Medical Coding Practice and Career Preparation - Mod 1: Coding Practice Physician Practice Encounters

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Question 25 (1 point) Review this health record. GENDER: MaleOCCUPATION: Police OfficerDATE OF BIRTH: 08-07-YYYYADMISSION DATE & TIME: 08-21-YYYYDIAGNOSIS INFORMATION N/APROCEDURE INFORMATION N/ANURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: Atenolol, Glyburide, and metformin BP: 140/60 P: 70 R: T: WT: 212 HEENT: Within Normal Limits CC: Patient states he has a lot of head congestion. PMH: Hypertension, diabetes type 2, coronary artery disease, hyperlipidemia, and osteoarthritis.NOTES: Patient complains of cold symptoms for two weeks. He is afebrile in clinic today. States he has a lot of head congestion. No chills or fever. Taking extra fluids. Sputum is white/brown.PHYSICIAN DOCUMENTATIONNotes: HPI: The patient was seen in the outpatient clinic today complaining of upper respiratory symptoms. His problems have persisted since he was last seen in April of this year by Dr. Watts. He denies any chills or fever, just the stuffiness, cough, and occasional runny nose. The patient's problems consist of the following:HypertensionDiabetes type 2Coronary artery diseaseHyperlipidemiaOsteoarthritisPresent medications consist of the following: Atenolol 25 mg q.d., Glyburide 10 mg b.i.d., metformin I gr in the morning, 500 mg at lunch, and I gr in the evening. He had fasting labs drawn this morning. The results are pending. His Accu-Chek done at home had been running in the 80s to 180 range. He seems to have better control now with the addition of the Metformin. A PSA was done in April which was 0.4.PE: On exam today, the patient had no acute physical findings. His weight was 212 pounds. Blood pressure 140/60. His temperature was 98.1. Pulse 70. Respirations 18. His HEENT was basically within normal limits except for some rhinorrhea. The lungs had wheezes bilaterally with some soft rhonchi. No rales were noted, and there was adequate air exchange. The heart had a regular rate and rhythm with no murmur, rubs, or skipped beat noted. The abdomen was soft, obese. Bowel sounds were normal active. There was no gross organomegaly noted. The extremities were normal. He had good color and warmth. The lower extremities had some mild edema of the lower calf and ankles. Peripheral pulses were present but diminished.ASSESSMENT: As listed above with an addition of bronchitis.PLAN: I will have a chest x-ray done today to rule out any acute phase. This is probably a COPD or a chronic bronchitis. The patient states he quit smoking three months ago. I will place him on Septra DS b.i.d. for 14 days. He is allergic to penicillin. He has been advised to increase his fluid intake. I have given him Chlor-Trimeton 4 mg also to help with his rhinorrhea. He will return in three months' time. Will repeat labs and reevaluate at that time. What is the correct coding assignment?

Bronchitis: J40, Rhinorrhea: J34.89, Hx of Tobacco Use: Z87.891, CAD: I25.10, HTN: I10, DM 2: E11.9, Hyperlipidemia: E78.5, Osteoarthritis: M19.90, Hx of Penicillin Allergy: Z88.0, E/M Visit: 99213

Question 3 (1 point) Review this scenario. Preoperative Diagnosis: Shortness of breath, abnormal chest x-ray showing left lower lobe massPostoperative Diagnosis: Carcinoma of the left lower lobe (per pathology report)Description of Procedure: Following local anesthesia, the pleural core needle biopsy is performed by passing the needle over the left side of the ribs under fluoroscopic guidance and the pleural cavity is entered and used to enter the area of the concern. Tissue is obtained from the lung for pathological examination. Which of the following ​is the correct ICD-10-CM and CPT code assignment for this physician's services? Question 3 options: C34.32, R06.02, 32408 C34.30, 32408, 77002 C34.32, 32400 C34.32, 32408

C34.32, 32408

Question 14 (1 point) Review this scenario. Patient with known ovarian carcinoma admitted for right oophorectomy. Patient also has type 1 diabetes mellitus. Right oophorosalpingectomy with lymph node samplings and peritoneal biopsies were completed to stage the cancer. Which of the following ​is the correct ICD-10-CM and CPT code assignment for this physician's service? Question 14 options: C56.1, E10.9, 58950 C56.1, 58943 C56.1, E10.9, 58943 D49.59, E10.9, 58940

C56.1, E10.9, 58943 - Ovarian carcinoma is assigned to code C56.1; with staging of ovarian malignancy and excision for malignancy, the code is 58943.

Question 20 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 06-20-1925ADMISSION DATE & TIME: 08-17-YYYYDIAGNOSIS INFORMATION1. Distal sensorimotor neuropathy2. ParesthesiasPROCEDURE INFORMATIONLevel 2 E/M visitNURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: AmitriptylinePHYSICIAN DOCUMENTATIONNotes: S: Some improvement in paresthesias since amitriptyline started, though he is using it only sporadically. O: As per previous visit, most notable findings being moderate distal weakness of right lower extremity, antalgic gait, diminished ankle jerks, vibratory sensation below knees, and low stocking sensory impairment. A: Distal sensorimotor neuropathy with symptomatic response to prescribed amitriptyline. P: Suggested he take amitriptyline daily each evening as originally prescribed. Reassess in 4 months. What is the correct coding assignment?

Distal sensorimotor neuropathy: G62.89, Underdosing of amitriptyline: T43.016A, Non-Compliance: Z91.14, E/M Visit: 99212 Notes: Patient admitted to taking medication sporadically. Polyneuropathy not stated as hereditary and noted to affect the lower extremity.

Question 16 (1 point) Review this health record. ADMISSION DATE & TIME: 09-01-YYYY GENDER: Male OCCUPATION: Retired DIAGNOSIS INFORMATIONDysthymia Abnormal gait PROCEDURE INFORMATIONLevel II E/M visit NURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: None CURRENT MEDICATIONS: SertralineBP: 110/60 P: 72 R: T: 96.7 WT: 201CC: Reports problems with balance.PMH: DysthymiaNOTES: Came here for a regular appointment today PHYSICIAN DOCUMENTATION Patient seen for regular appointment today. He is pleasant, cooperative, and coherent. Reports he is still having some problem with the balance. He walks with the cane, which is helpful. He is oriented in all three. No evidence of delusions, hallucinations, or dangerous behavior. Still he reports that he feels kind of depressed at times. However, he has been handling home situation fairly well. The patient has a good memory; insight and judgment seem very good. Takes the medication as prescribed, and fairly affective. DIAGNOSIS: Dysthymia. PLAN: Sertraline 50 mg every morning. What is the correct coding assignment?

Dysthymia: F34.1, Abnormal gait: R26.9, Basic follow-up visit: 99212

Question 21 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 06-06-1933ADMISSION DATE & TIME: 08-24-YYYYDIAGNOSIS INFORMATION1. Essential tremor2. Hypertensive vascular disease3. Bilateral subcortical infarctsPROCEDURE INFORMATIONLevel 2 E/M visitNURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: fexophenadine, clonazepam, desipramine, trazodone, terazosin, nifedipine, lovastatin, captopril, beclomethasone, timolol dropsBP: 144/90 P: R: T: WT: OVS: CC: Tremor. PMH: Essential tremor; bilateral subcortical infarcts secondary to hypertensive vascular disease.NOTES: Patient voices no additional complaints today. Alert. PHYSICIAN DOCUMENTATIONNotes: S: Upon recheck, tremor remains under control, manifest mainly during fine manipulations; no symptoms of TIA; schedule for right knee replacement at SMH next month; meds: fexophenadine, ASA BID, clonazepam 1 mg QID, desipramine 150 mg/day, trazodone 100 mg hs, terazosin, nifedipine, lovastatin, captopril, beclomethasone, timolol drops. O: BP 144/90, alert, impaired tongue motility, antalgic gait, impaired RAMs [L>R], no tremor, left hyperreflexia, + snout and jaw jerk. A: Essential tremor, responsive to primidone. Previous history of subcortical infarcts secondary to hypertensive vascular disease. Hypertension. P: Continue primidone 125 mg BID; revisit 4 months. Total time spent with patient was 25 minutes. What is the correct coding assignment?

Essential Tremor: G25.0, Hypertension: I10, Subcortical Infarct: Z86.73, E/M Visit: 99213 Level 3 E/M assigned based on Time which was documented as 25 minutes. Note: The impaired tongue motility is symptomatic of the diagnosis and not coded separately.

Question 30 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 04-01-YYYYADMISSION DATE & TIME: 02-08-YYYY 1210DISCHARGE DATE & TIME: 02-08-YYYY 1330CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: No YesCURRENT MEDICATIONS: No YesBP: 180/110 P: 72 R: 20 T: 98.8 CC: Complains of severe pain on movement. HPI: While snowmobiling, the patient states he flew off and landed on his right ribs and right shoulder. PHYSICIAN NOTES:HISTORY: Patient complains of severe pain on movement. He says while he was snowmobiling, he flew off the snowmobile and landed on his right ribs and right shoulder.EXAMINATION:GENERAL: Middle-aged white male.HEAD: Normocephalic.EENT: Within normal limits.RIGHT SHOULDER: Pain on abduction of right arm. Positive for deformity over mid-shaft right clavicle.CHEST: Positive tenderness to palpation on right post ribs.LUNGS: Clear. X-RAY, RIGHT CLAVICLE: Fracture, right clavicle shaft. X-RAY, RIBS: Nondisplaced fractures of right second, third, and fourth ribs. TREATMENT: Tylenol #3, q4h prn. Disposition #30. Copy of film to accompany patient. Clavicle brace sling applied.DIAGNOSIS: Fracture, shaft of right clavicle. Nondisplaced fractures of the right second, third, and fourth ribs in the anterior axillary line. Contusion of ribs, right, x 3.PHYSICIAN ORDERSX-ray, right shoulder, right clavicle, right ribs x 3.DISCHARGE INSTRUCTIONS: Brace sling. Follow-up with family MD in one wk.RADIOLOGY REPORTReason for exam: Snowmobile accident on a snowmobile trail located at a vacation resort. Technical data: Pain axillary (mid.) ribs, rt. clavicleRIGHT SHOULDER: Multiple views reveal the shoulder to be normal.RIGHT CLAVICLE: Complete x-ray reveals comminuted, essentially nondisplaced fracture of the shaft of the right clavicle.RIGHT RIBS: Two views reveal essentially nondisplaced fractures of the right second, third, and fourth ribs in the anterior axillary line. There is also some thickening of the pleura in this region suggesting associated hemorrhage. The heart and lungs are normal. What is the correct coding assignment?

Fracture Right Clavicle Shaft: S42.024A, Fracture Multiple Ribs Right Side: S22.41XA, Transport Accident, Snowmobile Unspecified Occupant: V86.92XA, Place of Occurrence, Snowmobile Trail at Resort Y92.838, Activity, Other Involving Snow and Ice: Y93.29, Other External Cause Status: Y99.8, E/M Visit: 99284 The following radiology codes would be hard coded via the charge description master: X-Ray, Multiple Views, Rt. Shoulder: 73030-RT, X-Ray, Complete, Rt. Clavicle: 73000-RT, X-Ray, Two Views, Rt. Ribs: 71100-RT, Brace Sling: A4565 Notes: The contusion of the ribs is not coded since superficial injuries (abrasions or contusions) are not coded when associated with more severe injuries of the same site.

Question 7 (1 point) Review this scenario. Preoperative Diagnosis: Chronic bilateral recurrent suppurative otitis media Postoperative Diagnosis: Same Operation: Bilateral myringotomy; placement of permanent ventilating tube Anesthesia: General Procedure: A standard myringotomy incision was made, and a copious amount of serous fluid suctioned from the middle ear cleft. A Goode T-tube was placed without problems. The procedure was then repeated on the left side in the same manner. Which of the following ​ICD-10-CM and CPT codes are reported by the surgeon for this procedure performed in the hospital surgery center? Question 7 options: H66.90, 69421-50 H66.3X3, 69436-50 H66.90, 69421 H66.3X3, 69436

H66.3X3, 69436-50 - The instructions in the CPT book state that the modifier -50 should be used to show a bilateral procedure.

Question 24 (1 point) Review this health record. GENDER: MaleOCCUPATION: Electrical EngineerDATE OF BIRTH: 12-04-YYYYADMISSION DATE & TIME: 08-19-YYYYDIAGNOSIS INFORMATION N/APROCEDURE INFORMATION N/ANURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: Isosorbide, glyburide, amlodipine, fosinopril, lansoprazole, warfarin, meclizine, amiodarone, Lasix.BP: 150/80 P: 76 R: T: WT: 223 OVS: CC: Neck and shoulder pain.PHYSICIAN DOCUMENTATIONHPI: The patient is a 62-year-old white male who is followed routinely at this facility. He has Type 2 diabetes, obesity, hypertension, coronary artery disease with atrial fibrillation, currently on long-term anticoagulation with warfarin, lumbago, and degenerative joint disease of the cervical spine. Today he complains of right neck and shoulder pain that he has had off and on for the past two or three weeks. According to the patient, he was involved in a motor vehicle accident several years ago, had surgery on his neck, and has had problems even before that. He complains of the pain starting at the base of the skull on the right side and radiating over to the top of the right shoulder. Occasionally, he has some numbness in his hands; specifically, when he does it is in the left hand. He offers no other complaints at this time.CURRENT MEDICATIONS: Isosorbide 20 mg twice a day, glyburide 5 mg twice a day, amlodipine 5 mg daily, fosinopril 10 mg a day, lansoprazole 30 mg a day, warfarin 7 mg a day, meclizine 25 mg daily, amiodarone 200 mg twice a day, Lasix 40 mg a day as needed for any edema.LAB FINDINGS: In June, hemoglobin 7.0, glucose 173. Renals and electrolytes were within normal limits.PE: Height 71", weight 223 lbs, BP 150/88, pulse 76, respirations 18. HEENT: Basically, within normal limits.NECK, UPPER EXTREMITIES (SHOULDER) EXAMINATION: There was pinpoint tenderness just below the occiput on the right lateral aspect with pain radiating from that point over to the right shoulder. There were no deformities. The musculature at that point felt hard, indicating possible muscle spasms. He had good sensation in the upper extremities. There were no limitations in movement, and he had good grip and strength in both hands.LUNGS: Had some bibasilar wheezes. However, no rales or rhonchi were noted.HEART: Regular rate and rhythm. No murmur noted.ABDOMEN: Obese with BMI 34.0, non-tender. There was no gross organomegaly noted.LOWER EXTREMITIES: Present. Shows signs of Peripheral vascular disease. He has moderate edema of the lower extremities. Pedal pulses were present, and there were no lesions noted.IMPRESSION: Possible cervical spine arthritis.PLAN: Xrays of the cervical spine. Repeat visit in 3 months. Robaxin for muscle relaxant, 750 mg 4 x day. He is to apply warm, moist heat. Implement exercise therapy. Hopefully, this will alleviate his discomfort. If there is anything acutely wrong with the x-rays, we will contact the patient and have him return sooner. What is the correct coding assignment?

ICD-10-CM codes M25.511, M54.2, R51, R60.0, I25.10, I10, E11.9, E66.9, Z68.34, I48.91, M47.812, M54.5, and Z79.01. CPT code 99213. Note: A definite diagnosis was never made so the symptoms are coded.

Question 27 (1 point) Review this health record. GENDER: FemaleDATE OF BIRTH: 10-19-YYYYADMISSION DATE & TIME: 02-08-YYYY 1230 DISCHARGE DATE & TIME: 02-08-YYYY 1330CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONCURRENT MEDICATIONS: NoCONDITION: Laceration, right index finger, on glass. Patient was washing dishes at home, and she dropped a glass and cut her finger.PHYSICIAN NOTES: Pregnant female at 16 weeks gestational age. Patient was washing dishes at home and dropped a glass and cut her finger. Examination of the right index finger revealed 4 cm circular, flapped laceration over the right proximal phalanx. There was no tendon injury. Patient was advised about possibility of devitalization of flap and possible requirement for plastic graft. Wound approximated with 4-0 silk stitches, #6. Tetanus and Diptheria(Td) booster. Penicillin 250 mg po qid X 7 days. DIAGNOSIS: Laceration, right index finger.PHYSICIAN ORDERS: Tetanus and diphtheria toxoids administered IM in right deltoid at 13:20.DISCHARGE INSTRUCTIONS: Keep wound dry and check closely. What is the correct coding assignment? Question 27 options:

Injury complicating 16 week pregnancy (cannot use incidental pregnancy without statement from physician, per guidelines): O9A.212, Flap Laceration, Rt. Index Finger, 4cm Circular: S61.210A, Encounter for Immunization: Z23, Contact with Broken Glass: W25.XXXA, Place of Occurrence, Home: Y92.009, Activity, Washing Dishes: Y93.G1, Other External Cause Status: Y99.8, 16 weeks gestation of pregnancy: Z3A.16, E/M Visit: 99282-25, Simple Suture, 4cm, Rt. Index Finger: 12002, IM Tetanus and Diphtheria, Rt. Deltoid, 0.5ml: 90714, 90471

Question 13 (1 point) Review this scenario. A patient who sings professionally has developed nodules on the vocal cords that require removal. The surgery is performed in the ambulatory surgery center owned by the hospital. An operating microscope is employed, since the nodules are quite small. A topical anesthetic is administered after the appropriate preparation and draping. Under direct laryngoscopy, the laryngeal tumors are isolated and dissected free using stripping forceps. The pathology report confirmed that the nodules were not malignant and described them as "singers' nodes." Which of the following ​is the correct ICD-10-CM and CPT code assignment for this physician's service? Question 13 options: J38.2, 31540, 69990 D14.1, 31540, 69990 D14.1, 31541 J38.2, 31541

J38.2, 31541

Question 29 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 08-30-YYYY ADMISSION DATE & TIME: 08-10-YYYY 1820 DISCHARGE DATE & TIME: 08-10-YYYY 1930CONDITION ON DISCHARGESatisfactoryTransfer to: Victor ERInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: YesCURRENT MEDICATIONS: NoEXPLAIN: Last tetanus. > 5 yearsBP: 120/80 P: 88 R: 20 HPI: LOC - ambulating well - alert & oriented. Laceration under eyelid.CONDITION: Broomstick by L eye.ASSESSMENT: Dr. Beeson spoke with Dr. Tyson in Victor. Dr. Tyson will meet with patient in Victor ER. Vision OD 20/30-1.PHYSICIAN NOTES: S: Patient is an 18-year-old white male who had the end of a broomstick jammed into his eye while horsing around at home with his younger brother. The patient arrived in the ED with a laceration of the lower lid and blurred vision. O: The patient has a 3 cm laceration which begins at the medial canthus, extending through the tear duct there, circling beneath the lower lid and then re-entering laterally and extending down through the lid margin inferiorly to a point where it disappears. Pupils are equal, round and reactive to light; extraocular muscles are intact. Vision in that eye is 20/60. He normally has 20/20 vision. There is slight steaminess of the anterior chamber and funduscopic exam does not visualize the optic disc or cup due to a hazy, diffuse and blurred redness through the ophthalmoscope. This may represent bleeding in the posterior chamber. There is no foreign body and no bleeding at present. There is no reason to suspect a fracture of the supraorbital or infraorbital rim at this point. A: Laceration, left lower eyelid; possible posterior chamber hyphema. P: Dr. Tyson was called and suggested we send the patient down right away. Tetanus/Diphtheria 0.5 cc administered IM, left deltoid.PHYSICIAN ORDERS: IM Tetanus/Diphtheria (Td), Lt. Deltoid, 0.5mlDISCHARGE INSTRUCTIONS: Transfer to Victor. What is the correct coding assignment?

Laceration, Lt. Lower Eyelid: S01.112A, Encounter for Immunization: Z23, Jammed Eye w/ Broomstick, Accidental: W22.8XXA, Place of Occurrence, Home: Y92.009, Activity, Horseplay: Y93.83, Other External Cause Status: Y99.8, /M Visit: 99283-25, IM Tetanus/Diphtheria (Td), lt. Deltoid, 0.5ml: 90714, 90471 Notes: There is notation on the nursing assessment that patient has allergies but no specifics are given. Patient is transferred for presumably more definitive care.

Question 22 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 05-22-1932ADMISSION DATE & TIME: 08-26-YYYYDIAGNOSIS INFORMATION1. Onychomycosis2. Hyperkeratoses3. Type 1 diabetes mellitus with polyneuropathyPROCEDURE INFORMATION1. Debridement, mycotic toenails (more than five)2. Reduction of digital hyperkeratoses, third and fourth toes, right footNURSING DOCUMENTATIONCC: Mycotic toenails. PMH: Onychomycosis, diabetes type 1 with neuropathy, hyperkeratoses.NOTES: Patient has no other concerns today.PHYSICIAN DOCUMENTATIONIAGNOSES: Onychomycosis. Hyperkeratoses. Type 1 diabetes mellitus with polyneuropathy. Follow-up diabetic maintenance-care was provided with debridement of 10 mycotic toenails and reduction of digital hyperkeratoses, third and fourth toes, right foot. The patient has an ulcer on the right heel, which is under the care of Dr. Hoffman. When first examining the patient this morning, dried blood was noted on all toes of the left foot. The patient admits to attempting nail-care yesterday evening and apparently created a mild laceration of the second toenail, left foot. There is an intact scab formation this morning. No further treatment is needed. The Plastizote chukka-style boots that were dispensed in April are comfortable, and patient likes them very much. No other concerns. Return to clinic in six weeks. What is the correct coding assignment?

Mycotic Toenails: B35.1, Hyperkeratosis: L85.9, DM, Type 1, Polyneuropathy: E10.42, E/M Visit: 99212-25, Debridement Toenails x 10: 11721-59, Reduction of Digital Hyperkeratoses, 3rd & 4th Digits, Right Foot: 11056

Question 12 (1 point) Review this scenario. Dr. Smith stops Dr. Jones in the hallway at the hospital and asks for his opinion on a patient. The conversation lasts approximately 20 minutes. Which of the following ​is the correct E/M code assignment? Question 12 options: 99211 99251 No code 99441

No code - Dr. Jones did not evaluate an established patient over the telephone; Dr. Jones did not even examine the patient. This should not be coded.

Question 1 (1 point) Review this scenario. A 13-month-old is brought to her pediatrician for her one-year checkup. During that exam, the physician discussed immunizations, developmental milestones, and age-related risks, such as climbing, falls, accidental poisoning, drowning, car seat usage, and early childhood education. A comprehensive examination was done per American Academy of Pediatrics guidelines. During her routine exam, the physician noted left otitis media and URI, and ordered antibiotics, to be rechecked in two weeks. Reporting of additional diagnoses included documentation of a medically appropriate history and examination and 20 minutes was spent with the 13-month-old. Which of the following ​is the correct ICD-10-CM and CPT code assignment for this visit? Question 1 options: Z00.121, H66.92, J06.9, 99391, 99213-25 Z00.110, H66.92, J06.9, 99391 Z00.121, H66.92, J06.9, 99392 Z00.121 H66.92, J06.9, 99392, 99213-25

Z00.121 H66.92, J06.9, 99392, 99213-25

Question 9 (1 point) Review this scenario. Preoperative Diagnosis: Desired sterility Postoperative Diagnosis: Same Procedure: Bilateral vasectomy The patient was premedicated, brought to the OR in the supine position, prepped with Betadine, and draped in sterile fashion. 2% Xylocaine was then injected on the left side. A 1.5 cm. nevus was removed from the skin of the left lower abdominal quadrant followed by simple closure. After picking up the vas with two fingers, the incision was made transversely about 3/4 cm long and deepened through the layer of the scrotum to reach the vas. An Allis clamp was used to pick up the vas, which was identified by the feel and look of the tube, and this was then cleaned off of the sheets and layers over the same. The artery to the vas was then coagulated. A 1cm segment of the vas was then isolated and divided between clamps. The cut end of the vas was then coagulated on both sides and 2-0 chronic transfixion stitch was taken on each end. Hemostasis was meticulously achieved, and then the sheath of the vas was closed over the superior end leaving the lower end outside the sheath. Closure of the scrotum was carried out in two layers of 3-0 chromic catgut, one for the other layers of the scrotum, and one for the skin. A similar procedure was carried out on the other side, and the procedure was then considered complete. The patient was taken to the recovery room in good condition. Which of the following ​is the correct ICD-10-CM and CPT code assignment for this physician's services? Question 9 options: Z30.2, D22.5, 55450, 11602-51 Z30.2, 55450 N46.9, 55250 Z30.2, D22.5, 55250, 11402-51

Z30.2, D22.5, 55250, 11402-51

Question 10 (1 point) Review this scenario. This is a 59-year-old male who presents to the ED complaining of injury to the left fourth finger sustained when he fell at work. He denies any other injury, weakness, or numbness. X-ray reveals a dorsal dislocation of the proximal interphalangeal joint of the left fourth finger. There was a small avulsion fracture to the base of the middle phalanx, as well. No other fractures were seen. The patient was given a digital block with 1% Xylocaine. After adequate anesthesia, longitudinal traction was applied to the finger, and the finger was easily reduced. Post reduction x-ray view was obtained. There was still a small avulsion fracture to the base of the middle phalanx. Otherwise no fractures were seen. The patient had full range of motion now with flexion and extension. The fourth finger was placed in a finger splint.Impression: Left fourth proximal interphalangeal joint dislocation, reduced. Avulsion fracture to the base of the middle phalanx. Which of the following ​is the correct CPT code assignment for treatment of the interphalangeal joint? Question 10 options: 26775-F3, 29130 26785-F3 26770-F3 26775-F3

26775-F3

Question 4 (1 point) Review this scenario. This 30-year-old female had a successful vaginal delivery after a previous cesarean delivery. The patient's previous cesarean section was four years ago. The attending physician also provided the antepartum and postpartum care. During the hospitalization, she had a postpartum bilateral tubal ligation performed. Which of the following ​is the correct CPT code assignment for this physician's services? Question 4 options: 59618, 58611 59610, 58605 59610 59614

59610, 58605 - The global code should be used to show the antepartum and postpartum care as well as the delivery. The tubal ligation should be coded.

Question 5 (1 point) Review this scenario. Dr. Bill admitted a patient to observation after seeing him in the Emergency Department with severe nausea, vomiting, and dizziness from dehydration. IVs were started, and the plan was to hydrate the patient and discharge him to home the next morning. The patient, however, had not improved enough the next day (day 2) and was kept an additional 24 hours. On day 3, the patient was discharged home. Assuming that all documentation guidelines for each level of service have been met, which of the following ​is the correct sequence of CPT codes for Dr. Bill's services? Question 5 options: 99219, 99231, 99217 99283, 99219, 99217 99219, 99224, 99217 99283, 99231, 99217

99219, 99224, 99217 - The Emergency Department visit should be bundled into the initial observation day code, and a separate outpatient care code is needed for day 2. Codes 99224 - 99226 were created to report observation care provided on days other than the initial date or date of dismissal.

Question 2 (1 point) Review this scenario. An 85-year-old patient of Dr. Smith's was brought to the clinic from her home after her family failed to get her to respond to their phone calls. She was poorly nourished, dehydrated, and confused. Dr. Smith admitted her to the hospital to stabilize her and then spent 45 minutes to discharge her to a nursing facility the next day. Dr Smith is the admitting physician for the nursing facility. Assuming that all documentation guidelines for each level of service have been met, which of the following ​is the correct CPT code assignment for Dr. Smith's services? Question 2 options: 99214, 99235, 99304 99214, 99222, 99239, 99304 99222, 99239, 99304 99222, 99304

99222, 99239, 99304 - A Separate code is required for the hospital discharge.

Question 15 (1 point) Review this scenario. Hospital Progress Note 2 AM to 3 AM - Emergent SUBJECTIVE: I was called regarding endotracheal tube cuff leak and copious secretions suctioned through ETT. N/G sounds not heard in stomach per nurse, though no evidence by exam that N/G was withdrawn partially. Dark gray-green material suctioned. Anesthesia called in. Pt is very afraid of losing airway. OBJECTIVE: Vital signs stabilized after new tube placed. Pt panicky but calmed when I arrived. Post suctioning had good breath sounds bilaterally with few mild right expiratory rhonchi. Cor 50s-60s. O2 sats remained in the 90s. Endotracheal tube replaced by anesthesia and verified with good bilateral breath sounds. ASSESSMENT: 1. Respiratory failure - holding own. Chest x-ray ordered. 2. Congestive heart failure - retaining fluid despite increased diuretics. 3. Nutrition - improved 4. Heart- remains in normal sinus rhythm 5. Atelectasis and pneumonia - now afebrile, still needs frequent pulmonary toilet. 6. INR 1.9PLAN: 1. Transfer out of ICU tomorrow 2. Increase Coumadin 3. Continue respiratory care and IV antibiotics. 4. Increase diuresis - she is above her dry weight. The physician documented 65 minutes of critical care services. Which of the following ​is the correct E/M code assignment for this physician's service? Question 15 options: 99233, 99354 99233 99291, 99292 99291

99291

Question 11 (1 point) Review this scenario. Dr. Morgan made a home visit to see his long-time patient who was dying of cancer. He pronounced the patient dead approximately 75 minutes after arriving. He stayed an additional 30 minutes comforting the family and discussing her disease process. He documented a comprehensive interval history and a detailed exam. Medical decision making was straightforward. Total time spent counseling the family was 85 minutes. Which of the following ​is the correct CPT code assignment for Dr. Morgan's services? Question 11 options: 99358 99345-21 99350, 99358 99350

99350, 99358 - Using time as a controlling factor, the correct CPT codes would be 99350 and 99358.

Question 23 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 08-18-YYYYADMISSION DATE & TIME: 08-24-YYYYDIAGNOSIS INFORMATION N/APROCEDURE INFORMATION N/ANURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: diltiazem, Isordil, Metamuci, Colace, and timolol.BP: P: R: T: WT: OVS: CC: Chronic constipation. Soreness around the anal region and incontinence of stool and sometimes urine. PMH: Coronary artery disease with sick sinus syndromes, glaucoma, and status post pacemaker implantation in November YYYY. PMH: Coronary artery disease with sick sinus syndromes, glaucoma, and status post pacemaker implantation in November YYYY. PHYSICIAN DOCUMENTATIONThe patient is an 89-year-old white veteran with coronary artery disease with sick sinus syndrome, status post pacemaker implantation in November. He is being followed up by the cardiologist, went last week and reports that he is doing well. The patient also has chronic constipation, mild dementia, positive PPD and negative x-ray. He complains of soreness around the anal region and incontinence of stool and sometimes urine. He is currently on diltiazem CD 180 mg per day and Isordil 20 mg b.i.d., Metamucil one pkg per day and Colace p.r.n. He has glaucoma, for which he takes timolol eye drops. On exam, the patient is an alert, well-oriented veteran not in any distress, pleasant. Vital sounds as per the nursing staff. Chest is clear, CVS:NSR. Abdomen: Soft, benign, no masses felt. Rectal exam: The anal area and the surrounding perineal area are erythematous, and there is a tear going from the rectum to the anal region and slight oozing of blood was noted. Rectal exam was done, and I could not feel any masses in the rectum, however, it was painful for him. ASSESSMENT: Anal tear (nontraumatic) with hemorrhoids. PLAN: Sitz bath, protective ointment around that area, and surgical consult and keep the pressure off and give doughnut ring. What is the correct coding assignment?

Anal Tear (non traumatic): K62.81, Fecal Incontinence R15.9, Hemorrhoid: K64.9, Chronic Constipation: K59.09, CAD: I25.10, Glaucoma: H40.9, Sick sinus syndrome: I49.5, S/P Pacemaker: Z95.0, E/M Visit: 99212 Notes: The documentation in this record is a bit vague (which is typical of real-world). There could be some opportunities to query the physician for additional documentation, but based on what we know, this is how it's coded.

Question 17 (1 point) Review this health record. ADMISSION DATE: 08-26-YYYYGENDER: FemaleOCCUPATION: Bus DriverDIAGNOSIS INFORMATION1. Anger reaction2. Possible reaction to PrednisonePROCEDURE INFORMATIONPsychotherapyNURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: PrednisoneCC: Feelings of angerPMH: Crohn's DiseasePHYSICIAN DOCUMENTATIONPatient is under treatment for Crohn's Disease with Prednisone, which she began taking recently for a flare-up of symptoms. She is presently taking 15 mg BID. The patient is aware of her disease and is followed up by Dr. Weaver. She was referred to me for psychotherapy because of strong feelings of anger towards kids who she knows are responsible for breaking into her cabin last weekend and taking a video camera. During the 50-minute psychotherapy session, she asked if these feelings could be aggravated by the Prednisone. I said that it was a possibility. She explained that the police will not do anything because there is no evidence that these people are responsible for the theft. The patient states that these same kids have been vandalizing homes over the past year, and everyone knows who it is. However, even though it is in the hands of the police, they are still not doing enough, which angers her. She tells me that she would like to get a shotgun for protective purposes, and she thinks that these people will probably try to come around on the weekend, thinking that her family is not there. She would like to surprise these people and to perhaps use the shotgun if she feels that her life is in danger. We talked at length about the situation, and I advocated that if she waits at the cabin on the weekend, hoping that these people will show up, she has her husband or a girlfriend with her. She agreed.FOLLOW-UP NOTE: On 8-26-YYYY I attempted to call her husband, but I was unable to reach him because he was never at the location. (I had asked the patient to ask her husband to call me; however, he hasn't as of yet.) On 8-27-YYYY, I called the patient, and she stated that she was feeling less angry and more calmed down. Her friend, who is always around and stays with her at times, was there. I spoke with her friend, Paula, and she seemed acquainted with the situation. She explained that the patient was angry the day before but seemed to be calmer today. She stated that she would be with the patient on the weekends or whenever she was not working. She will not allow the patient to stay alone, especially with a gun, until the situation is resolved. Paula will discuss the situation with the patient's husband. I will see the patient in 2 weeks. What is the correct coding assignment?

Anger Reaction: R45.4, Crohn's Disease: K50.90, Psychotherapy: 90834 Notes: Cannot code possible Prednisone reaction. Physician did not perform a medical evaluation.

Question 18 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 01-21-YYYYDIAGNOSIS INFORMATION1. Anxiety with depression2. Coronary artery disease3. Cerebrovascular disease4. Esophageal reflux5. HyperlipidemiaPROCEDURE INFORMATIONLevel 3 E/M visitNURSING DOCUMENTATIONMEDICATIONS ALLERGIES/REACTIONS: NoneCURRENT MEDICATIONS: Cimetidine, FluoxetineBP: 122/70 P: 60 R: 18 T: WT: 183 HEENT: Within Normal LimitsCC: Feels tired all the time and no energy.PMH: Hyperlipidemia, coronary artery disease, cerebrovascular disease, esophageal reflux, anxiety with depression.NOTES: Patient says he is feeling tired all the time and no energy.PHYSICIAN DOCUMENTATIONNotes: The patient has the following problems: Hyperlipidemia, coronary artery disease (CAD), cerebrovascular disease (CVD), esophageal reflux, and anxiety with depression. HPI: The patient is an 82-year-old white male who was last seen in June of this year for the above problems. At that time, the patient was placed on Cimetidine twice a day and Fluoxetine 10 mg a day. The patient had been followed up in the past by a private M.D. in Fairport. However, he no longer sees him, and at this time, he is using our practice as his primary care providers. (I have instructed our office manager to work with him to locate a new general or family practitioner who can serve as his primary care provider. In the meantime, we will monitor all of his problems, prescribing appropriate medication, and ordering appropriate follow-up ancillary tests.) There are no labs done on this patient as of yet. He comes in today without any new complaints, except for his original complaint of feeling tired all the time and no energy.PE: Today on examination, the patient was 57 inches tall, weighed 184 lbs. Blood pressure: 122/70. Pulse: 60 per minute. Respiration: 18 per minute.HEENT: Basically, within normal limits. He wears glasses for visual acuity. He has hearing aids bilaterally. NECK: Supple. Trachea is midline. Thyroid not palpable.LUNGS: Clear to A&P.HEART: sounds were regular without murmur or ectopic beat noted.ABDOMEN: slightly obese. It was nontender. There was no gross organomegaly noted. His bowel sounds were normal.EXTREMITIES: The lower extremities were present. He had good circulation with some very mild edema around the ankles.ASSESSMENT: As stated above in the problem list.PLAN: I would like to see this patient back in three months' time. Before leaving today, he will be referred and taken to psychiatry where he can have a new appointment set up and have his medications renewed. He is also scheduled to meet with our office manager, who will work with him to identify a new primary care provider (such as a family practitioner, internist, general practitioner). He will have labs requested in the next two to three weeks. We will check his blood chemistries and hemogram to monitor CAD, CVD, and hyperlipidemia. I also want to get fecults times three. I will see him in three months. He will continue his CAD and CVD medications, along with Cimetidine 400 mg, which he will take just once a day at nighttime. He is also taking Lovastatin for his hyperlipidemia 40 mg a day. He has used blocks under the head of his bed, which has relieved his nighttime heartburn. I would advise him to continue doing this, as well as taking the Cimetidine at bedtime. He is being referred as stated to psychiatry for follow up, and I will see him in three months. What is the correct coding assignment?

Anxiety w/ Depression: F41.8, CAD: I25.10, Cerebrovascular disease: I67.9, Hyperlipidemia: E78.5, Esophageal Reflux: K21.9, E/M Visit: 99213 Notes: Patient is considered established because he was seen in June of this year. Physician did review all medications to ensure all his chronic conditions were properly treated.

Question 19 (1 point) Review this health record. GENDER: MaleOCCUPATION: RetiredDATE OF BIRTH: 08-12-1929ADMISSION DATE & TIME: 08-24-YYYYDIAGNOSIS INFORMATION1. Gait disorder2. Cervical spondylosis3. Peripheral neuropathyPROCEDURE INFORMATIONLevel 2 E/M visitNURSING DOCUMENTATIONCURRENT MEDICATIONS: Warfarin, digoxin, VerapamilPHYSICIAN DOCUMENTATIONNotes: S: Patient returns for recheck of gait instability; there is no change in gait instability; when he had a head CT and had to lie quietly with his neck extended, the gait instability was worse for 20-30 minutes after test; meds - Warfarin, digoxin, Verapamil. O: Alert, ataxic gait with foot slapping and instability on tandem, mild distal weakness and wasting, barely detectable DTRs, impaired vibration below hips, impaired position sense in toes; head CT revealed diffuse atrophic changes; EMG revealed distal demyelinating axonal neuropathy. GHb and TSH unremarkable. A: Ataxic gait disorder with central/peripheral components in context of cervical spondylosis and peripheral neuropathy. P: B12/folate [I can find no evidence in his chart that these have ever been done], revisit one month. Total time of visit with patient was 15 minutes. What is the correct coding assignment?

Ataxic Gait Disorder: R26.0, Cervical Spondylosis: M47.812, Peripheral Neuropathy: G62.9, E/M Visit: 99212, total time is used to assign the E/M level. Time is specified as 15 minutes and this meets a level 2 established patient E/M code.

Question 31 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 11-07-YYYYADMISSION DATE & TIME: 02-09-YYYY 0120DISCHARGE DATE & TIME: 02-09-YYYY 0230CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: No, EXPLAIN: NKACURRENT MEDICATIONS: No, EXPLAIN: NoneBP: P: 88 R: 16 T: 98CONDITION: Laceration R kneeASSESSMENT: 1 1/2 - 2 yrs. last tetanusLEVEL IIIPHYSICIAN NOTES:V-shaped laceration, right knee 1.5 cm x 1.5 cm. Patient states he injured his knee at home when he slipped and fell down his front steps. Irrigated vigorously with normal saline solution. 8.0 cc 1% Xylocaine administered. #3-4-0 chronic deep suture and #10-3-0 Prolene simple interrupted suture placed. Antibiotic ointment applied. Adaptic, pressure dressing, and ace wrap applied. DIAGNOSIS: V-shaped laceration, right knee, 1.5 cm x 1.5 cm. What is the correct coding assignment?

Knee Laceration: S81.011A, Encounter for Immunization: Z23, Fall from Steps: W10.8XXA, Place of Occurrence, Home: Y92.008, E/M Visit: 99283-25, laceration Repair, Intermediate, 3 cm: 12032, IM Tetanus/Diphtheria, Lt. Deltoid, 0.5ml: 90714, 90471

Question 32 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 03-26-YYYYCONDITION ON DISCHARGE:SatisfactoryInstruction Sheet GivenADMISSION DATE & TIME: 02-09-YYYY 1700DISCHARGE DATE & TIME: 02-09-YYYY 1740NURSING DOCUMENTATIONALLERGIES: Yes, EXPLAIN: PenicillinCURRENT MEDICATIONS: No, EXPLAIN: T.T. w/in 2 yearsBP: 170/110 P: 80 R: 20 T: 98.7CONDITION: Fell on ice Feb 9, lacerated chin.ASSESSMENT: Small laceration on chin. No LOC. States "stiffness of jaw." Negative for any other injury.PHYSICIAN NOTES: This 22-year-old white male slipped on the ice in his driveway and struck his chin against a pipe. He presents now with a laceration on the chin. The patient denies any loss of consciousness, but he does have a slight amount of jaw discomfort. With motion, however, he has no pain or tenderness. Physical exam reveals an alert, cooperative 22-year-old white male with a 1.5 cm jagged laceration on his chin. The patient has full range of motion of the jaw and no discomfort with forced biting on either side. The neck is supple and nontender. The wound was cleaned with Betadine, anesthetized with 1% Carbocaine, and irrigated copiously with normal saline. It was closed with five #6-0 nylon sutures. The patient was instructed to keep the wound clean and dry and to return in four days for suture removal; return sooner if any evidence of infection should occur.DIAGNOSIS: 1 1/2 cm laceration, chin.PHYSICIAN ORDERS: 6-0 nylon sutures.DISCHARGE INSTRUCTIONS: Keep clean and dry. What is the correct coding assignment?

Laceration Chin: S01.81XA, Fall on Ice: W00.0XXA, Struck against pipe: W22.8XXA, Place of Occurrence, Driveway of Home: Y92.008, Allergy to Penicillin: Z88.0, E/M Visit: 99282-25, Laceration Repair, 1.5cm: 12011

Question 35 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 09-27-YYYYADMISSION DATE & TIME: 10-13-YYYY 1040DISCHARGE DATE & TIME: 10-13-YYYY 1110CONDITION ON DISCHARGE:SatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: No, EXPLAIN: NKACURRENT MEDICATIONS: Yes EXPLAIN: AntibioticBP: 120/80 P: 88 R: 18 T: 97.4CONDITION: Recheck laceration, left lower leg. (Patient previously gored by pig on his farm.)ASSESSMENT: Dressing fell off wound this morning. Drain also fell out. Continues to have some bloody drainage.PHYSICIAN NOTES: This patient returns for recheck of laceration, left lower leg, because the dressing fell off this morning and the drain fell out at the same time. Patient was seen in the ED last week, and laceration was sutured at that time. Laceration looks good. Drain removed in entirety with remaining dressing. Patient to return in 9 days for suture removal; sooner if any signs of infection develop.DIAGNOSIS: Recheck laceration.PHYSICIAN ORDERSDISCHARGE INSTRUCTIONS: Keep clean and dry. What is the correct coding assignment?

Laceration Leg: S81.812D, Struck by Pig: W55.42XD, E/M Visit: 99281

Question 28 (1 point) Review this health record. GENDER: FemaleDATE OF BIRTH: 09-10-YYYY ADMISSION DATE & TIME: 08-09-YYYY 2005DISCHARGE DATE & TIME: 08-09-YYYY 2103CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: NoCURRENT MEDICATIONS: NoBP: 100/70 P: 108 R: 16 T: 99CONDITION: Laceration, right hand (at home) on glass.ASSESSMENT: Bleeding controlled. Multiple lacerations, right fingers and hand. Two larger lacerations, right wrist.PHYSICIAN NOTES: Patient is a 35-year-old female who struck her right hand through a glass window at home, sustaining several lacerations, particularly about the right wrist. There were two wrist lacerations, each 2 centimeters in length. There were also several smaller nicks on the dorsum of the hand and finger. A 4-centimeter lacerated flexor carpus ulnaris tendon, right, was noted upon further evaluation. It was repaired with a figure-of-eight 3-0 Vicryl suture, and skin was closed with interrupted 4-0 Prolene. The other 2-centimeter skin laceration, right wrist, was closed with interrupted 4-0 Prolene. Dry sterile dressings were applied, the wrist was splinted with a plastic splint, and the patient was administered a tetanus toxoid booster. She was started on Ampicillin for four days as prophylaxis against infection. She is to return on Thursday for a dressing change. DIAGNOSIS: Multiple lacerations, right wrist. Laceration, flexor carpi ulnaris tendon, 4 centimeters. PHYSICIAN ORDERS: 1/2 cubic centimeter tetanus and diphtheria toxoids (Td), IM, right deltoidDISCHARGE INSTRUCTIONS: Return Thursday for dressing change. What is the correct coding assignment?

Laceration Specified Tendon Wrist: S66.821A, Laceration Rt. Finger: S61.219A, Laceration Rt. Hand: S61.411A, Laceration Rt. Wrist: S61.511A, Encounter for Immunization: Z23, Contact with Broken Glass: W25.XXXA, Place of Occurrence, Home: Y92.009, E/M Visit: 99283-25, Repair Laceration, Rt. Flexor Tendon (includes suture of 2cm wrist lac): 25260-RT, Repair Laceration, Simple, Rt. Wrist 2cm: 12001-51, IM Tetanus/Diphtheria(Td), Rt. Deltoid, 0.5ml: 90714, 90471

Question 34 (1 point) Review this health record. GENDER: FemaleDATE OF BIRTH: 03-29-YYYYADMISSION DATE & TIME: 10-02-YYYY 1645DISCHARGE DATE & TIME: 10-02-YYYY 1721CONDITION ON DISCHARGE:SatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: No, EXPLAIN: NKACURRENT MEDICATIONS: No EXPLAIN: None. Last tetanus shot 6-7 years ago.BP: 124/80 P: 88 R: 20 T: 98.4CONDITION: 2 lacerations: left arm on couch and right 3rd knuckle, 0900, 10-02-YYYY.ASSESSMENT: Approximately - 1" laceration, 3rd knuckle, right hand. 1" laceration, left forearm. Occurred 0900 this a.m.PHYSICIAN NOTES: S: 23-year-old white female who lacerated her right hand and left forearm in separate incidents at home. O: Patient has shallow laceration of the right 3rd MP joint. It was closed cleaned well with Betadine and infiltrated with 1% Xylocaine and closed with 4-0 silk. She has a 1.5 cm laceration of the left forearm too, which was also cleaned with Betadine and infiltrated with 1% Xylocaine and closed with 4-0 silk. A: 1.5 cm laceration of the right 3rd finger and left forearm. P: Per infection and suture guidelines.DIAGNOSIS: Two 1.5 cm lacerations of right third finger and left forearm. What is the correct coding assignment?

Laceration, Forearm, Left: S51.812A, laceration, Middle Finger, Right: S61.212A, Accident NOS: X58.XXXA, Place of Occurrence, Home: Y92.009, Laceration Repair, Forearm, 1.5 cm + Finger, 1.5 cm: 12002

Question 6 (1 point) Review this scenario. A 10-month-old infant was found to have a heart murmur during the newborn hospital stay. A 2D echocardiogram and Doppler study demonstrated a ventricular septal defect. At the age of 3 months, congestive heart failure developed, which has been managed by digitalis administration and diuretics. During this encounter, a cardiac catheterization is performed to measure the magnitude of the defect and to assess pulmonary artery pressure and resistance. A right heart catheterization with selective biplane cineangiocardiograms to the femoral vein for pulmonary angiography and supravalvular aortography were performed in the cardiac catheterization suite of the hospital. Because of the age of the patient, conscious sedation was provided using an intravenous route by the physician. The procedure lasted 30 minutes. Which of the following ​ICD-10-CM and CPT codes are reported by the pediatric cardiologist reporting this service? Question 6 options: Q21.0, I50.9, 93530-26, 93567-26, 93568-26 Q21.0, I50.9, 93530, 93567, 93568 R01.1, I50.9, 93530-26, 93567, 93568 Q21.0, I50.9, R01.1, 93530, 93567, 93568

Q21.0, I50.9, 93530-26, 93567-26, 93568-26 - The heart murmur is not reported because the etiology is stated as ventricular septal defect reported in code Q21.0. Modifier -26 is required on codes 93530, 93567, and 93568 because they are procedures that have both technical and professional components.

Question 26 (1 point) Review this health record. GENDER: MaleDATE OF BIRTH: 05-09-YYYYADMISSION DATE & TIME: 03-09-YYYY 1610DISCHARGE DATE & TIME: 03-09-YYYY 1630CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: NoEXPLAIN: No known allergies.CURRENT MEDICATIONS: Last tetanus toxoid greater than 10 years ago.BP: 122/80 P: 76 R: 24 T: 98.8 CC: HPI: Small two-inch puncture wound noted on the lateral aspect below right knee. No drainage noted.CONDITION: Puncture wound, right leg with nail today.ASSESSMENT: Dr. Beeson cleansed wound with Phisohex. PHYSICIAN NOTES: Patient punctured right lateral calf with rusty nail while working in his wood shop at home. Last tetanus over 10 years ago. Small two-inch puncture wound. No erythema, ecchymosis, or peripheral vascular involvement. DIAGNOSIS: Puncture wound of right calf. Wound cleaned. PHYSICIAN ORDERS: Tetanus and diphtheria toxoids (Td) 0.5 ml administered, IM, left deltoid. DISCHARGE INSTRUCTIONS: Ice left arm. Aspirin, 2 tablets, every four hours. Return if signs of infection. What is the correct coding assignment?

Rt. Lateral Calf, Puncture Wound, 2": S81.831A, Encounter for Immunization: Z23, Nail Entering through Skin: W45.0XXA, Place of Occurrence, Home, Wood Shop: Y92.008, E/M Visit: 99281-25, Tetanus and diphtheria toxoids (Td) , 0.5ml: 90714, 90471 Notes: The physician didn't document past family/social history, which would meet the expanded problem-focused history, but there isn't a true expanded problem-focused examination documented. In order to use 99282, the physician has to document all 3 of the key components: expanded problem-focused history; expanded problem-focused exam; and medical decision making of low complexity. In this documentation, he only met 2. That would mean the exam was problem focused only, with code 99281.

Question 8 (1 point) Review this scenario. This adult female presented to the emergency department with injury of the left ribcage. This injury resulted from striking the corner of a countertop during a fall. The emergency medicine physician performed an expanded problem focused history, a detailed examination, and medical decision making of moderate complexity. The emergency medicine physician confirmed a stable rib fracture on the left side. Which of the following ​ICD-10-CM and CPT codes are reported for the services rendered by the emergency medicine physician? Note: No External Cause codes are required by her health plan. Question 8 options: S22.32XA, 21800, 99283-25 S22.32XA, 29200 S22.32XA S22.32XA, 99283

S22.32XA, 99283

Question 33 (1 point) Review this health record. GENDER: FemaleDATE OF BIRTH: 06-27-YYYYADMISSION DATE & TIME: 10-13-YYYY 2350DISCHARGE DATE & TIME: 10-14-YYYY 0158CONDITION ON DISCHARGESatisfactoryInstruction Sheet GivenNURSING DOCUMENTATIONALLERGIES: No, EXPLAIN:CURRENT MEDICATIONS: No. EXPLAIN: None. Unsure about tetanus status.BP: 128/70 P: 108 R: 28 T: 97.4 CC: Scalp lacerations. Headache. HPI: Pt. was the passenger in a MVA a short time ago. Was wearing a seatbelt. Thinks she may have been unconscious momentarily. Has a 2 inch laceration behind the right ear in the parietal area and a 3 inch laceration in the left parietal area. Also has multiple abrasions on both arms and on the dorsal right thigh.CONDITION: Motor vehicle accident. Lacerations to scalp. Headache.TREATMENT: Tetanus/diptheria (Td) toxoid administered.PHYSICIAN NOTES: 18-year-old female involved in a motor vehicle accident as a passenger on Highway 101 and apparently was wearing full seat restraints at the time. The patient was able to crawl out of the car. There was no firm history of any loss of consciousness, although she apparently was dazed for a minute or two. She remembers all the events surrounding the accident. There is no amnesia, and she is oriented x3 in the ER. Although there were numerous scrapes and contusions about the extremities, particularly the right arm and the left leg, there was no evidence of any long bone fractures. There is no tenderness along the c-spine, and she had a good range of pain-free motion of the c-spine. She had a laceration bilaterally in the parietal area of the scalp. There was no drainage from the ears. The pearls extraocular eye movements are intact. No evidence of any loose teeth and no evidence of any facial bone fractures. No pain on rib compression. Heart NSR, she moved the upper extremities freely and easily through a full range of motion. No evidence of any abdominal injury, and no pain or tenderness on palpation. Compression of the pelvis did not produce any discomfort, no pain along the thoracic or lumbar spine. She had a full range of motion in lower extremities. No nausea or vomiting, denies any headache, although she complains of pain along the laceration. Hair was shaved about the margins of the wounds, which were then washed and infiltrated with lidocaine and sutured with interrupted 3-0 etholon sutures. Complete skull x-rays were negative for fractures. Patient denies any dizziness. She was ambulatory and walked to the bathroom without difficulty and was allowed to go home with her grandmother with instructions to have the wound checked in 2 -3 days, sutures out in 8 days. Head injury sheet was dispensed, and she is to return if any of the outlined symptoms should occur.DIAGNOSIS: Multiple contusions and abrasions. Two lacerations of scalp totaling 12.7 centimeters.PHYSICIAN ORDERS: Nugauge; Extra sutures. Skull x-rays. Small ice packs. Tylenol tabs 325 mg p.o. Tetanus/diphtheria toxoid, left deltoid, IM.RADIOLOGY REPORT: Reason for Exam: MVACOMPLETE SKULL X-RAY: Four views of the skull show no evidence of any fractures. Incidentally, the patient has a 2mm radiopaque density projected over the left angle of the mandible. This could conceivably represent either a stone in the parotid gland or some radiopaque debris on the patient's skin or clothing. What is the correct coding assignment?

Scalp Lacerations: S01.01XA, Multiple Abrasions Both Arms and Dorsal Right Thigh per HPI: S70.311A, S40.812A, S40.811A (arm abrasions NOS is indexed to abrasion of upper arm), Encounter for Immunization: Z23, MVA, Passenger: V49.9XXA, Place of Occurrence, Highway: Y92.411, E/M Code: 99284-25, Laceration Repair, Scalp, 12.7 cm: 12005, IM Tetanus/Diphtheria Toxoid, 0.5ml: 90714, 90471


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