AAPC CPC CHAPTER 19

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Brief HPI :

1 to 3 elements

CASE 2 Susan is a 67 years-old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year but it has grown a lot this last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.) PAST MEDICAL HISTORY: Hypertension, arthritis. ALLERGIES: None. MEDICATIONS: Benicar and Vytorin. SOCIAL HISTORY: Cigarettes: None. PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery.) MEDICAL DECISION MAKING: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3-mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results. What are the CPT® and ICD-10-CM codes reported?

11300 D49.2 Z85.828

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

32 Response Feedback: Rationale: Modifier 32 is used for services related to mandated consultation and/or related services by a third party payer, governmental, legislative or regulatory requirements.

Extended HPI:

4 or more elements (or status of 3+ chronic conditions)

CASE 1 Mark is a 45 years-old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. PAST SURGICAL HISTORY: Nasal surgery, knee surgery. (Past medical history) SOCIAL HISTORY: Cigarettes: None. (Social history) FAMILY HISTORY: He does have a family history of melanoma in his paternal grandfather who died from it. (Family history) PHYSICAL EXAMINATION: On examination, he has subcutaneous masses of his left forearm and two spots of his left posterior arm. That is the biggest of those three. It is about 1.3 cm. He has four on his right upper extremity, two on his lower forearm and two on his posterior arm. He has some of his belly. (Organ: Skin) MEDICAL DECISION MAKING: The patient has multiple lipomas (Diagnosis) which are tender. He would like them removed. With his permission, I have drawn how we would incise the skin over these and about how long the scar would be. There is really no alternative to treatment other than surgery. Some plastic surgeons will do this with liposuction, but I have found that personally the recurrence rate is quite high when I have tried to do it with liposuction, so I generally just excise them. Risks would include infection and bleeding. (Elective major surgery (removal of subcutaneous lipoma has a 90-day global); although provider documents risk of infection and bleeding, this is not above the normal risk associated with a surgery.) We do not know why people get these, so this is something that Mark will have to deal with forever. We will do that here in the office. We will do about three at a time. We are going to start with his left upper extremity. It will be a privilege to take care of Mark. What are the CPT® and ICD-10-CM codes reported?

99201 D17.21 D17.22 D17.1

A new patient is seen in the pediatric office for ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (100.7°F). She has not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion, or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat, and neck. The patient is determined to have otitis media. Amoxicillin is prescribed. What is the correct E/M code reported for this visit?

99202

CASE 5 The patient is a 32 year-old male here for the first time. (New patient.) Chief Complaint: Left knee area is bothersome,(Chief complaint.) painful moderate severity.(HPI: Severity) The patient also notes swelling (HPI: Associated Signs & Symptoms) in the knee area,(HPI: Location) limited ambulation,(HPI: Severity again (not counted twice)) and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. (HPI: Duration) Problem occurred spontaneously. Problem is sporadic.(HPI: Timing) Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems so patient has avoided using it. (HPI: Modifying factors and their affects.) Past Medical History: Patient denies any past medical problems. Surgeries: Patient has undergone surgery on the appendix. Hospitalizations: Patient denies any past hospitalizations that are noteworthy. Medications: Hydrocodone Allergies: Patient denies having allergies. (PFSH: Past Medical History) Family History: Mother: No serious medical problems; Father: No serious medical problems.(PFSH: Family History) Social History: Patient is married. Occupation: Patient is a chef. (PFSH: Social History) Review of Systems: Constitutional: Denies fevers. Denies chills. Denies rapid weight loss. Eyes: Denies vision problems. Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems. Cardiovascular: Denies chest pains. Denies an irregular heartbeat. Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath. Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool. Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination. Integumentary: Denies any rashes. Denies having any insect bites. Neurological: Denies numbness. Denies tremors. Denies loss of consciousness. Hematologic/Lymphatic: Denies easy bruising. Denies blood clots. Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite. (ROS: Complete) Review of Previous Studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. (Previous studies reviewed used in MDM.) Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. (Exam: Eyes) Gait is normal. (Exam: Musculoskeletal) Skin is intact. No rashes, abrasions, contusions, or lacerations. (Exam: Skin)No venous stasis. No varicosities. (Exam: Cardiovascular) Reflexes are normal patellar. No clonus.(Exam: Neuro) Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. (Exam: Musculoskeletal) Neck: Neck is supple. No JVD. (Exam: Neck) Impression: 1. Infective synovitis of the left knee 2. Contracture of the left knee 3. Possible medial meniscal tear of right knee (Uncertain diagnosis) Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day (Over the counter medication), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy.(Physical therapy prescribed) We will obtain an MRI (Additional test ordered) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Uncertain prognosis on the tear. The patient is sent for additional work-up to determine if there is a tear present.) What are the CPT® and ICD-10-CM codes reported?

99203 M65.162 M24.562

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

99203, K40.90

99203, K40.90 Response Feedback: Rationale: This is a new patient office visit which is coded from range 99201-99205. For a new patient office visit, all three key components must be met in order to support the level of visit. We have a detailed history (Extended HPI + Extended ROS + Pertinent History), Comprehensive exam (Const, Skin, Lymphatic, Eyes, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary) and moderate MDM (New problem, no additional work up, no tests, elective surgery). The level of visit is 99203. In the ICD-10-CM Alphabetic Index look for Hernia, hernial/inguinal (indirect). Indirect is a nonessential modifier listed for Hernia, hernial/inguinal. You are directed to K40.90. Verify code in the Tabular List.

CASE 3 IDENTIFICATION: The patient is a 37 year-old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37 year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist. PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD-10-CM codes reported?

99212 M79.89 I27.20

An established patient is seen in clinic for allergic rhinitis. A problem focused history, expanded problem focused exam, and a low level of medical decision making are performed. What E/M code is reported for this visit?

99213

Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit?

99213, 99354

99213, 99354 Response Feedback: Rationale: This is an established patient. Two of the three key elements are required for an established patient. An expanded problem focused exam and moderate MDM meet or exceed the requirement for code 99213. The provider spent an additional 45 minutes with the patient discussing the patient's new diagnosis. Prolonged Service codes 99354-99357 are used when provider or other qualified heath care professional provides prolonged service involving direct patient contact that is provided beyond the usual service. The codes reported based on the place of service and total time. Codes 99213 and add-on code 99354 are used to report the services.

CASE 6 Established patient Chief complaint: thoracic spine pain PROBLEM LIST: 1. Rheumatoid arthritis, right and left hands. 2. Compression fracture of the thoracic spine T11. 3. Alcoholism. 4. Depression/anxiety. REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every other week, Celexa 20mg a day, Klonopin .5mg as needed, aspirin 81mg a day, Ambien 10mg as needed, Hydrocodone as needed. PHYSICAL EXAM: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular. MUSCULOSKELETAL EXAM: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis. REVIEW OF DEXA(Dual Energy X-ray Absorptiometry) SCAN: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward's triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from 2005. ASSESSMENT: 1. Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated. 2. Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective. PLAN: 1. Continue current therapy. 2. Aspirate the synovial cyst in the left second finger. 3. Follow up in about 6-8 weeks. 4. Repeat labs prior to visit. PROCEDURE NOTE: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know. What are the CPT® and ICD-10-CM codes reported?

99213-25 20612-F1 77080 J1020 M06.041 M06.042 M71.342 M80.08XD

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

99218, 99217 Response Feedback: Rationale: Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code 99217 states this code is to be utilized to report all services provided to a patient on discharge from observation status if the discharge is on other than the initial date of observation status Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge.

CASE 8 Hospital Admission Chief complaint: Nausea and vomiting, weakness HPI: The patient is a 78 year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: MORPHINE Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. Family History: Mother deceased after childbirth. Father deceased from asphyxia. ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. Eyes: Negative for vision changes. Pulmonary: Negative for dyspnea. Cardiovascular: Negative for angina. Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. Neurologic: Negative for headaches. Negative for seizures. Psychiatric: Negative for anxiety. Negative for depression. Integumentary: Positive for rash for which she takes Benadryl. Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. Objective: Vital signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. Generally: No apparent distress, oriented x 3, pleasant Spanish speaking female. Head, ears, eyes, nose, throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus. Neck: Supple, full range of motion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy's sign. Back: Costovertebral angle tenderness Extremeties: No clubbing, cyanosis or edema. Laboratory Studies. Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. Assessment 1. Nausea, vomiting, diarrhea, likely gastroenteritis 2. Cystitis 3. Hypokalemia 4. Hyponatremia 5. Cholelithiasis 6. Diabetes mellitus type 2 7. Hypertension Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff-toxin and fecal stool culture and sensitivity. What are the CPT® and ICD-10-CM codes reported?

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

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

99223

CASE 9 Hospital progress note Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain. The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date. Objective: Vital Signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98. General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). Laboratory Data: Shows C Diff-toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. Assessment: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Hypokalemia 6. Diabetes mellitus type 2 7. Hypertension If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest-x-ray PA and lateral this morning to evaluate that. What are the CPT® and ICD-10-CM codes reported?

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

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

99235 Response Feedback: Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate." The provider performed a comprehensive history, comprehensive exam and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

CASE 10 Discharge summary Hospital course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that. Discharge Diagnoses: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Diabetes mellitus type 2 6. Hypertension Discharge Medications: 1. Levaquin 500 mg p.o. daily x2 days 2. Ciloxan ointment, apply b.i.d.to left eye x 4 days/ 3. Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20 4. Benadryl 25 mg p.o. daily p.r.n. rash 5. Diovan 320 p.o. daily 6. Calcium 600 mg p.o. daily 7. Vitamin C 500 mg p.o. daily. 9. Metformin 1000 mg p..o. daily 10. Lipitor 20 mg p.o. at bedtime 11. Coreg CR 20 mg p.o. daily. Discharge Diet: Cardiac Activities: ad lib Discharge Instructions: Patient to be NPO after midnight Sunday. Dismiss: Home Condition: Good Follow-up: Follow-up with me in 1 week. Follow-up on Monday morning for cholecystectomy. NPO after midnight on Sunday. What are the CPT® and ICD-10-CM codes reported?

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

The attending provider at the hospital spent 25 minutes with the patient in the morning and another 15 in the afternoon examining the patient, writing discharge orders and giving discharge instructions to the patient. What CPT® code is reported for the discharge?

99239 Response Feedback: Rationale: In the CPT® Index look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge provider on the discharge date is included in the time. The provider spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.

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

99242

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

99243 Response Feedback: Rationale: A consultation requires all three key components be met to support the level of visit. History - HPI (extended), ROS (Extended), PFSH (complete) = Detailed Exam - Detailed MDM - New problems no additional work-up, one data point given (review/order of test in medicine section) for the EMG or Nerve conduction study. The level of risk is moderate (elective major surgery). The documentation supports a 99243.

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

99281 Response Feedback: Rationale: Emergency Department services must meet or exceed three of the three key components. The provider performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined) and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code.

The EMS brought a 31 year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?

99285 Response Feedback: Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.

ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric. PHYSICAL EXAM: 96/60, 112, 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema. LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate. IMPRESSION Hypoxic respiratory failure Community acquired pneumonia Septic shock Non-oliguric acute renal failure PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90 Usual labs ordered for tomorrow. Critical care time: 35 minutes What CPT® code(s) is/are reported?

99291 Response Feedback: Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient's condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?

99291-25, 31500, 36510, 94610 Response Feedback: Rationale: When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 ... each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). According to CPT® Critical Care Services guidelines these procedures are not included in the critical care codes. Therefore, they can be reported separately in addition to critical care services with modifier 25 appended to code 99291.

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

99309 Response Feedback: Rationale: For subsequent nursing facility care codes, 2 of three key components must be met. History - (Extended), ROS (Extended), PFSH (1-Pertinent) = Detailed Exam - Detailed exam of eyes, ENT, Neuro. MDM - New problem with additional workup, lab ordered, moderate risk (undiagnosed new problem with uncertain prognosis) = moderate medical decision making. The documentation supports 99309.

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

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

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

99348

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

99348 Response Feedback: Rationale: In the CPT® Index look for Home Services/Established Patient and you are directed to code range 99347-99350. Two of three key components must be met to support a level of visit for established patient home services. 99348 is the correct code choice.

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

99367 Response Feedback: Rationale: In CPT® Index, look for Conference/Interdisciplinary Medical Team and you are directed to codes 99367, 99368. 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code.

After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported?

99382 Response Feedback: Rationale: This is a new patient to the pediatric clinic. Look in the CPT® Index for Preventive Medicine/New Patient and you are directed to code range 99381-99387. The code selection is based on age. Code 99382 is for ages 1-4 making it the correct code choice.

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

99391 Response Feedback: Rationale: Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 25.

A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI. What CPT® code(s) is/are reported for this visit?

99393, 99213-25

CASE 4 AGE: 33 year-old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.) HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. (Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.) PAST MEDICAL HISTORY: Depression. FAMILY HISTORY: no cancer or heart disease, mother has hypertension. SOCIAL HISTORY: TOBACCO USE: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. REVIEW OF SYSTEMS: Patient denies any symptoms in all systems except for HPI. PHYSICAL EXAM: (Comprehensive physical exam.) CONSTITUTIONAL: Well developed, well-nourished individual in no acute distress. EYES: Conjunctivae appear normal. PERLA ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx. NECK: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted. RESPIRATORY: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. CARDIOVASCULAR: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema. CHEST/BREAST: Breasts normal to inspection with no deformity, no breast tenderness or masses.(Breast exam.) GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all 4 quadrants. GU: EXTERNAL/VAGINAL: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.(Thin prep Pap smear collection.) CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.(Pelvic exam.) ADNEXA/PARAMETRIA: No masses or tenderness noted. LYMPHATICS: No lymphadenopathy in the neck, axillae, or groin. MUSCULOSKELETAL EXAM: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability. EXTREMITIES: BILATERAL LOWER: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone. SKIN: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers. NEUROLOGIC: CNs II-XII grossly intact. PSYCHIATRIC: Mood and affect appropriate. LABS/RADIOLOGY/TESTS: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, PAP smear. ASSESSMENT/PLAN: UNSPECIFIED ACQUIRED HYPOTHYROIDISM What are the CPT® and ICD-10-CM codes reported?

99395 Z00.00 Z01.419 E03.9

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

99397

A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?

99475 Response Feedback: Rationale: This visit meets the criteria for Inpatient Neonatal and Pediatric Critical Care. Codes 99471 - 99476 are used to report the direction of the inpatient care of a critically ill infant or young child from 29 days through less than 6 years. Codes are further divided by initial and subsequent care. This is the initial care of a critically ill 3 year-old. Services provided in the ER by the admitting provider may not be coded. When a neonate, infant or child requires initial critical care services on the same day the patient has already received hospital care or intensive care services by the same provider, only the initial critical care service code (99468, 99471, 99475) is reported. Code 99475 is the correct code for this service.

99393, 99213-25

99214, K37, R12

A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

99475

99242

99212

A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.

92950, 99291-25, 36556, 31500

A 5 year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported?

99235

The acute tonsillitis is reported first; the chronic tonsillitis is reported second.

A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?

99367

Established patient office visit

A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?

Associated Signs/Symptoms:

A physician's impressions formulated during the interview lead to questioning about additional sensations or feelings. Generalized symptoms, such as chills and fever, headaches, weakness, exhaustion are often relevant.

99382

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

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

99213

An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the provider reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and follow up X-ray. What CPT® code is reported?

20610-50

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

99291-25, 31500, 36510, 94610

Where are clinical examples for evaluation and management codes found in CPT®?

Appendix C Response Feedback: Rationale: Appendix C of CPT® contains clinical examples of evaluation and management codes. The appendix may be used in addition to the E/M code descriptors.

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

As though it was a simple closure Response Feedback: Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one-layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material is coded using the appropriate E/M code.

Established patient CHIEF COMPLAINT: Fever. PRESENT ILLNESS: The patient is a 2 year 3 month-old female with less than 1 day of a high fever with decreased appetite. There has been no vomiting or diarrhea. Parents are unaware of any cough. Tylenol has been given which reduced the fever. PAST MEDICAL HISTORY: Otherwise negative. CURRENT MEDICATIONS; Tylenol® 160 mg q.4 h. per infant Tylenol® drops. ALLERGIES; NONE. IMMUNIZATIONS: Up to date. REVIEW OF SYSTEMS: As per HPI. Rest of review of systems reviewed and negative. PERSONAL, FAMILY, SOCIAL HISTORY: The patient is not exposed to secondhand cigarette smoke. What is the level of history?

Comprehensive

Physical Exam: GENERAL APPEARANCE: Healthy appearing individual in no distress ABDOMEN: Soft, non-tender, without masses. No CVA tenderness FEMALE EXAM: VULVA/LABIA MAJORA: No erythema, ulcerations, swelling, or lesions seen. BARTHOLIN GLANDS: No cysts, abscesses, induration, discharge, masses, or inflammation noted. SKENE'S: No cysts, abscesses, induration, discharge, masses, or inflammation noted. CLITORIS/LABIA MINORA: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable. URETHRAL MEATUS: Meatus appears normal in size and location. No masses, lesions or prolapse. URETHRA: No masses, tenderness or scarring. BLADDER: Without fullness, masses or tenderness. VAGINA: Mucosa clear without lesions, Pelvic support normal. No discharge. CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal. ADNEXA/PARAMETRIA: No masses or tenderness noted. Based on the 1995 documentation guidelines, what is the level of exam?

Comprehensive

Physical Exam: CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90% GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is supple and the trachea is midline. Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft and nondistended. There is no tenderness, rebound or guarding noted. There are no masses. No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic. NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla. MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or edema to the digits. What is the level of exam?

Comprehensive Response Feedback: Rationale: Organ Systems: Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Integumentary, Neurologic, Lymphatic, Musculoskeletal. Ten organ systems were examined. The level of exam is Comprehensive.

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

Detailed Response Feedback: Rationale: Organ Systems: Constitutional, Skin, Respiratory, Cardiovascular, Gastrointestinal, and Musculoskeletal. There are six organ systems examined with detailed documentation. The level of exam is Detailed.

According to CPT® guidelines what is the first step in selecting an evaluation and management code?

Determine the category or subcategory Response Feedback: Rationale: According to the CPT® guidelines the first step to determining a level of evaluation and management visit is to determine the category or subcategory of service.

99232

Dr. Jones documents Mrs. Smith's condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and a low medical decision making. What CPT® code should be reported?

TIP: Chronic Conditions

Elements of HPI are easily defined when the patient presents with a new or acute problem. Here are some tips for documenting an extended HPI for a chronic condition: Chief Complaint HPI (History of Present Illness) ROS (Review of Systems) PFSH (Past Medical, Family & Social History) History Component GIVE STATUS (Quality) Is the condition improving/worsening/stable? Have they experienced an exacerbation of the condition since you last saw the patient? When were they diagnosed or how long has the patient had the condition? (Duration) How is the condition being managed? Medications? Diet? Exercise? Has the patient undergone surgery to help manage or correct the condition?(Modifying Factors) Give some idea of the severity—is the patient homebound or disabled, does it affect activities of daily living? Pain 1-10? If condition can be measured with lab (ex cholesterol)- give those results.

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

Emergency Department Services

Timing:

Establishing the onset for each symptom or problem and a rough chronology of the development of the problem are also important. Is the pain continuous or nocturnal?

E/M services are further categorized based on the setting in which the service is provided. What are they??

Examples of settings include: Office or other outpatient setting Inpatient Hospital Emergency department (ED) Nursing facility (NF) Outpatient Hospital

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

Expanded problem focused

HISTORY OF PRESENT ILLNESS A 73-year-old man who is a veterinarian is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple, both in January 20XX. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is and thinks it may be another skin cancer. He is also concerned about another lesion that has been present for a while, just lateral to his right eye. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past. REVIEW OF SYSTEMS: Otherwise well, no other skin complaints. PAST MEDICAL HISTORY Coronary artery disease status post bypass surgery, history of squamous and basal cell carcinomas as noted above, hay fever, and hyperlipidemia. He has had lipomas removed. MEDICATIONS: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec®, 5% saline in eyes. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of skin cancer or other skin problems. SOCIAL HISTORY: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married. What is the level of history?

Expanded problem focused

Emergency Department Services

A 77 year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported?

G0102 Response Feedback: Rationale: CMS has very specific guidelines on eligibility and coding of preventive services. There is no specific CPT® code for a digital rectal exam. Code 45990 is a diagnostic exam that includes a diagnostic anoscopy and rigid proctoscopy. Neither service is documented nor is it stated that the patient received an annual exam. The service provided is best represented by HCPCS code G0102. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html)

HPI (History of Present Illness) Elements?

HPI (History of Present Illness) 7. Location Quality Severity Duration Timing Context Modifying Factors Associated Signs/Symptoms.

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

High Response Feedback: Rationale: New problem to examiner, additional workup - dialysis (four points); Labs, EKG, and X-ray reviewed (three points); risk is High (chronic illness posing a threat to life). The medical decision making is High.

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

High Response Feedback: Rationale: Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.

Components used in selecting a level of E/M service.

History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time

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

I20.1

Quality

If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)?

Office Visit: Here for six month check up HPI: Follow up evaluation of DM and hypertension... She is under a lot of stress. No other new problems or complaints. A/P: DM, essential hypertension Plan is to continue the same. Return to office in 6 months for follow up. What is the level of medical decision making?

Low

Established patient CHIEF COMPLAINT: Gallstones and reflux. HISTORY OF PRESENT ILLNESS: This is a 61 year-old woman who comes back to see me today with a 2-year history of severe gallbladder attacks. Also of note, she has had ongoing reflux problems for many years. Within the last few months, her reflux has worsened. ASSESSMENT/PLAN: This is a 61 year-old woman with likely symptomatic cholelithiasis and reflux. Her number one concern right now is the gallbladder attacks. This sounds like symptomatic cholelithiasis. As a result, we recommended for her to have laparoscopic cholecystectomy with intraoperative cholangiogram. The risks and benefits were explained to the patient who understood and agrees for us to proceed. With regards to her reflux, it is partially controlled by her medication. She also is overweight and might have symptom improvement after weight loss. She is also very hesitant to proceed with the Nissan fundoplication because her husband had the surgery done before and had some problems with vomiting afterwards. She does have objective evidence of reflux as well and is a good candidate for surgery. However, we will let her decide whether she wants to proceed with surgery or not. What is the level of medical decision making?

Moderate

99213, 99354

99288, 99291, 92950

Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. Defibrillation is performed with 250 joules to a NSR. What are the appropriate procedure codes for this encounter?

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

New patient office visit Response Feedback: Rationale: The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient since the cardiologist accepted the patient and is taking over the care of a specific problem.

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

Non-billable Response Feedback: Rationale: The follow-up visit from the neurosurgeon the day following surgery is bundled in the surgical procedure and is not billable. The visit is within the global period of the procedure.

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

Outpatient consultation

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

Preventive medicine, established patient Response Feedback: Rationale: The mother "takes her 2-year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.

The patient presents to the clinic today for a follow-up of his hospitalization for pneumonia. He was placed back on Singulair® and has been improving with his breathing since then. He has no complaints today. What is the level of history?

Problem focused CC: Follow-up of hospitalization for pneumonia. HPI: Modifying Factor: He was placed back on Singulair® and has been improving with his breathing since then. ROS: None PFSH: None

If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)?

Quality

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

R11.2

What ICD-10-CM code is reported for vertigo?

R42

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

Subsequent Hospital Care Response Feedback: Rationale: Codes from the Subsequent Hospital Care subcategory would be used for days two, three and four. The code for the first day would be from the Initial Hospital Care subcategory. Day five could be reported with either subsequent hospital care or hospital care discharge depending on the role of the provider.

Context:

The physician may obtain a description of where the patient is and what the patient does when signs or symptoms begin. Does the symptom occur with activity? Is the symptom aggravated or relieved?

Duration:

The physician should determine how long the patient has had the problem. (24 hours, 1 day, 2 weeks, 3 months?)

Quality:

The physician should encourage the patient to describe the quality of the symptoms, since some diseases or conditions produce specific patterns of complaints. For example, pain may be described as sharp, dull, throbbing, stabbing, acute or chronic, stable, improving or worsening.

Severity:

The physician should get some idea about the severity of the discomfort or sensation or pain. The patient may describe the severity of the pain by employing a crude self-assessment scale to measure subjective levels (e.g. 1-10) with one being no pain and 10 the worst pain experience. The pain may also be estimated through nonverbal signals of discomfort, such as the patient lying perfectly still or continuously pacing the floor.

Location:

The physician should have an understanding as to the location of the problem. For example, if a patient complains of pain, a physician should ask if the pain is diffuse or localized, unilateral or bilateral? Does it radiate or is it referred to another location? The physician may also ask the patient to point to the specific area.

99231

The physician was called to the hospital floor for the medical management of a 56 year-old patient admitted one day ago with aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported?

99222

The provider admitted an 18 month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. A comprehensive history, comprehensive exam and moderate decision making is documented. If cultures are negative and the patient remains afebrile for 48 hours, the infant will be discharged home. What CPT® code is reported for this visit?

I20.1

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

Modifying Factors:

What has the patient attempted to do for relief? Have over-the-counter medications been attempted? What were the results?

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

Location, quality and duration

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

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