Chapter 10: Coding Compliance Programs

A 67-year-old established female patient was admitted to the outpatient hospital surgery center for a scheduled diagnostic arthroscopy of her right shoulder because of constant pain on rotation of the shoulder. Prior to entering the operating room she told the nurse, "I have been feeling weak and tired ever since my last visit." The surgeon performs a level 4 re-examination prior to the surgery. The findings were negative and the diagnostic arthroscopy, right shoulder, was performed uneventfully. Procedure/Service: Diagnostic arthroscopy, right shoulder. Enter code:________ Diagnosis: Pain, right shoulder. Enter code:_________ Procedure/Service: Outpatient encounter, established patient, level 4. Enter code:_________ Diagnosis: Weak and tired. Enter codes:__________ , __________

29805-RT M25.511 99214-25 R53.1 , R53.83

Case: The patient was treated in the office to rule out pneumonia. The patient had been experiencing wheezing and congestion, and respirations were labored. The chest x-ray done in the office was positive for pneumonia. The following diagnoses were documented on the patient's chart. Enter diagnosis pointer letter(s) to justify medical necessity of each procedure/service provided. A. Pneumonia B. Wheezing C. Congestion D. Labored respirations Procedure/service: Office encounter. Enter diagnosis pointer(s):_______ Procedure/service: Chest x-ray. Enter diagnosis pointer(s):______

A, A For the office encounter, A. pneumonia justifies medical necessity. For the chest x-ray, A. pneumonia justifies medical necessity. Note: Do not enter B. wheezing, C. congestion, or D. labored respirations as diagnosis pointers because they are signs of A. pneumonia.

The patient was seen by the provider during an office encounter for sore throat. Patient has past history of urinary frequent, but is symptom free today. Rapid strep test and urinalysis tests were negative during this encounter. Diagnosis is acute pharyngitis. Select the first-listed diagnosis.

Acute pharyngitis (with negative rapid strep test)

Case: The physician treated the patient in the nursing facility for the second time since admission. The patient complained of malaise. It was noted that the patient had a cough as well as a fever of 103°F and that the pharynx was erythematous (abnormally red in appearance, which is a sign of infection). The following diagnoses were documented on the patient's chart. Enter diagnosis pointer letter(s) to justify medical necessity of each procedure/service provided. A. Malaise B. Cough C. Fever of 103°F D. Erythematous pharynx E. Acute pharyngitis Procedure/service: Nursing facility encounter. Enter diagnosis pointer(s):_______

E For the nursing facility encounter, E. acute pharyngitis justifies medical necessity. During the nursing facility encounter, the physician documented acute pharyngitis as a diagnosis. Note: Do not enter A. malaise, B. cough, C. fever of 103°F, or D. erythematous pharynx as diagnosis pointers because they are signs of E. acute pharyngitis.

S: This 17-year-old patient presents to the office with a sore throat, fever, and swollen glands, 2 days' duration. O: Oral temp 102.4°F; pulse 84; respirations 18; BP 118/78; wt 138 lb. The throat is markedly erythematous with evidence of exudative tonsillitis. Ears show normal TMs bilaterally. Few tender, submandibular nodes, bilaterally. A: Acute tonsillitis. P: 1. Obtained throat culture that was sent to the lab. Waiting for results. 2. Patient started on an empiric course of Pen Vee K 250 mg #40 to be taken qid × 10 days. 3. Encouraged patient to increase oral fluid intake. 4. Patient to call office in 48 hours to obtain culture results and report patient's progress. Diagnosis: Exudative tonsillitis. Enter ICD-10-CM code:________

J03.90

S: Patient complains of stomach pain, 3 days' duration. Patient also stated that both legs still get painful from the knees down. O: Ht 5'6"; Wt 164 lb; BP 122/86; pulse 92 and regular; temp 97.0°F, oral; chest normal; heart normal. The Doppler arteriogram of lower extremities taken last week at the hospital is reported as within normal limits bilaterally. A: Another episode of chronic atrophic gastritis. Leg pain, left. P: Carafate 1 g. Take 1 tablet qid before meals and at bedtime, #120 tabs. Diagnosis: Chronic atrophic gastritis. Enter ICD-10-CM code:________ Diagnosis: Leg pain, left. Enter ICD-10-CM code:_________

K29.40 M79.605

The patient received care for a musculoligamentous sprain, left ankle during this office encounter. Patient complained of edema, left lateral malleolus and limited range of motion due to pain. X-ray was negative for fracture. Select the first-listed diagnosis.

Musculoligamentous sprain, left ankle

S: Patient seems to be doing quite well, postop cholecystectomy; however, the pain experienced prior to surgery is not gone. O: Incision is well healed. Abdomen is soft and nontender. A: Surgical aftercare. Pathology report revealed chronic cholecystitis and cholelithiasis. P: 1. Lengthy discussion with patient and spouse about treatment in the future. Asked that they call any time they have questions. 2.Return visit here on a prn basis. Diagnosis: Aftercare, surgery. Enter ICD-10-CM code:________

Z48.815

A 66-year-old established Medicare patient came to the office for an annual physical. Patient has a past history of hypertension, controlled by medication, and new complaints of dizziness and tiredness (which the physician determined was related to today's increased blood pressure). During the course of the examination, the physician found blood pressure of 160/130. Because this was the third encounter with an elevated blood pressure, a diagnosis of hypertension was established and the patient placed on prescription medication. A level 4 E/M service was provided for this established patient in addition to the preventive medicine encounter. Procedure/Service: Preventive medicine encounter, established patient, age 66. Enter code:_________ Diagnosis: Annual exam. Enter code:_________ Procedure/Service: Office encounter, established patient, level 4. Enter code:_________ Diagnosis: Hypertension. Enter code:__________

99397 Z00.01 99214-25 I10

Dr. B performed a postoperative examination on an established patient and also removed the sutures from an open appendectomy that the patient underwent while on vacation in another part of the country. Procedure/Service: Postoperative care, open appendectomy. Enter code:__________ Diagnosis: Aftercare, surgery. Enter code:_________

44950-55 Z48.02

The patient was seen in the emergency department (ED) at 10:00 A.M. for right lower quadrant pain; the ED physician provided a level 2 E/M service. Ultrasound revealed an inflamed appendix. A surgeon was called in, who evaluated the patient (conducting a level 3 new patient E/M outpatient service) and performed an outpatient laparoscopic appendectomy at 1:00 P.M. for the ruptured appendix with abscess. The patient was discharged at 9:00 A.M. the next morning. Procedure/Service: Emergency department encounter, level 2. Enter code:___________ Diagnosis: Ruptured appendix with abscess. Enter code:_____ Procedure/Service: Ultrasound, abdomen. Enter code:_____ Diagnosis: Ruptured appendix with abscess. Enter code:_______ Procedure/Service: Outpatient encounter, new patient, level 3, decision for surgery. Enter code:_______ Diagnosis: Ruptured appendix with abscess. Enter code:_____ Procedure/Service: Laparoscopic appendectomy. Enter code:_______ Diagnosis: Ruptured appendix with abscess. Enter code:________

99282 K35.33 76705 K35.33 99203-57 K35.33 44970 K35.33

An emergency department (ED) physician performed a level 3 evaluation and management service on a patient who was seen for complaints of severe abdominal pain, nausea, and vomiting. An abdominal ultrasound revealed an enlarged gallbladder. A surgeon was called in, evaluated the patient (conducting a level 3 new patient E/M outpatient service), and performed a laparoscopic cholecystectomy, which revealed acute cholecystitis. The patient's stay was less than 24 hours. Procedure/Service: Emergency department encounter, level 3. Enter code:_______ Diagnosis: Acute cholecystitis. Enter code:________ Procedure/Service: Ultrasound, abdomen. Enter code:________ Diagnosis: Acute cholecystitis. Enter code:_______ Procedure/Service: Outpatient encounter, new patient, level 3, decision for surgery. Enter code:_________ Diagnosis: Acute cholecystitis. Enter code:__________ Procedure/Service: Laparoscopic cholecystectomy. Enter code:_________ Diagnosis: Acute cholecystitis. Enter code:__________

99283 K81.0 76705 K81.0 99203-57 K81.0 47562 K81.0

Case: The patient was treated in the office for abdominal cramping and bloody stools. A hemoccult test was positive for blood in the stool. The patient was scheduled for proctoscopy with biopsy two days later, and Duke C carcinoma of the colon was diagnosed. The patient was scheduled for proctectomy to be performed in seven days. The following diagnoses were documented on the patient's chart. Enter diagnosis pointer letter(s) to justify medical necessity of each procedure/service provided A. Abdominal cramping B. Blood in the stool C. Duke C carcinoma, colon Procedure/Service: Hemoccult lab test. Enter diagnosis pointer(s):______ Procedure/Service: Proctoscopy with biopsy. Enter diagnosis pointer(s):_________ Procedure/Service: Proctectomy. Enter diagnosis pointer(s):____________

B, C, C

Case: The patient was treated in the emergency department for chills and fever. The physician noted left lower abdominal quadrant pain and tenderness. The physician diagnosed acute diverticulitis. The following diagnoses were documented on the patient's chart. Enter diagnosis pointer letter(s) to justify medical necessity of each procedure/service provided. A. Chills B. Fever C. Acute diverticulitis Procedure/service: Emergency department encounter. Enter diagnosis pointer(s):_________

C

The patient presented as pale, diaphoretic, and in acute distress. Examination revealed pulse 112 and regular, respirations 22 with some shortness of breath, limited chest expansion, and scattered bilateral wheezes. Blood culture test established a diagnosis of bacterial endocarditis. Select the first-listed diagnosis.

Bacterial endocarditis

The patient presented to the office with distended urinary bladder, enlarged prostate, and urinary retention. Prostate-specific antigen (PSA) blood test established a diagnosis of benign prostatic hypertrophy. Select the first-listed diagnosis.

Benign prostatic hypertrophy (BPH)

Case: The patient was treated in the office for urinary frequency with dysuria, sore throat with cough, and headaches. The urinalysis was negative, and the strep test was positive for streptococcus infection. The patient was placed on antibiotics and was scheduled to be seen in 10 days. The following diagnoses were documented on the patient's chart. Enter diagnosis pointer letter(s) to justify medical necessity of each procedure/service provided. A. Urinary frequency with dysuria B. Sore throat with cough C. Headaches D. Strep throat Procedure/service: Office encounter. Enter diagnosis pointer(s):_______ Procedure/service: Urinalysis. Enter diagnosis pointer(s):______ Procedure/service: Strep test. Enter diagnosis pointer(s):______

D, D, D

S: Patient returns today for follow-up of chronic angina and dyspnea. Patient says the angina still appears mainly when resting, and particularly upon awakening in the morning. This is accompanied by some dyspnea and pain occasionally radiating into the left jaw, but no palpitations. The angina is relieved by nitroglycerin. The patient continues to take Inderal 40 mg qid. O: BP, left arm, sitting, 128/72; weight is 150 lb. Chest is clear. No wheezing or rales. A: Unstable angina. Patient again refused to consider a heart catheterization. P: New RX: Isordil Tembids 40 mg. Refill nitroglycerin. Diagnosis: Unstable angina. Enter ICD-10-CM code:________

I20.0

The patient was seen in the office for right leg pain and weak right leg. Patient also complains of tightness in the lower back from difficulty walking. CT scan was negative, and after extensive examination the provider documented partial drop foot gait, right, as the diagnosis. Select the first-listed diagnosis.

Partial drop foot gait, right

S: Patient complains of generalized stiffness and being tired. Patient also notes that the left knee was swollen and felt hot to the touch last week. Patient was last seen 18 months ago on Penicillamine and 2 mg prednisone bid. Patient's other medications are loperamide for loose stool and Tagamet 300 mg bid. O: Examination reveals some swelling of the left knee with active synovitis of the left knee and minimal fluid. Patient's present weight is 134 lb, BP 116/72. The hematocrit performed today is 37.5 and sed rate is 65. A: This patient has active rheumatoid arthritis, left knee. P: 1. Increase prednisone to 5 mg bid, and Penicillamine to 500 mg bid. 2. X-ray of left knee tomorrow. 3. Recheck CBC, sed rate, and urinalysis in 4 weeks. 4. Discussed with patient the possibility of injecting steroids into the left knee if no improvement is shown. Diagnosis: Rheumatoid arthritis, left knee. Enter ICD-10-CM code: _____ Diagnosis: Synovitis, left knee. Enter ICD-10-CM code:_______

M06.862 M65.88