complaints, he examined Lois's abdomen, chest, neck, and back, which revealed lower right quadrant pain accompanied . by nausea, vomiting, and a low-grade fever. Dr. Fein made the straight forward decision to admit Lois overnight to the hospital to rule out appendicitis. Determine the proper E/M code that should be reported for this encounter.

00326

Dr. Foda is called in to administer general anesthesia to Morgan Saffire, a 6 month old female, diagnosed with congenital tracheal stenosis. Dr. Caudwell performs a surgical repair of her trachea. Determine the proper code(s) that should be reported for the anesthesia in this encounter.

81005-91x3

Dr. Georges is implementing a new treatment protocol for Priscilla Roper. He ordered that qualitative urinalysis be performed first thing in the morning, again at noon, and again at 5:00PM. Erline Cutter, RN, collected the specimens from Priscilla's catheter and sent them to the lab for each of the tests. Report the appropriate code or codes for the pathology lab's work.

37236

Dr. Grubman is in the OR today to perform a transcatheter placement of an intravascular stent, percutaneously, in Olivia Samuel's common iliac. Determine the correct procedure code(s) for this encounter.

00790-P3

Dr. Jeffries administered general anesthesia to Wilson Meyers, a 62 year old male with benign hypertension due to Cushing's disease. Wilson came today for Dr. Ephron to perform a laparoscopic cholecystectomy with cholangiography for acute cholecystitis. Determine the correct anesthesia code for this encounter.

00580-P5

Dr. Jeppapi administered general anesthesia to Zena Afronski, a 31 year old female with acute arteriosclerosis. Dr. Able was called back in from vacation to perform a heart/lung transplant this morning. Determine the correct anesthesia code for this encounter.

A03.0

Francie Holland, a 23 year old female, came to see Dr. Kensington due to severe abdominal pain. She had a fever and stated that she had bloody diarrhea for the past 2 days. Dr Kensington's examination revealed that she was dehydrated as well. Francie stated she ate at a new restaurant at the beach where she had a salad and a vegetable plate. After taking some tests, he diagnosed Francie with Shigella dysenteriae (bacillary dysentery). Code for the diagnosis.

Z85.820

Frederick Westchester, a 53 year old male, came to see Dr. Henner, his dermatologist, for an annual checkup. Two years ago, Dr. Henner removed a malignant melanoma from Frederick's left forearm. The malignancy was totally removed, but he comes to see his physician for a checkup once a year. What diagnosis code(s) should be reported for this encounter?

44140-22

Fredrick Stiner, a 15 year old male, is 5ft 6in, 365lb. Dr. Girst performs a partial colectomy with anastomosis. The procedure, however, takes several hours longer than usual due to the fact that Frederick is morbidly obese. Determine the correct procedure code(s) that should be reported for this encounter between Dr. Girst and Fredrick Stiner.

N28.9

Frieda Sacks, an 81 year old female, has been having problems with her kidneys for awhile, with two kidney infections over the last 5 years. Dr Cannon diagnosed her with acute renal insufficiency. What diagnosis code(s) should be reported for this encounter?

F20.0

Gary R., a 20 year old male, is a junior at a state university. Over the past month, his parents have noticed that his behavior has become quite peculiar. Several times, his mother has overheard him speaking in a quiet yet angry tone, even though no one was in the room with him. Over the past 7 to 10 days, Gary has refused to answer or make calls on his cell phone, stating that he knows if he uses the phone, it will activate a deadly chip that has been implanted in his brain by evil men from space. Gary's parents, as well as his brother and his best friend, have attempted to convince him to join them at an appointment with a psychiatrist for an evaluation, but he adamantly refused, until today. Several times, Gary has accused his parents of conspiring with the alines to steal his brain. He no longer attends classes and will soon flunk out unless he can get some help. Other than a few beers with his friends Gary denies abusing alcohol or drugs. There is a family history of psychiatric illness; an estranged aunt has been in and out of psychiatric hospitals over the years due to erratic and bizarre behavior. Dr. Zavakos diagnosed Gary with paranoid schizophrenia. What diagnosis code(s) should be reported for this encounter?

M00.022, B95.61

Gary Simmons, a 19 year old male, came in with complaints of intense pain and swelling of his left elbow. Vital signs evidence a low-grade fever. Gary states that he injured his forearm in hockey practice and it got infected, but he was too busy with classes and practice to go to the medical clinic on campus. Now, all of a sudden, he has pain in his elbow that he cannot ignore. Dr. Lannahan applied a local anesthetic and used fine needle aspiration to extract some synovial fluid. Analysis shows gross pus and testing shows a high white blood cell count. The synovial fluid glucose is 55 mg/dL. This confirmed a diagnosis of acute septic arthritis, due to gram-positive Staphylococcus aureus. What diagnosis code(s) should be reported for this encounter?

44960-79

Judith Conchran, a 41 year old female, had a gastric bypass performed by Dr. Fellowes 10 days ago. She comes to see him today because she has a fever and pain radiating across her abdomen. Dr. Fellowes examines her, calls an ambulance, and takes her to the hospital and up to the operating room, where he performs an appendectomy to remove her ruptured appendix. The global postoperative period for a gastric bypass is 90 days. Dr. Fellowes performed Judith's appendectomy during the postoperative period for the bypass, and it had nothing to do with the first procedure. What would the correct procedure code be?

99341

Jules Paganto, a 39 year old male, suffers from agoraphobia and cannot leave his home. Dr. Volente went to the house to examine Jules because he was complaining of chest congestion. Dr. Volente took a problem-focused history, as this was the first time he had seen Jules. The doctor examined Jule's HEENT and chest and concluded that Jules had a chest cold. He told Jules to get some OTC cold medicine and to call if the symptoms did not go away within a week. Determine the proper E/M code that should be reported for this encounter.

45388, 99156, 99157

Justin Abernathy, a 61 year old male, was suffering from fecal incontinence, diarrhea, and constipation. He came to the Ambulatory Care Center so that his gastroenterologist, Dr. Minton, could perform a colonoscopy. First, Ellen Brennon, RN, administered Demerol and Versed by IV, and the patient was brought into the examination room. The variable flexion Olympus colonoscope was introduced into the rectum and advanced to the cecum. In the midsigmoid colon, a 3-mm sessile polyp was destroyed. The procedure took about 30 minutes, and Justin tolerated the procedure well. Determine the correct procedure code(s) for this encounter.

29065

Justine had fractured her ulna and radius after falling off her skateboard. She got caught in an unexpected rainstorm that drenched her, and her cast. Dr. Keller replaced the long-arm cast. Determine the correct procedure code(s) for this encounter.

H61.012

Kaitlyn Logan, a 27 year old female, was at a club and met a guy doing ear piercings. She got a piercing through the cartilage of her upper left ear. Now, 3 days later, her ear is erythematous, swollen, and painful to the touch. Dr Sweeting examined her ear and diagnosed her with acute perichondritis of the left pinna. He prescribed fluoroquinoline with a semisynthetic penicillin and told her to come back in 2 weeks. What diagnosis code(s) should be reported for this encounter?

Z12.11

Kathryn Rogers, a 49 year old female, came in to see Dr. Apter to get a colonoscopy. Dr. Apter explained last week that this was an important screening for malignant neoplasms of the colon and was recommended for all adults aged 50 and over. After the screening, Dr. Apter told Kathryn she was fine and there were no abnormalities. What diagnosis code(s) should be reported for this encounter?

93303, 93530

Mason Franks, a 4 month old male, was experiencing cyanotic episodes known as "blue" spells. Dr. Zahn, his pediatrician, performed a transthoracic echocardiogram, which identified a ventricular septal defect and hypertrophied walls of the right ventricle. He then performed a right cardiac catheterization that confirmed a diagnosis of tetralogy of Fallot. Code for this encounter between Mason Franks and Dr. Zahn.

14040

Larissa Cheek had a 2.5cm x 1cm contracted scar on the back of her hand, making it difficult to use her fingers completely. Dr. Villa performed a Z-plasty tissue transfer to disrupt the scar tissue and elongate the transferred tissues. He noted that the secondary defect was 3 sq. cm. What procedure code(s) would be reported for this encounter.

33681

Lia Westerly, an 11 week old female, was diagnosed with ventricular septal defect (VSD) after her pediatrician, Dr. Harris, ordered an echocardiography. A large VSD was identified in the septum. Due to the size of the defect, Dr. Harris admitted Lisa into the hospital today to close the defect with a patch graft. Determine the correct procedure code(s) for this encounter.

15271-76

Lilly Drummond, a 14 year old female, was burned on her left forearm when she missed catching a flaming baton during cheerleading practice. Five days ago, Dr. Cheng applied a skin allograft to the burned area. Lilly is admitted today because the graft is not healing properly, and Dr. Cheng is going to apply a new allograft of 20 sq. cm. Determine the correct procedure code for this encounter.

K57.32

Lisa Begas, a 63 year old female, came in complaining of a low grade fever with chills for 3 days, nausea and vomiting, and cramps. Dr Allendale did a CT scan of her abdomen and pelvis, and determines that she had diverticulitis without perforation or bleeding of the colon. What diagnosis code(s) should be reported for this encounter?

33206-23

Louisa Cabana, a 61 year old female, arrived for the insertion of a permanent pacemaker, atrial with transvenous electrodes. Dr. Snyder, knowing that Louisa has been diagnosed with Parkinson's disease, causing her to have uncontrollable tremors, decided that conscious sedation (which is the standard of care) was insufficient to ensure the patient's safety. He called Dr. Corman to administer general anesthesia. Determine the correct anesthesia code for this encounter.

I12.9, N18.3

Matthew Spencer, a 69 year old male, is admitted to Franklin General Hospital for observation with a diagnosis of stage 3 chronic renal disease due to benign hypertension. What diagnosis code(s) should be reported for this encounter?

M26.621

Manual Daniels, a 43 year old male, came to see Dr. Biehl complaining of pain and stiffness in his lower jaw. Upon examination, Dr. Biehl noted swelling and erythema at the temporomandibular joint. Dr. Biehl diagnosed Manuel with arthralgia of temporomandibular joint, right side. What diagnosis code(s) should be reported for this encounter?

99375

Mara Morietty, a 55 year old female, was diagnosed with advanced pancreatic cancer and is being cared for at her home by her family, with the help of a home health agency. Dr. Clarke is providing care plan oversight services for the first month of care. The plan includes home oxygen, IV medications for pain control management, and diuretics for edema and ascites control. Dr. Clarke also discusses end-of-life issues, living will directive, and other concerns with the family, the nurse, and the social worker. Dr. Clarke includes documentation of his 45 minute assessment, as well as notes on modifications to the care plan. Certifications of care from the nursing staff, the social worker, the pharmacy, and the company supplying the DME for support are also in the record. Determine the proper E/M code that should be reported for this encounter.

M41.54, Y84.2

Marci Wakefield started having pain in her back, after completing a full course of radiation treatments for a malignant tumor. Dr. Diaz diagnosed her with scoliosis of the thoracic region as a result of the radiation. What diagnosis code(s) should be reported for this encounter?

81003

Margaret O'Hanahan came to see Dr. Marinson. She states that she has been feeling a stinging pain when she urinates. She confirms some lower back aches but denies hematuria. Dr. Marinson asks Margaret to go into the bathroom and provide a urine sample, which is then tested in the office by dipstick, automated without microscopy. Determine the correct procedure code(s) for this encounter between Margaret and Dr. Marinson.

D69.3

Marissa Rubine, a 27 year old female, came to see Dr. Post with complaints of bruising "suddenly appearing" on her arms and legs. She states that she had two recent episodes of epistaxis but denies any other bleeding. She denied taking any drugs or smoking, and states she has no risk factors for HIV. Physical examination revealed the spleen was not palpable. Petechiae are noted scattered on her legs bilaterally. Blood Work Results: -hemoglobin (138 g/L)- Normal -white cell count- normal -platelet count of 10 x 10 ^9/L- low (normal>150x10^9/L) -erythrocyte sedimentation rate was 6mm/h -direct Coombs' test- negative -antinuclear- absent -DNA-binding antibodies- absent -rheumatoid factor- absent Bone Marrow Aspiration: high number of normal megakaryocytes but otherwise normal. Dx: Immune Thrombocytopenia Purpura She is placed on a short course of prednisolone. What diagnosis code(s) should be reported for this encounter?

O86.11, B95.2, O94

Marjorie Ableman, a 31 year old female, gave birth, vaginally, to a beautiful baby girl 3 weeks ago. She comes today to see Dr. Beale because of feelings of fatigue. After exam and blood tests, Dr. Beale diagnoses her with postpartum cervical infection caused by Enterococcus. What diagnosis code(s) should be reported for this encounter?

70553

Mark Silver, an 81 year old male, has been having problems with his memory and his walking. After an extensive examination, his neurologist, Dr. Chernuchin, orders an MRI, brain, with and without contrast, to determine if Mark is suffering from hydrocephalus. Determine the correct procedure code(s) for this encounter.

Dr. Petrone will report code 29882-56. Dr. Wellington will report code 29882-54 Dr. Shields will report code 29882-55

Nadia Forrester, a 37 year old female, was on vacation, hiking through the mountains when she fell over a log and wrenched her knee very badly. She was flown to the nearest hospital and placed under the care of Dr. Petrone. After the diagnostic tests were completed, Dr. Petrone recommended arthroscopic surgery to treat the knee. Dr. Wellington performed a surgical arthroscopy and repaired the medial meniscus. Immediately after the surgery, Nadia flew home, and she went to her family physician, Dr. Shields, for the follow-up appointments. Determine the codes reported for Dr. Petrone, Dr. Wellington, and Dr. Shields regarding this encounter.

78014, 79101

Nadya Bartlett, a 43 year old female, had gained a great deal of weight recently with no change in her diet or exercise regimen. After a thorough examination, Dr. Posner ordered nuclear imaging of her thyroid, with uptake. Radiopharmaceuticals were administered intravenously. The report came back to Dr. Posner with the multiple determinations of Nadya's exam. Determine the correct procedure code(s) that should be reported for this encounter between Dr. Posner and Nadya Bartlett.

G30.1, F02.80

Nate Mercado, an 81 year old male, came to see Dr. Bronson with complaints of increasing forgetfulness and difficulty remembering new information. He states virtually no ability to focus or concentrate. His presentation confirms a deterioration in personal hygiene, and his appearance is somewhat disheveled. Nate's daughter insisted that he come to the doctor. After a neurologic exam, psychometric testing, a PET scan, and an EEG, Dr. Bronson diagnosed Nate with late-onset Alzheimer's disease. What diagnosis code(s) should be reported for this encounter?

S61.052A, W55.11xA, Y92.830, Y93.01, Y99.8

Nathan Kirchner, an 8 year old male, was hiking in a public park with his Boy Scout Troop. When they came to a clearing and saw a foal and its mother looking over the fence in a corral in the northeast edge of the park. He reached out his left hand to pet the foal, and the mother horse bit his thumb. His scout leader took him to the ER. After examination and some tests, Dr. Clifton cleaned the wound, applied a sterile dressing, and gave Nathan an antibiotic. What diagnosis code(s) should be reported for this encounter?

P61.0

Neonate Alvarez, male, was born vaginally yesterday, 09/05/2018, at 15:25 without incident. Apgar scores: 1min.-10, 5min.-10 Four hours later, extensive purpura became visible on his abdomen, arms, and legs. No jaundice was observed. His 29 year old mother was given a blood transfusion for a postpartum hemorrhage after her first pregnancy 3 years earlier. The mother's serum was found to contain IgG antibodies to the father's platelets and to some of a panel of platelets from normal, unrelated donors. These antibodies were typed as specific anti-HPA-1A antibodies and had been incited by the previous pregnancy and transfusion. These antibodies crossed the placenta, manifesting as alloimmune thrombocytopenia in this neonate. Additionally, the neonate was found to have red cell incompatibility. An exchange transfusion was performed to compensate for hemolysis. White it is unusual for an ABO incompatibility to require an exchange transfusion, it worked. The neonate's platelet count returned to normal quickly due to free reactant antibody to platelets having been removed by the exchange. We kept the neonate for observation for another 48 hours and then discharged him to his mother. She was told to follow up in 1 week at the office or phone PRN. What diagnosis code(s) should be reported for this encounter?

H40.031

Patient Name: Peter Calvern Date of Operation: 10/05/2018 Preoperative Diagnosis: Narrow-angle glaucoma, right eye. Postoperative Diagnosis: Narrow-angle glaucoma, right eye. Operation Performed: Laser iridotomy, right eye. Surgeon: JoAnn Hannigan, MD Anesthesia: Topical Proparacaine. Indications For Procedure: The patient is a 67 year old male with a history of narrow-angle glaucoma, at high risk for blindness or angle-closure glaucoma, diagnosed on physical examination by gonioscopy. Risks, benefits, and alternatives of laser iridotomy were discussed with the patient preoperatively. The patient agreed and signed appropriate consent preoperatively . Description of Procedure: On the day of the procedure, the right eye was identified as the operative eye. The patient received 3 sets q. 5 minutes of the following drops: proparacaine, pilocarpine, and lopidine. Appropriate constriction and anesthesia were achieved. The patient was then brought back to the laser suite, where first the argon laser was used to pretreat the iris superiorly in an area that was covered by the lid wit the following settings: 800 milliwatts, 0.06 second duration and 50 micron spot size. Then, the YAG laser was used to complete the iridotomy with the following settings: 5 millijoules, 2 pulses and a total of 2 pulses applied. Good flow of aqueous was noted from the posterior chamber to the anterior chamber and a patent iridotomy was obtained. The patient was given the following postoperative instructions: No bending, coughing, lifting, straining, or sneezing. Return to the clinic for further followup care, and the patient is to use prenisolone acetate 1 drop, left eye, 4 times a day for 1 week. What diagnosis code(s) should be reported for this encounter?

N43.0, N35.8

Patient Name: Walter Primiera Preoperative Diagnoses: 1.) Left hydrocele, possible right. 2.) Urethral meatal stenosis. Postoperative Diagnoses: 1.) Left encysted hydrocele 2.) Urethral meatal stenosis. Operations Performed: 1.) Left hydrocelectomy 2.) Diagnostic laparoscopy. 3.) Urethral meatoplasty Anesthesia: General and caudal. What diagnosis code(s) should be reported for this encounter?

H26.131, W21.07, Y93.64, Y99.8

Patient's Name: Arlene Masconetti MRN: ALMAS0122 Date of Procedure: 07/22/2018 Pre/Postoperative Diagnosis: Cataract, traumatic and mature, right eye. Procedure Performed: Phacoemulsification and implantation of intraocular lens, right eye Surgeon: Jason Britemann, MD Anesthesia: MAC with retrobulbar Procedure: Patient is a 37 year old female who had been playing softball with co-workers and got hit by a ball in the right eye, causing a total traumatic cataract. She tried to ignore the discomfort, but it was interfering with her doing her work, and she was afraid to drive. Patient was given the complete information on this procedure, possible outcomes, and projected outcomes, and she signed consent. Prior to bringing the patient to the operating room, the patient received three sets of topical dilating, antibiotic drops. Description of Operation: The patient was brought to the procedure room and placed in a supine position on the operating table, and was prepped and draped in a sterile manner. She was sedated and retrobulbar injection of 0.75% Marcaine and 1% Lidocaine was made. No complications were evident. A lid speculum was inserted to part the eyelid A paracentesis was made infratemporally. The anterior chamber was filled with air and then indocyanine green to stain the anterior capsule. The cataract was noted to be extremely mature. A small capsulorrhexis was initiated. Immediately, milky white fluid extruded from the capsulorrhexis opening. A 27-guage cannula was then used to aspirate this fluid. The cystotome was then used to complete the capsulorrhexis. The nucleus was gently rocked to facilitate mobility. The phacoemulsification apparatus was introduced into the eye. The nucleus was phacoemulsified and removed without any complications. The remaining cortex was removed with irrigation and aspiration. An SA60 AC 21-diopter lens was placed in the bag and the remaining viscoelastic was removed. One interrupted 10-0 nylon suture was placed in the cornea. The patient tolerated the procedure well. The lid speculum was removed. One drop of Betadine, one drop of Ciloxan, and bacitracin ointment were plalced into the eye and patch and shield were applied. The patient was returned to post anesthesia care in satisfactory condition. The patient was instructed to take the eye patch off at 6PM and use the topical Viamox and Pred Forte eye drops every 2 hours until bed time. What diagnosis code(s) should be reported for this encounter?

I25.10, I10, Z87.891, Z79.82

Patient: Basti, Carl Reason for Consultation: Surgical evaluation for coronary artery disease. History of Present Illness: The patient is a 47 year old male who has a known history of coronary artery disease. He underwent previous PTCA and stenting procedures in December and most recently in August. Since that time, he has been relatively stable with medical management. However, in the past several weeks he started to notice some exertional dyspnea with chest pain. For the most part, the pain subsides with rest. For this reason, he was reevaluated with a cardiac catheterization. This demonstrated 3-vessel coronary artery disease with a 70% lesion to the right coronary artery; this was a proximal lesion. The left main had a 70% stenosis. The circumflex also had a 99% stenosis. Overall left ventricular function was mildly reduced with an ejection fraction of about 45%. The left ventriculogram did note some apical hypokinesis. In view of these findings, surgical consultation was requested and the patient was seen and evaluated by Dr. Isaacson. Past Medical History: 1.) Coronary artery disease as described above with previous PTCA and stenting procedures. 2.) Dyslipidemia 3.) Hypertension Allergies: None. Medications: Aspirin 81 mg daily, Plavix 75 mg daily, Altace 2.5 mg daily, metoprolol 50 mg b.i.d., and Lipitor 10 mg q.h.s. Social History: He quit smoking approximately 8 months ago. Prior to that time, he had about a 35 to 40 pack per year history. He does not abuse alcohol. Family Medical History: Mother died prematurely of breast cancer. His father died prematurely of gastric carcinoma. Review of Systems: There is no history of any CVAs, TIAs, or seizures. No chronic headaches. No asthma, TB, hemoptysis, or productive cough. There is no congenital heart abnormality or rheumatic fever history. He has no palpitations. He notes no nausea, vomiting, constipation, diarrhea, but immediately prior to admission, he did develop some diffuse abdominal discomfort. He says that since then this has resolved. No diabetes or thyroid problem. There is no depression or psychiatric problems. There are no musculoskeletal disorders or history of gout; no hematologic problems or blood dyscrasias; no bleeding tendencies; and no recent fevers, malaise, changes in appetite, or changes in weight. Physical Examination: BP 120/70, pulse is 80. He is in a sinus rhythm on the EKG monitor. Resp. 18 and unlabored. Temp 98.2 F. Weight 260 lbs. Height 5' 5". In general, this was a pleasant male who is currently is not in acute distress. Skin color/turgor are good. PERRLA. Conjunctivae clear. Throat is benign. Mucosa was moist and noncyanotic. Neck veins not distended at 90 degrees. Carotids had 2+ upstrokes bilaterally without bruits. No lymphadenopathy was appreciated. Chest had a normal AP diameter. The lungs were clear in the apices and bases; no wheezing or egophony appreciated. The heart had a normal S1, S2. No murmurs, clicks or gallops. The abdomen was soft, nontender, nondistended. Good bowel sounds present. No hepatosplenomegaly was appreciated. No pulsatile masses were felt. No abdominal bruits were heard. His pulses are 2+ and equal bilaterally in the upper and lower extremities. No clubbing is appreciated. He is oriented x3. Demonstrated a good amount of strength in the upper and lower extremities. Face was symmetrical. He had a normal gait. Impression: This is a 47 year old male with a significant multivessel coronary artery disease. The patient also has a left main lesion. He has undergone several PTCA and stenting proceudres within the last year to year and a half. At this point, in order to reduce the risk of any possible ischemia in the future, surgical myocardial revascularization is recommended. What diagnosis code(s) should be reported for this encounter?

77761

Patient: Craig Bennington Date of Procedure: 09/25/2018 Preoperative Diagnosis: Adenocarcinoma of the prostate Postoperative Diagnosis: Adenocarcinoma of the prostate Surgeon: Carlos Arias, MD Anesthesia: General Anesthesia via LMA Complications: None Drains: One 18-French Foley catheter per urethra Indications for Procedure: This patient has a new diagnosis of adenocarcinoma of the prostate diagnosed due to a very slowly rising PSA. His current PSA level is only 2.0, but prostate ultrasound biopsies were performed showing adenocarcinoma of the prostate at the left base of the prostate, and two biopsies were positive out of eight with a Gleason score of 6. Treatment options have been discussed, and he wishes to proceed with prostate brachytherapy. Informed consent has been obtained. Description of Procedure: The patient was placed on the operating table in the supine position. General anesthesia was administered VIA LMA. He was then placed in the dorsal lithotomy position and sterilely prepped and draped in the usual fashion. The prostate ultrasound were inserted. The prostate was visualized using the preplanned study as a guide. Intracavitary application of prostate brachytherapy was performed. The patient tolerated the procedure well and had no immediate intraoperative or postoperative complications. We implanted a total of 54 iodine-125 radioactive seeds through 12 needles with each seed of containing 0.373 milliecurie per seed. During the procedure, the patient received 4 mg of Decadron IV and 400 mg of Cipro IV. Subsequent fluoroscopy showed good distribution of the seeds throughout the prostate. The patient will have a CAT scan of the pelvis and simulation for his seed localization. Total target dose is 14,500 cGy. The patient will be discharged with prescriptions for Cardura 1 mg a day for a month with two refills; Tylenol No. 3 one t.i.d. p.r.n. for pain, a total of 20; Pyridium Plus one b.i.d. for 10 days; Cipro 500 mg b.i.d. for 5 days; and prednisone 10 mg t.i.d. for a week. Discharge instructions were explained to the patient and his wife. He will return to see Dr. Freguson, his oncologist, in 2 weeks and Dr. Victors, his urologist, in 4 weeks for a followup. Determine the correct procedure code(s) for this encounter.

E66.01, E11.9, I10, E78.5, Z78.42

Patient: Eric Micoh Reason for Consultation: preoperative evaluation for bariatric surgery. History of Present Illness: The patient is a 47 year old morbidly obese male with a BMI of 46.3 and multiple medical problems including hypertension, diabetes, and dyslipidemia. He has been overweight most of his life. The patient was considering bariatric surgery and he is planning to for a lap band procedure. He says that snoring is not a very common complaint of his wife. He snores mainly when he drinks; otherwise, it could be soft snoring or sometimes no snoring at all. There was no mention of witnessed apneas. He does not wake himself up choking or gasping for air. He is a very quiet sleeper with not much tossing and turning. He wakes up feeling refreshed for the most part, unless he sleeps for 5 hours or so. He goes on his day with no difficulty as far as excessive daytime sleepiness or fatigue. He is only tired if he had a really long busy day. His Epworth sleepiness score today was between 5 and 6. He has never fallen asleep behind the wheel or got himself in an accident. His weight has been steady. He has been overweight since he was 15 years old. He never had any symptoms suggestive of cataplexy, sleep paralysis, or hypnagogic or hypnopompic hallucinations. He denies any symptoms of restless legs. No symptoms of parasomnia. No sleep onset or sleep maintenance insomnia. Assessment and Plan: 1.) Even though this patient does not have any of the cardinal symptoms of obstructive sleep apnea including snoring, witnessed apneas, or excessive daytime sleepiness, he does have physical features that increase the risk of sleep apnea including obesity, large neck circumference, crowded airway with high Mallampati class, as well as his multiple associated cardiovascular and metabolic disorders including hypertension that is not very well controlled on different blood pressure medicines, diabetes, and dyslipidemia. 2.) I had a very long discussion with him today about the need for a sleep study to rule out obstructive sleep apnea, even though he does not have the classic symptoms. I also explained to him the risks in the peri-operative period for patients with obstructive sleep apnea that has not been treated. At this point, he wants to wait and think about it as well as talk it over with the bariatric surgery team. He does not think he has sleep apnea. He does not think he would be able to perform the sleep study, as he will have a hard time sleeping outside of his house. 3.) I explained to him the risks involved with untreated moderate-to-severe obstructive sleep apnea, including worsening cardiovascular disease, arrhythmias, risk of stroke, and increased overall mortality. 4.) I also mentioned to him that there is a possibility of doing a portable sleep study at home if that would be something he is willing to pursue. 5.) In the meantime, he should continue to lose weight, avoid alcohol and sedatives, exercise routinely, and avoid driving if drowsy. 6.) We will follow up with him as needed if he is willing to pursue this further.

D70.9

Patient: Frank Copeland Date of Admission: 03/15/2018 Date of Discharge: 03/21/2018 Admission Diagnosis: Neutropenic fever. Discharge Diagnoses: 1.) Neutropenic fever. 2.) Acute myelogenous leukemia, status post induction and three cycles of high-dose Ara-C 3.) Thrombocytopenia Procedures Performed: 1.) Two-view chest x-ray. 2.) One unit of PRBC transfusion. Hospital Course: The patient is a very pleasant 54 year old male with acute myelogenous leukemia who has undergone three cycles of high-dose Ara-C. He was transferred here after he presented to an outside facility with a 1-day onset of fevers and chills. He had measured temperature at the outside hospital at that time of 102 degrees. He was transferred to this facility and admitted to the oncology service. He was initially placed on cefepime, and blood cultures were drawn. All cultures throughout the course of his hospitalization turned out to be negative. He, however, remained febrile for the majority of his hospitalization. Upon presentation, he did complain of 1-day onset of profuse watery diarrhea that was extremely foul smelling. Of note, he was on p.o. prophylactic Levaquin due to his neutropenia. He was also on prophylactic acyclovir. Due to his being on antibiotics and history of diarrhea, a stool PCR was collected but resulted negative. Before the stool PCR resulted, he was placed on Flagyl as empiric coverage for suspected C. Diff Colitis. After the stool PCR resulted negative, Flagyl was discontinued. During the short 24 hours when he was on Flagyl, he seemed to have defervesced, and his fever curve trended down. However, after the Flagyl was discontinued, he started having worsened diarrhea and the fevers went back up again. For this reason, a C. diff PCR was ordered and the Flagyl was resumed. The C diff PCR was also negative. Until that point, he remained on cefepime and the Flagyl was also decided to be continued since the patient seemed to improve with it. The thinking was that he may have had some colitis that was not related to C. diff. Six days into his hospitalization, he continued to have fever. At this juncture, vancomycin was added to see if this would help. Repeat blood cultures were negative. Cultures were even drawn from the port that he had. There was some discussion as to whether his fevers may have been caused by the cefepime. The cefepime was discontinued. At this time, however, his fever curve had already started slightly trending down. Over the next 48 hours, he remained afebrile. The vancomycin and Flagyl were discontinued the day before discharge, and he remained afebrile that night. His diarrhea had resolved over the last 4 to 5 days of his hospitalization and he received Imodium for this. The remainder of his hospitalization was unremarkable and he felt well. Of note, he did complain of poor appetite. We advised him to try to eat as much as he can and at the very least remain hydrated with Gatorade, and he understood that it may take some time for his appetite to completely return to normal. He did frequently have hypokalemia and hypomagnesemia. This was presumed to be secondary to the diarrhea. both of these electrolytes have replaced appropriately. However, even after the diarrhea resolved, he continued to have hypokalemia despite replacement. He later notified us that this issue is not new and that he actually takes potassium supplementation at home. He reported that he had p.o. potassium chloride at home and that he did not need medication or a refill for this. He could not, however, recall the dosage. We do not know the etiology of his hypokalemia as this was not worked up while he was inpatient due to again thinking that his hypokalemia was a result of his diarrhea. On the day of discharge, he was also instructed to resume his prophylactic Levaquin and acyclovir. Discharge Medications: 1.) Acyclovir 400 mg p.o. b.i.d. 2.) HCTZ 25 mg p.o. daily 3.) Lopressor 25 mg p.o. b.i.d. 4.) Pravastatin 10 mg p.o. at bedtime 5.) Norethindrone 5 mg p.o. daily 6.) Levaquin 500 mg p.o. daily 7.) Zofran 4 mg sublingually q.8 hours p.r.n. pain. 8.) Norco 5/325 one tablet p.o. p.4 hours p.r.n. pain. Followup Appointment: Dr. Constantine Revorsky in 1 week for followup for chemotherapy. Followup Labs and Studies: CBC, CMP before appointment with Dr. Revorsky Discharge Diet: Regular as tolerated. Discharge Activity: As tolerated. Determine only the principal diagnosis.

95004x12

Patient: Marina Louongo Reason for Visit: Skin testing to environmental allergens. History of Present Illness: The patient was a long-standing pateint of Dr. Yeager in Masonville, her previous hometown in the north side of the state, and had received immunotherapy for the past several years. She was referred to us by her new neighbor. She had been getting injections for grass/ragweed/plantain, cat/dog/mold, dust mite, and trees. She states she has been having some difficulty with local reactions and swelling to the tree injection. She is using Tylenol before and after injections along with ice, which has helped somewhat. She gets injections every 3 weeks. Patient sates she had an episode one time where her arms swelling significantly and she required oral prednisone. She typically has allergy symptoms in February, March, November and December with rhinitis, congestion, and itchy eyes. She was going to get dust covers for her pillow and mattress but hasn't gotten around to it. Her bedroom is carpeted. She denies smoking. Current Medications: Flonase and Clarinex prior to injections. Physical Examination: She is a healthy-appearing, well-nourished, well-developed 27 year old female in no acute distress. Skin testig via prick was positive to birch 2+, beech 2+, ash 0/1+, hickory 1+, mite DF 2+ and histamine 3+, grass 3+, mugwort 1+ birch 3+, oak 4+, maple 3+. Impression: Seasonal and perennial allergic rhinitis. Recommendations: 1.) Continue immunotherapy here with birch/oak/maple, mite DF/DP, grass/mugwort. 2.) Continue Flonase two sprays per nostril daily during the spring and fall. 3.) Environmental control measures regarding dust and pollen. 4.) Report was sent to Dr. Yeager, along with patient's signed Release of Information form so we can get copies of her previous medical records. Determine the correct procedure code(s) for the encounter between Marina and Dr. Yeager.

99335

Patrick Chapman, a 77 year old male, has been living at Northside Assisted Living Facility for 6 months. Dr. Colon, his primary physician since he moved in, comes in today to see Patrick because of a complaint of leg pain. Dr. Colon documents a problem-focused interval history, an expanded problem-focused exam, and MDM of moderate complexity. Determine the proper E/M code that should be reported for this encounter.

G89.29 ,G43.829

Pattie Moscowicz came in to see Dr. Levine with complaints of extreme pain in her head. She stated that she was nauseous and irritable and that light made the pain even worse. Patti stated that these headaches seemed to happen every month, right before she got her menstraul period, and she couldn't take it anymore. She begged for something to help with the pain. After a full examination, Dr. Levine diagnosed her with chronic premenstrual migraine. What diagnosis code(s) should be reported for this encounter?

11104

Paula had a rash that would not go away. So, she went to see Dr. Denardo, a dermatologist., who took a punch biopsy in an effort to diagnose the cause of her rash. Dr. Denardo closed the small defect with one stitch. Dr. Denardo's coder would report:

91037

Paulina Porter, a 39 year old female, has been battling with indigestion for over a year. After trying virtually every over-the-counter medication possible, she came to see Dr. Dahl, who decided to administer an esophageal acid reflux test. The test was administered in the office using a nasal catheter intraluminal impedance electrode. The 45 minute test was recorded and analyzed and interpreted by Dr. Dahl.

K72.2, T39.015A

Pauline Ochoa has been taking aspirin several times a day every day for pain in her knees. Her husband, John, came hoe and found her lying on the kitchen floor. Emergency medical services (EMS) brought her to the ED. Tests revealed an acute perforated, hemorrhagic peptic ulcer due to chronic use of aspirin. What diagnosis code(s) should be reported for this encounter?

K00.7

Perry brought his 8 month old son, Benjamin, to Dr. Reddington, his pediatrician, because he had been crying all night long. It seemed nothing he or his wife did calmed him. After examination, Dr. Reddington diagnosed Benjamin with teething syndrome and provided Perry with several ways to help the family through this experience. What diagnosis code(s) should be reported for this encounter?

27756

Peter Kessler, a 17 year old male, plays basketball on his high school team. While practicing in his driveway, he fell and fractured the shaft of his tibia. Dr. Warden, the orthopedist on duty at the emergency room, is able to use a percutaneous fixation using pins. Determine the correct procedure code(s) for this encounter.

90471, 90658

Phillip Landstone, a 21 year old male, came in so Dr. Micah can administer a flu vaccine before he starts volunteering at Community Hospital. Dr. Micah documents that the vaccine was trivalent, split virus, 0.5mL dosage, administered IM. Provide the proper code(s) for this procedure.

51728

Rachel Naviga, a 39 year old female, G3 P3, states she has been dealing with stress incontinence increasingly over the last several years. She had three vaginal deliveries, with the largest infant weighting 7.5 lbs. Rachel states that her leakage, frequency, volume, timing, and associated symptoms (urgency, stress, urinary frequency, nocturia, enuresis, incomplete emptying, straining to empty, leakage without warning) have become bothersome and she wants to do something about it. Today she presents for a complex cystometrogram with voiding pressure study to confirm or deny the diagnosis of stress urinary incontinence prior to the scheduling of surgery. Determine the correct procedure code(s) for this encounter.

77080, 77081-59

Rachel VanHeusen, a 65 year old female, arrived at the Kinsey Imaging Center to have a DEXA bone density study, both axial and appendicular skeleton. Dr. Underwood, the staff radiologist, analyzed the images and wrote a report. Determine the correct procedure code(s) for this encounter.

E80.0

Rachel Ward brought her 3 year old son Ethan to his pediatrician, Dr. Inger. She was very distressed because Ethan had eruptions on his arms, legs, and face that appeared after he had spend the day at the beach. She had also noticed that his urine appeared to be reddish in color. Dr. Inger examined Ethan and discovered he had splenomegaly. The blood test came back positive for hemolytic anemia. Both of these conditions are signs of erythropoietic porphydria, also known as Gunther's disease. Dr. Inger diagnosed Ethan with this condition. What diagnosis code(s) should be reported for this encounter?

G54.1

Simon Clossberg is a 37 year old architect. While on a business trip to Los Angeles, Simon and guys on his team decided to have some fun and rented motorcycles. Taking a turn too wide, Simon was involved in a one-vehicle motorcycle accident. In the accident, Simon was pinned and slid between the bike and the pavement, ultimately landing on his back. A police officer witnessed the accident and immediately called for medical assistance. EMTs arrived within minutes and immediately immobilized Simon's neck and secured him to a rigid board prior to transporting him to the ED of the nearest hospital. Upon arrival at the ED, Simon was conscious and complained of pain in his lower back. ED physician Dr. NeJame examined Simon and found numerous abrasions and contusions, in addition to a loss of both sensation and motor control of his legs. After he was stabilized, Dr. NeJame admitted Simon and called for a neurologic consult. Dr. Cheslea completed the neurologic assessment. The neurologic exam revealed the following: Simon demonstrated normal or near normal strength in flexing and extending his elbows, in extending his wrists, and when flexing his middle finger and abducting his little finger on both hands. However, he exhibited no movement when medical personnel tested his ability to flex his hips, extend his knees, and dorsiflex his ankles. Stretch reflexes involving the biceps, brachioradialis, and triceps muscles were found to be normal, while those involving the patella and ankle were absent. In addition, Simon was found to have normal sensitivity to pin prick and light touch in areas of his body above the level of his inguinal (groin) region, but not below that region of the body. Dr. Cheslea diagnosed Simon with lumbosacral plexus disorder. What diagnosis code(s) should be reported for this encounter?

R10.11, Z98.890

The attending physician, Raymond Morrison, MD included this in the discharge summary: Admission Diagnosis: Abdominal pain, status post appendectomy Final Diagnosis: Abdominal pain, unknown etiology, status post appendectomy Brief History: Patient underwent an appendectomy for perforated appendicitis 6 weeks ago. . . . Three days prior to admission, she had recurrent bout of diffuse, dull abdominal pain in the right upper quadrant with associated nausea and anorexia. She was admitted to the hospital at the time for workup of this pain. At this time, the patient has just had a regular meal without difficulty and feels like returning home. She will be discharged home at this time and can follow up with her primary MD. We will see her on an as-needed basis. What diagnosis code(s) should be reported for this encounter?

M50.022, M50.023, G89.11, V43.92xA

The attending physician, Thomas Talbott, MD, included this in the discharge summary: Admission Diagnosis: Acute cervical pain, admitted through ED after MVA Final Diagnosis: Acute cervical pain and radiculitis secondary to degenerative disc disease with post-traumatic activation of pain. Brief History: Patient is a 41 year old male who was involved in a motor vehicle accident admitted after being brought to the ED by the ambulance that responded to the accident scene. Patient showed signs of neck and arm pain associated with cervical radiculopathy, radiating into the shoulders along with constant headaches. He has numbness and tingling into the hands and fingers. Radiology: X-rays AP and lateral cervical spinal x-rays demonstrate evidence of significant degenerative disc disease at C5-6 and C6-7 levels. MRI of cervical spine demonstrates evidence of significant degenerative disc disease at the C5-6 and C6-7 levels with osteophyte formation and canal compromise with the spinal canal diameter reduced to approximately 9mm. Lumbar spine MRI demonstrates mild degenerative disc disease; otherwise normal. Recommendation to patient is to undergo an anterior cervical diskectomy and fusion utilizing an autologous iliac bone grafting and placement of anterior titanium plate after reviewing with patient regarding risks and benefits of surgery, the patient refused and requested to be discharged immediately.

O13.2

Zena Browning, a 23 year old female, is 20 weeks pregnant. Dr. Shinto diagnoses her with gestational hypertension. Even though there is no evidence of proteinuria, he is concerned about the effect of the condition on her pregnancy and writes a prescription. What diagnosis code(s) should be reported for this encounter?