CHAPTER 12

ASSESSMENT/PLAN1. SOB and Dizziness: Related to patient's bilateral Pulmonary Embolisms; continue on Lovenox, patient has some drainage around PEG tube site, I will discuss with oncology regarding xarelto,2. High troponin: I think probably related with PE, check Echo and now WMA, no further work up at this time3. Leakage around Peg Tube: consult Dr. X he had placed PEG4. Anemia5. Consult PT/OT What diagnosis codes are reported? A I26.99, K94.23 b. I26.99, R06.02, R42 c. R06.02, R42 d. I26.99, Z93.1

A I26.99, K94.23

A patient is diagnosed with diabetic retinopathy.

E11.319

A patient is treated for pure hypercholesterolemia and hypertension.

E78.00 I10

Patient is seen in his physician's office and diagnosed with benign hypertension and stage 3 chronic kidney disease. 2 ANSWERS

I12.9 N18.30

Patient is seen in his physician's office and diagnosed with benign hypertension and stage 3 chronic kidney disease. 2 DX

I12.9 N18.30

Patient is diagnosed with acute systolic heart failure due to hypertension with CKD stage 4. 3 DX

I13.0 I50.21 N18.4

03/01/20XX Room X XYZ Hospital System DISCHARGE DIAGNOSES: Exertional angina. Hypertension. Hyperlipidemia. HISTORY OF PRESENT ILLNESS: This 70 year-old woman presented for a chief complaint of exertional chest discomfort.(Chief Complaint exertional chest discomfort for main reason for visit.) In the emergency room because of her history, it was felt that she had exertional angina and she was admitted for rule out of Myocardial Infarction (MI) (Cannot code rule out diagnosis.) and further testing. PAST MEDICAL HISTORY: 1. Hypertension - well controlled on Metoprolol.2. Hyperlipidemia - well controlled with Altoprev. CURRENT MEDICATIONS: At the time of admission include: Metoprolol 50 mg (Metoprolol is a beta blocker that affects the heart and circulation. Used to treat angina and hypertension. Also used to treat or prevent heart attack.) twice a day, Altoprev 40 mg (Altoprev (Lovastatin) reduces levels of bad cholest

I21.4 E78.5 I10 J84.10 Z79.899

A patient presents for treatment of left ventricular failure.

I50.1

Office Visit Progress Notes 01/15/20XX 10:15 am History: The patient is a 66-year-old female here for follow-up of her multiple issues. She recently had a urinary tract infection (UTI) with hematuria. She is on antibiotics (Because the patient is still on antibiotics, the UTI is still considered current.) and her INR was super-therapeutic. Today her INR is 2.7 she denies any further bleeding. She has one more day of antibiotics. She also has renal insufficiency. Her other issues include diabetes mellitus type 2. On low-dose glyburide with no symptoms of hypoglycemia and no change in vision or neuropathies continued Pravachol 20 mg daily without myalgia's or nausea Major Problem List: DIABETES MELLITUS TYPE 2 HYPERTENSION RENAL INSUFFICIENCY associated with DM Review of Systems (ROS): Negative except as noted. Current Medications: Rx: PRAVACHOL 20MG (Pravachol reduces levels of bad cholesterol and triglycerides in t

I82.419 E11.9 E78.5E N28.9 I10 Z79.01 Z68.43 E66.01 N39.0 Z79.84 Z88.8 Z91.041

A patient presents for management of chronic DVT of the lower extremities. 1 ANSWER

I82.503

1. Transient aphasia. 2. History of deep venous thrombosis of upper extremity. 3. Poor compliance. 4. The patient is supposed to be on Coumadin, not on it, which led to underdosing (Because patient did not take the coumadin prescribed, underdosing or poor compliance resulted). Instead she has been on an Aspirin regimen (Current use of Aspirin). 5. ESRD, on dialysis (The patient has ESRD and is on dialysis making this a current diagnosis). 6. COPD (Patient has a co-morbidity of COPD). COURSE OF STAY: The patient was admitted with the diagnoses above. I have seen the patient in the past and resumed her Coumadin (Resumed coumadin for known DVT in upper extremity). She has a known deep venous thrombosis in an upper extremity (DVT in the upper extremity). The patient has been told she must take her Coumadin, but she has not taken it (Patient intentionally not taking Coumadin). She was admitted and she was not anti-coagula

I82.629 R47.01 T45.516A J98.11 J44.9 Z91.128 N18.6 Z99.2

A patient presents for acute, recurrent sinusitis. 1 ANSWER

J01.91

CC: Cough times three weeks with head cold. RM patient is coughing up stuff. HPI: Interval History: Patient presents today for Upper Respiratory Infection (URI) symptoms. Has had nasal congestion, productive cough, and sore throat for three weeks. Productive cough, thick green phlegm. Thick green nasal drainage. Sore throat which is worse at night. Dyspnea during exertion. Cough is worse at night. Mild headache at times but mainly sore throat. Denies nausea, vomiting, diarrhea, constipation. Afebrile. He had tried Tylenol Cold, plain Tylenol, nasal spray, and Nettie pot which have been somewhat helpful. ROS: HEALTH SCREEN: Nutrition: Negative for unintentional weight change, trouble chewing, trouble swallowing, trouble talking, non-healing wounds. Function: Negative for change in activity level, need for assistance in performing self-care. Abuse: Negative for concerns about personal safety, concerns about safety of o

J40 E11.9 Z79.4 Z79.84 I10 E78.5 Z87.891

Visit Date: 02/01/20XX Provider: X, DPM Reason for Visit FUNGAL NAILS BILATERALLY.(Primary reason for visit is fungal nails bilaterally.) CONCERNED FOR INGROWN NAIL LEFT HALLUX. BMI Recorded as: Not collected today Pain scale O Smoking Status Unknown If Ever Smoked; Tobacco Cessation Info Given? No Medication list, last Reconciled on xx/xx/xxxx x:xx pm by X, MD Clopidogrel Bisulfate (Plavix) 75 Mg (The patient is on Plavix which is an anti-platelet medication.) Tablet, po 1 tab daily, #30 TAB, Metformin Hcl 850 Mg (Metformin HCL is an oral diabetes medication that helps control blood sugar levels.) Tablet, po 1 tab BID, #60 TAB Ref 5 bid Levothyroxine 75mg (Levothyroxine replaces a hormone normally produced by the thyroid gland to regulate the body's energy and metabolism.) for thyroid disease Noted Allergies: Tylenol (Verified Allergy, Unknown) Statins-Hmg-Coa Reductase Inhibitor (Verified Allergy, Unknown) Medica

L60.0 B35.1 E11.42 E07.9 Z79.890 Z79.02 Z79.84 Z88.6 Z88.8

A patient came in for debridement of a stage 3 pressure ulcer of the left heel. 1 ANSWER

L89.623

Reason for Visit Referred here by X, NP at Dallas CO. Clinic for left foot deformity. Toes on Left foot turn inward. Patient is unsure how long the foot has been this way. Does not wear inserts. Denies pain. Small heel spur and 5TH Metatarsal fracture at base on X-ray done at Dallas CO. on xx/xx/20xx. He has put in a walking boot times three weeks, but never went back for follow up. The patient also has diabetes and hypertension. Both are well-controlled with medication managed by X, NP. BMI Recorded as: Not Collected today Pain scale: O Medication List Last Reconciled today. Metformin Hcl 850 Mg (Metformin HCL is a oral diabetes medication that helps control blood sugar levels.) Tablet 850 Mg po 1 tab bid, #60 Tab Ref 5 Prov: xxxxxx FNP, BC xx/xx/20xx Lisinopril 40 Mg (Lisinopril is an ACE inhibitor used to treat high blood pressure and CHF.) Tablet 40 Mg po 1 tab daily, #30 tab Ref 5 Prov: xxxx FNP, BC xx/xx/20xx C

M20.32 E11.9 I10 Z79.84 Z79.02

NEW PATIENT VISIT PATIENT: EE DATE: 03/21/20XX HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old woman referred to this office by her primary care physician, Dr. S. The patient had right hip replacement and did well. The patient states that since the hip replacement, she has had muscle pain in the thigh, hips, her low back, and she is having difficulty standing up. The patient states that in the past, she was told that her leg is short 1.5 inches. The patient states that the orthopedist said he would try to lengthen it. The patient has pain standing, walking, and stairs cause shooting electric pain. The patient states that if she is perfectly still, she has no pain, but the pain can get as severe as 7- 8/10. The patient has seen physical therapy, her family physician, and her surgeon. The patient had checkup after her surgery and had injections in both of her knees, which was somewhat helpful. PAST SURGICAL HI

M21.70 M40.204 M47.814 Z96.641 E03.9 I10 Z79.890 Z85.828

Reason for Visit: Here for three month re-check. Left knee pain. Problems with pain in joint involving lower leg and unspecified essential hypertension. Active Allergies: NKDA Active Medications reconciled today. Vitamin D 200mg 1 tablet, 0 refills xx/xx/20xx. Hydrochlorothiazide-lisinopril 12.5 mg·10 mg tablet 1/2 tablet po every day, 0 refills xx/xx/20xx. Nystatin topical 100000 units/g cream top bid; 1 refill xx/xx/20xx. Aspirin 325 mg tablet po every day (long-term). Review of Systems: General Constitution: Patient Denies Mood change, Fatigue, Weakness; Morbid Obesity. HEENT: Patient Denies Sinus problems. Cardiovascular: Patient Denies Chest pain, Chest pressure/discomfort, Lightheadedness, Palpitations, Leg cramps, Swelling. Respiratory: Patient Denies Chest congestion. Gastrointestinal: Patient Denies Abdominal pain, Nausea, Vomiting, Heartburn, Change in bowel habits, Blood in the stool. Genitourinary: Pati

M25.561 M25.562 I10 Z68.42 E66.01 Z79.82 N64.4

A patient with age related osteoporosis suffered a L1, L2 vertebral fracture is receiving debridement of the fracture. 1 DX

M80.08XA

A patient presents for surgical creation of an AV fistula for end stage renal disease that is currently on renal dialysis. 2 ANSWERS

N18.6 Z99.2

HISTORY AND PHYSICAL EXAMINATION DATE OF ADMISSION: 04/01/20XX CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: This 71-year-old white male was in his usual state of relatively good health He had been very busy over the last week baling and farming, but felt like he was doing well and had not done much over the weekend. He felt fine and went out on the morning of admission, was walking around the farm, when he had the feeling that he was going to pass out and not really a tunneling of vision, but just the sensation that he was going to pass out. He turned around and yelled at his brother and then fell to the ground. There is no seizure activity described. He eventually was helped up after probably less than one to two minutes onto a golf cart type vehicle. Emergency Medical Services (EMS) was called and brought to the Emergency Room. He did have a similar spell approximately five years ago, which resulted in a f

R55 I12.9 Z86.73 I82.5Z1 E78.5 N18.9 K21.9 M17.0 Z79.02 Z88.6

PATIENT NAME: JH MEDICAL RECORD NUMBER: 242424 ACCOUNT NUMBER: 345666 DATE OF BIRTH: 08/04/XXXX LOCATION: XXXX DATE OF ADMISSION: 03/02/20XX DATE OF CONSULTATION: 03/02/20XX REQUESTING PHYSICIAN: X, MD CONSULTING PHYSICIAN: M, DO CHIEF COMPLAINT: She was admitted after having a fall and has a subcapital fracture of the right hip. HISTORY OF CHIEF COMPLAINT: The patient is a 68 year-old white female in excellent health. She has a history of hypertension and sarcoid. She came into the ER. She was found to have a displaced subcapital hip fracture, and is now admitted for a right hemiarthroplasty. PAST MEDICAL HISTORY: She has a history of spinal stenosis, back pain, and hypertension. There is no previous history of coronary disease or diabetes. She has some dyslipidemia and COPD. Her sarcoid is presented by hilar adenopathy with no other sequelae. PAST SURGICAL HISTORY: She had a lumpectomy of the breast for DCIS 12 yea

S72.011A W19.XXXA I10 I44.7 J44.9 D86.1 E78.5 Z79.899 Z88.0

A patient is seen for follow up for Coumadin management. The provider orders an INR. The patient is taking Coumadin for atrial fibrillation. 3 ANSWERS

Z51.81 I48.91 Z79.01

A patient is seen for follow up for Coumadin management. The provider orders an INR. The patient is taking Coumadin for atrial fibrillation. 3 DX

Z51.81 I48.91 Z79.01

A patient presents for a follow up after an admission one week ago for a CVA. The patient does not seem to have any residual effects of the stroke. 1 ANSWER

Z86.73

A patient presents for a follow up after an admission one week ago for a CVA. The patient does not seem to have any residual effects of the stroke. 1 DX

Z86.73

FOLLOWUP VISITHISTORY OF PRESENT ILLNESSThe patient is a 61 year-old male with a previous cerebrovascular accident. He walks with a cane. He persists in smoking cigarettes. He was hospitalized three months ago and had an endoscopy. There were no significant findings.Currently he is on hydrochlorothiazide, isosorbide, simvastatin and Lisinopril.He has a history of hypertension, hyperlipidemia, and peripheral vascular disease. No chest pain, orthopnea or nocturnal dyspnea.PHYSICAL EXAMINATIONVITAL SIGNS: Today in the office his pulse is 90 and regular. Blood pressure today is 118/76. He weighs 118 pounds. Respirations are 20.NECK: Carotids have a good upstroke. No bruits, no jugulovenous distention. The thyroid is not enlarged.LUNGS: Clear bilaterallyCARDIOVASCULAR: Normal S1 , Normal S2. Soft systolic murmur at the lower left sternal border.ABDOMEN: Abdomen is soft and nontender. No hepatosplenomegaly. No bruits.EXTRE

a. I10, E78.5, Z86.73, I73.9, R01.1, F17.210

Assessment:1. Wheezing and cough x 1 week. Specimen sent to lab. Confirmed positive Klebsiella Pneumonia of lungs. Organism verified and antibiotic resistance panel, placed on Levaquin 750 mg every day x 14 days.2. Report to office immediately if signs and symptoms worsen or change noted in sputum such as blood or jelly-like mucus. What diagnosis codes are reported? a. J15.0 b. A49.8 c. J15.0, A49.8 d. J18.9, A48.9

a. J15.0

Discharge DiagnosisDecubitus ulcer of buttock, stage 4Unclear etiology, BCx NGTD, BRI shows gluteal abscesses and orthopedic SGY was considering IR to drain abscesses, but it did not happen Friday. Likely will happen on Monday. Wound is draining anyhow. He will need plastic surgery consult to evaluate early this coming week.Osteomyelitis, acuteMRI shows osteomyelitis on left BKA stump.Back pain due to Spina Bifida What diagnosis codes are reported? a. L89.304, T87.44, M86.162, Q05.9 b. L89.304, M86.10, Q05.9 c. L89.304, M86.159, M54.9 d. L89.304, T87.44, M86.162, Q05.9, Z89.519

a. L89.304, T87.44, M86.162, Q05.9

Reason for Consultation: Abnormal Renal FunctionHISTORY OF PRESENT ILLNESS:The patient is a 67-year-old lady referred through the courtesy of DR. S because of abnormal renal function. The patient has a history of hypertension, asthma, and thyroid cancer. Thyroid was removed and completed chemotherapy with no further evidence of cancer. She was admitted 5 days ago with vomiting and dehydration. The labs on admission revealed a BUN of 31 with a creatinine of 2.0 which has increase up to BUN of 65 with a creatinine of 3.8. This consultation was requested for evaluation of her renal condition.PAST MEDICAL HISTORY:1. Hypertension2. Atherosclerotic heart disease3. Asthma4. Hypothyroidism5. Thyroid Cancer6. Anemia of chronic diseaseIMPRESSION:1. Chronic Kidney disease, stage 3, with superimposed acute renal failure, as well as acute tubular necrosis.2. Hypertension3. Thyroid Carcinoma4. AsthmaRECOMMENDATIONS:1. Strict intak

a. N17.0, I12.9, N18.30, J45.909, E89.0, Z85.850, Z92.21

When submitting records for a RADV audit, will additional current diagnoses that were not originally reported be considered when documentation is submitted for the audit? a. Yes, additional current diagnoses not included on claims data may be approved during the audit. b. Yes, claims are not required to capture risk adjustment factors. c. No, the audit is performed based on the diagnoses originally submitted. d. No, because the RADV audit is prospective only predictive modeling is used.

a. Yes, additional current diagnoses not included on claims data may be approved during the audit.

Outpatient office visit A 50-year-old female for follow up on protein calorie malnutrition. This pleasant lady has had continued problems with lack of appetite and this is likely contributed to her HIV medications. Assessment:1. PCM2. HIV positive What diagnosis codes are reported? a. Z21, E46 b. E46, B20 c. E46 d. B20, E46, R63.0

a. Z21, E46

What is the purpose of the risk adjustment values? a. Budget for the care of the patient for the following year. b. Review the claims for up-coding or over-coding. c. Statistics of the diagnoses of patients. d. Target providers with inappropriate coding patterns.

a. Budget for the care of the patient for the following year.

What is the guideline for coding "probable," "suspected," "possible," or "questionable" in the inpatient setting? a. Code the condition as if it was established b. Query the provider before coding c. Code the sign and symptoms d. Code with the sign and symptom and the condition

a. Code the condition as if it was established

Predictive modeling can use many data elements. Which are beneficial for identifying a person with diabetes? I. Rx claims II. Medical claims III. DME claims a. I, II and III b. II and III only c. I only d. I and II only

a. I, II and III

Which of the following data elements are used in predictive modeling? I. DME claims II. Prescription drug events III. Physician claims data IV. Facility claims data a. I, II, III, and IV b. I, II, and III c. I, II, and IV d. III and IV

a. I, II, III, and IV

What is the purpose of the RADV audit? a. Verify accuracy of the diagnosis submitted for payment. b. Verify provider's signature/attestation. c. Verify accuracy of the CPT® codes submitted for payment. d. Verify the provider's use of quality measures.

a. Verify accuracy of the diagnosis submitted for payment.

Using the ICD-10 HCC and RxHCC Mapping document included in the course materials, determine which of the documented conditions have a risk adjustment factor assigned under CMS-HCC V24 and RxHCC V08 for the following scenario. A patient with type 2 DM and HTN presents with acute abdominal pain, nausea, and vomiting. The patient is diagnosed with acute appendicitis requiring surgery. The diagnosis codes reported for this encounter include K35.80, E11.9, and I10. a. All conditions have an HCC and RxHCC assigned. b. E11.9 has an assigned CMS-HCC and both codes have an assigned RxHCC. c. None of the conditions are assigned a CMS-HCC or RxHCC. d. Only E11.9 has an assigned CMS-HCC and RxHCC.

b. E11.9 has an assigned CMS-HCC and both codes have an assigned RxHCC.

HPI Comments: This is an 86-year-old AAF with the following known medical problems: Alzheimer's, HTN, and DM presenting via EMS from their nursing home for PEG tube replacement. Peg has been replaced three times in past three days because patient repeatedly removes it at nursing home in their increased combative state. What diagnosis codes are reported? a. G30.9, I10, E11.9, Z93.1 b. G30.9, F02.811, I10, E11.9, Z43.1 c. I10, E11.9, Z43.1 d. G30.9, F02.80, I10, E11.9, Z43.1

b. G30.9, F02.811, I10, E11.9, Z43.1

HPI: 56-year-old female who is well known to my practice. Ms. F is widowed for 9 years now and lives with her daughter. The patient was found to be unable to live on her own after leaving a fire burning on her stove all day on one occasion and on another occasion she drove three hours away to the grocery store and stopped to get gas and forgot where she was, where she came from and could not get herself home. Her dementia with Alzheimer's has progressed severely over the last year and she must now also attend an adult daycare as she cannot be left alone. The daughter is considering nursing home options and the patient is sometimes aware of this and other times forgetful of the situation, as she sometimes believes her daughter is her sister in her confused states.A: 1. Severe Alzheimer's dementia, 2. HTN-stable 3. Hyperlipidemia-stablePlan: Maintain meds as prescribed, refills given on all today and she is to retu

b. G30.9, F02.C0, I10, E78.5

HPI: 57-year-old male with history of HTN and Epilepsy. Here for follow up to check labs for meds. He is on Dilantin and Atacand.Exam well within normalAssessment:1. HTN, continue meds2. Epilepsy, check Dilantin levels. Refill med What diagnosis codes are reported? a. G40.909, Z86.79 b. G40.909, I10 c. I10 d. G40.909

b. G40.909, I10

ASSESSMENT 1. Coronary Artery Disease: status post CABG2. Benign essential hypertension: Blood pressure would normally be adequately controlled on his current regimen except that we are finding a mildly enlarged aortic root on his most recent echo (4.2 cm). Will add an evening dose of 25 mg. Metoprolol in an effort to keep his systolic pressures between 110 and 120.3. Aneurysm of the thoracic aorta: Mildly enlarged aortic root. Repeat echo evaluation will be done on an annual basis along with aggressive blood pressure management. His beta blocker will be increased. Currently asymptomatic4. Hyperlipidemia: He has reached his target LDL reduction below 70 with his current therapy. What diagnosis codes are reported? a. I25.10, I10 b. I25.10, I10, I71.20, E78.5, Z95.1 c. I10, I71.20, E78.00, Z95.1 d. I25.10, I10, I71.60

b. I25.10, I10, I71.20, E78.5, Z95.1

What does the acronym MEAT stand for? a. Monitor, Engage, Activate, Therapy b. Monitor, Evaluate, Assess, Treat c. Manage, Engage, Add, Therapy d. Main, Encounter, Arrive, Treatment

b. Monitor, Evaluate, Assess, Treat

Oncology CenterDiagnosis: MS. F is a 68-year-old female with a diagnosis of recurrent, poorly differentiated, papillary carcinoma of the thyroid gland, initial stage unclear. The patient completed 3,000 cGy in 10 treatments five months ago with significant improvement, due to the patient's condition and performance status, split-course radiotherapy was offered. The patient will continue to be treated with chemotherapy.PHYSICAL EXAMINATION: Reveals an eight pound weight loss in the past two months. HEENT is unremarkable. Examination of the neck revealed the neck mass to have significantly decreased in size. However, it is hard and fixed. Her lungs are clear to auscultation. Cardiac exam reveals a regular rate and rhythm. Cranial nerves II-XII are grossly intact. The patient's Karnofsky performance status is approximately 70.Assessment: The patient developed lung metastasis. I do not think that radiotherapy would b

c. C73, C78.00

Assessment and Plan:Cirrhosis, this is secondary to chronic HCV. She has stable but depressed liver function. An attempt to treat this with peginterferon and ribavirin was unsuccessful in the past. She had only two doses of peginterferon and had to stop because of side effects. We need to consider treating with oral anti-HCV meds.Hx of Acute blood loss anemiaHepatic Encephalopathy. Under control on lactulose. Serum ammonia has increased some after TIPS but she is not confused. What diagnosis codes are reported? a. K70.30, B18.2 b. K74.60, B18.2, D62, K76.82 c. K74.60, B18.2, K76.82 d. K70.30, K75.9

c. K74.60, B18.2, K76.82

Using the ICD-10 HCC and RxHCC Mappings document included in the course materials, determine which of the documented conditions have a risk adjustment factor assigned under CMS-HCC V28 for the following scenario.A patient presents with an acute exacerbation of COPD. She is complaining of burning when she urinates. While at the office a urine sample is obtained. The patient has a UTI. The diagnosis codes reported for this encounter include J44.1 and N39.0. a. Neither condition is assigned an CMS-HCC. b. Both conditions have a CMS-HCC assigned. c. Only J44.1 has an assigned CMS-HCC. d. Only N39.0 has an assigned CMS-HCC.

c. Only J44.1 has an assigned CMS-HCC.

Which statement is TRUE regarding the CMS Stars quality rating system? a. Quality bonus payments are made to Medicare Advantage plans who score at least five stars. b. Quality bonus payments are made to physician who score at least five stars. c. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. d. Quality bonus payments are made to physician who score at least four stars.

c. Quality bonus payments are made to Medicare Advantage plans who score at least four stars.

For commercial plans, funding is allocated based on which of the following? a. Audited diagnosis codes b. Previous year's known diagnoses c. Projected diagnosis codes d. Current year's known diagnoses

d. Current year's known diagnoses

A patient is diagnosed with severe malnutrition. What ICD-10-CM code is reported? a. E44.0 b. E42 c. E40 d. E43

d. E43

Assessment Depression: Onset weeks ago she is experiencing irritable mood and fatigue and loss of energy Chronic problems addressed today: 1. Diabetes with neuro Manifestation Type II Controlled 2. Diabetic polyneuropathy 3. Heartburn Chronic What diagnosis codes are reported? a. E11.49, K21.9 b. F32.A, E11.49, E11.42, R12 c. F32.9, E11.9, G60.9, K21.9 d. F32.A, E11.42, R12

d. F32.A, E11.42, R12

SUBJECTIVE:An 86-year-old male here in the office in follow up. Having trouble with neuropathic symptoms, numbness, tingling, burning in his feet. He tried Nortriptyline. It did not seem to help much at all. Still on simvastatin 20 for hyperlipidemia, aspirin for his history of old MI, and albuterol for COPD. Patient having no coughing, or shortness of breath right now continue with Symbicort. No chest pain or palpitations. No back pain.OBJECTIVE:He is afebrile. Blood Pressure is 128/74. LUNGS: Clear. CARDIAC EXAM: Regular rate and rhythm.ASSESSMENT AND PLAN:1. Peripheral neuropathy. Nonresponsive to Nortriptyline. Try Lyrica 50 mg. If causes dizziness advised him to stop. The only other option would be to try Cymbalta or Neurontin.2. Hyperlipidemia. Continue Simvastatin.3. Gastroesophageal Reflux disease. Continue Rantidine.4. Healthcare maintenance. Flu shot given. Follow up two weeks. What diagnosis codes are repo

d. G62.9, E78.5, K21.9, I25.2, J44.9, Z79.82

TODAYS PROBLEMS:S - Patient had a Flu shot in NovemberPatient is here for breast examPatient here for follow-up of HTN and high cholesterolO - Pleasant female in NAD. Repeat BP 120/80Neck: normal thyroid; no adenopathyLungs: ClearCOR: RRR S1S2 without murmur or gallopABD: soft NT, without HSM or massesEXT: no edemaBreasts: no masses or D/CA/P:1. HTN controlled without Maxzide, may stay off of it and continue Metoprolol alone2. High cholesterol, check lipids and AST on lovastatin3. Normal breast exam, mammogram due in June4. Osteoporosis, on FosamaxFollow-up in six months What diagnosis codes are reported? a. I10, E78.5 b. I10, E78.00 c. I10, E78.5, M81.0 d. I10, E78.00, M81.0

d. I10, E78.00, M81.0

DISCHARGE DIAGNOSES1. Exertional angina2. Hypertension3. HyperlipidemiaHISTORY OF PRESENT ILLNESS:This 70-year-old woman presented to the emergency room for a chief complaint of exertional chest discomfort. In the emergency room because of her history, it was felt that she had exertional angina and she was admitted for rule out of MI and further testing.PAST MEDICAL HISTORY:Significant for:1. Hypertension.2. Hyperlipidemia.HOSPITAL COURSE: Initial impression was the patient had chest pain with several cardiac risk factors. The patient was placed on telemetry and serial determination of cardiac enzymes were performed. Cardiac enzymes remained in the normal range. EKG significant only for sinus bradycardia.DISCHARGE MEDICATIONS: Continue Metoprolol 50 mg twice a day, Altoprev 40 mg daily, aspirin 81 mg daily. Start Imdur 30 mg daily, Nitrostat 0.4 mg sublingually p.r.n. chest pain. EKG significant only for sinus bradyc

d. I20.8, R00.1, I10, E78.5, Z79.82

Office Visit Ms. X is almost 81 years old. She comes into the office for a four-month follow-up. History of hypertrophic obstructive cardiomyopathy, congestive heart failure, and paroxysmal atrial fibrillation. At present she is doing extremely well. She offers no complaints of PND, orthopnea, or shortness of breath. She is back to working in her yard. She denies any lightheadedness, dizziness, syncope or swelling of the legs.Physical Examination: On examination she weighs 132 pounds. Her blood pressure is 136/80, heart rate is 68 and regular. No jugular venous distention. Carotids without any bruit. Lungs are clear on auscultation. Heart sounds are regular with a grade 2/6 systolic ejection murmur. Abdomen is soft. No hepatic enlargement. Aorta is normal. Femoral pulses normal. No ascites. No peripheral edema.Impression:1. Hypertrophic obstructive cardiomyopathy.2. Paroxysmal atrial fibrillation-continue Eliquis.3.

d. I42.1, I48.0, I50.9, Z79.01

When are cancer diagnoses coded as current? a. Once a patient is diagnosed with cancer they are always coded as active. b. Patient is documented in remission. c. Patient was diagnosed within the last five years with cancer. d. Patient is receiving active treatment.

d. Patient is receiving active treatment.

Which one of the following is NOT allowable for coding in the outpatient setting? a. ICD code instead of a written description b. Consistent with c. Use of the up and down arrows d. All options are not appropriate

d. All options are not appropriate

History of Present Illness The patient is here for further evaluation of his back and abdominal pain. He was brought to the hospital two days ago and developed back pain. It looked like he had a compression fracture. He was brought back now because of his abdominal pain. CT of the Abdomen and Pelvis was done without contrast. It showed that he had a T11 compression fracture. Besides that, he has no obvious reasons for his abdominal pain, and this seems to be a separate issue. He has no new bladder or bowel dysfunction, history of fever, chills or nausea and vomiting.Assessment1. T11 compression fracture.2. Abdominal pain.Plan: At this time, I would probably brace him at his age. For his abdominal pain, I would go forward with a bowel regimen. If the bracing does not help, a Kyphoplasty could be done in the future, but at age 93, with a 2 to 3-day history of back pain, I am not sure that Kyphoplasty is yet warranted.

d.M48.54XA, R10.9