A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 7.docx

A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 7: ADVANCED OUTPATIENT HOSPITAL CODING Directions: Code the following cases for outpatient facility purposes using ICD-10-CM, and CPT codes. Sequence codes in the correct order. Calculate the APC. Assign modifiers when appropriate. Use external cause codes when appropriate. Do NOT code procedures that are captured by the facility chargemaster. 1. EMERGENCY DEPARTMENT VISIT PATIENT: MAX OFFICE RECORD NUMBER: 08-68-23 DATE OF SERVICE: 04-16-XX PHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This 28-year- old male established patient presents to the emergency department because of urticaria since last night. There are two issues that might have occurred. He ate an apple last night that seemed to be imperfectly ripe. It might not have been washed. The second is he has had a cat for the past couple of days that seems to want to sleep on his bed and be near him that used to always be inside but now it goes outside and plays and rubs in the bushes, then comes back inside. The patient denies allergies, or taking any current medications. Patient denies any previous illnesses. OBJECTIVE: Physical examination reveals urticaria present over patchy surface areas of his body. The lungs are clear to auscultation. Cardiac exam is normal. lMPRESSlON: Allergic urticaria, probably food induced or cat induced. PLAN: I gave him an injection of Benadryl and epinephrine. We are going to do oral Benadryl 50 mg tid prn and prednisone 40, 30, 20, and 10 mg q. day for 4 days. The patient is instructed to see an allergist for a complete allergy workup. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): L50.0 CPT code(s) with modifier, if applicable: 99281 APC: 609 2. EMERGENCY DEPARTMENT VISIT PATIENT: KIMBERLY OFFICE RECORD NUMBER: 01-68-23 DATE OF SERVICE: 03-15-XX PHYSICIAN: DR. KIM, M.D. SUBJECTIVE: This 51-year-old female established patient presents to the emergency department complaining of sore throat. Patient has been ill now for about 3 days with sore throat, cough and earache. She notes her cough is productive of green sputum. She also complains of some fatigue, some backache and her chest hurts when she coughs; it is waking her at night. The patient takes no medications regularly, has no significant medical problems. OBJECTIVE: Physical exam reveals a well-developed, well-nourished female who is alert and oriented. Vitals show a temperature of 98.5, respiratory rate of 18, heart rate 90, blood pressure 113/63, her O2 sat is 97% on room air. TMs are clear bilaterally although there is a little fluid present. They are not red or injected. Her oropharynx shows moderate injection without exudates. Neck is supple with few anterior cervical nodes. She is not tender over maxillary sinuses. Lungs are clear to auscultation. A quick strep test was obtained which was negative. ASSESSMENT: Upper respiratory infection with bronchitis and pharyngitis. PLAN: The patient was advised in symptomatic treatment, fluids, Robitussin during the day, and Motrin or Tylenol. She is given a prescription, which she can take at bedtime, for cough control. If she is not improved she should be re-evaluated. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): J06.9, J40, J02.9 CPT code(s) with modifier, if applicable: 99284 APC: 615 3. EMERGENCY DEPARTMENT VISIT PATIENT: TIMOTHY OFFICE RECORD NUMBER: 15-68-24 DATE OF SERVICE: 04-26-XX PHYSICIAN: DR. KIM. M. D. IDENTIFICATION: This is a 5-year-old Caucasian male. CHIEF COMPLAINT: Skull laceration. HISTORY OF PRESENT ILLNESS: This evening at 4:00 pm, patient was on a ladder to a swimming pool at the family’s single-family house. He was about 3½ feet off the ground, when he slipped and fell onto his back and head. Patient did not suffer any loss of consciousness and has been acting normally, though he has a cut over the back of his head and is quite anxious. Patient has not had any nausea or vomiting. ALLERGIES: NONE. Immunizations up-to-date. CURRENT MEDICATIONS: Ental and albuterol. PREVIOUS ILLNESSES: History of asthma. PHYSICAL EXAM: VITAL SIGNS: T 99.3°F, P 72, R 22. GENERAL: Young, Caucasian child in no acute distress. HEENT: Normocephalic. Eyes were unremarkable. TMs, no hemotympanium noted, no battle sign noted, no facial asymmetry noted. There was a 2.5 cm laceration over the occipital region of the patient's skull. This was lightly obliquely oriented. This was all the way through the skin, but the galea appeared intact and there were no palpable stepoffs. NEUROLOGICAL: Patient had grossly intact exam with normal grip bilaterally and normal knee jerks bilaterally and normal gait. Over the patient's back, there were two superficial abrasions medial to the right medial scapula border. The more superior abrasion was 2–3 cm in size. The more inferior abrasion was 4–5 cm in size. IMPRESSION: Two-point-five centimeter occipital skull laceration superifical abrasions over the right back area PLAN: The patient’s scalp laceration was treated with TAC topical anesthetic. Patient continued to have pain sensation after this, therefore, after the wound was prepped the area was infiltrated with 1% Lidocaine with epi. The wound was subsequently closed with four interrupted 4–0 prolene sutures. After being inspected, no debris or gross contamination was noted. Wound instructions were given. The patient is to follow up in 7 days to have the sutures removed. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S01.01XA, S40.211A, W11.XXXA, Y92.016 CPT code(s) with modifier, if applicable: 12001 APC: 133 4. EMERGENCY DEPARTMENT VISIT PATIENT: ZACK OFFICE RECORD NUMBER: 00-15-88 DATE OF SERVICE: 10-15-XX PHYSICIAN: DR. KIM. M. D. HISTORY: The patient is a 33-year-old male who presents to the ER having fallen while playing baseball landing on his left shoulder. He has had pain and swelling near the point of the left shoulder since the injury. He also complains of a recurring lump at the right base of the neck over the last several years. OBJECTIVELY: The patient is alert and in no acute distress. He demonstrates soft tissue swelling and tenderness maximal over the left AC joint. There is no deformity and pulling on the arms does not markedly aggravate the pain. The patient is able fully to abduct the shoulder. He is able to scratch behind his back and scratch behind his head. There is no distal neurovascular compromise in the left upper extremity. X-ray of the clavicle is normal. AC weighted joints are normal. ASSESSMENT: First-degree AC separation left shoulder. PLAN: A sling will be worn prn for comfort. Follow up prn PROBLEM NUMBER 2: The lump near the base of the right side of the neck on the back is palpated and felt to be consistent with a noninflamed sebaceous cyst. At the patient's request, this is removed. Under local anesthesia, an elliptical incision is made. The cyst capsule is identified and bluntly dissected from the wound. The cyst is removed intact and measures 1.5 cm. The wound is closed in layers with #4–0 Vicryl and #4–0 Prolene subcuticular stitch. ASSESSMENT: Sebaceous cyst. PLAN: The patient is given the usual wound care instructions and advised to return in 12 days for suture removal. LEFT CLAVICULAR VIEW WI'I'H AC JOINT VIEWS: The clavicle appears intact without evidence of fracture. AP and angled views of the AC joint show no widening or displacement. The coracoclavicular distance is normal. IMPRESSION: Normal left clavicle and AC joint. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S43.112A, L72.3, W19.XXXA, Y93.64, Y99.8 CPT code(s) with modifier, if applicable: 99282-25, 11422-59, 12041-51 APC: 613, 20, 133 5. EMERGENCY DEPARTMENT VISIT PATIENT: SUZANNE OFFICE RECORD NUMBER: 12-68-23 DATE OF SERVICE: 06-16-XX PHYSICIAN: DR. KIM. M. D. HISTORY: 48-year-old white female who presents. She has been taking Amoxicillin from her gynecologist for the past few days for upper respiratory infection sort of symptoms and now she has developed a blotchy rash on her left posterolateral trunk as well as her right upper extremity. This rash is extremely itchy. She has been taking some Dimetane DX but it does not seem to be helping. She then began the Amoxicillin but she has been only taking it for a couple of days. PHYSICAL EXAMINATION: Today she is in no acute distress other than the complaints of the significant pruritus along with this rash. She does not have any facial swelling or pharyngeal swelling or shortness of breath. Tympanic membranes are clear bilaterally. Throat is clear. Neck is supple. Although this is not a typical systemic reaction, it certainly appears to be more of a drug reaction than any other dermatitis that I can think of. It is mostly macular, erythematous and extremely pruritic type dermatitis in these two large areas. It is possible that it just has not developed enough time to spread to the rest of her body. She is not in any acute distress at this time. We will start her on antihistamines in the form of Seldane 60 mg bid that she will take at least for a 3–5 day period. She will discontinue Amoxicillin at this time and notify her physician that she has a drug allergy to Amoxicillin. IMPRESSION: Acute drug reaction. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): L27.1, T36.0X5A, J06.9 CPT code(s) with modifier, if applicable: 99282 APC: 613 6. SAME DAY SURGERY PATIENT: TERRY OFFICE RECORD NUMBER: 12-68-23 DATE OF SERVICE: 04-10-XX PHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This 72-year-old established patient presents today with complaints of a lump on the left side of his neck. The patient had been previously advised it would be best to excise the lump and send to pathology for definitive diagnosis. OBJECTIVE: Examination today reveals the patient has an area of induration, which is approximately 1.5 cm in diameter below his left jaw line. The procedure, risks, complications, and alternatives were discussed with the patient. The patient agreed to proceed with a resection of the lump today. ASSESSMENT: Lump left neck, which appears to be dermatofibroma. PROCEUDRE: The left jaw line was injected with local anesthetic. The 1.5 cm lump was excised with a wide excision. After resection, the lump appeared to be a dermatofibroma. Specimen was sent to pathology. Closure was performed with interrupted 4–0 Vicryl and Dermabond to seal the skin edges. Routine wound care was given. The patient is to follow up on a prn basis. We will call with pathology report results. PATHOLOGY: 1.5 cm Dermatofibroma left neck. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ ICD-10-CM diagnosis code(s): D23.4 CPT code(s) with modifier, if applicable: 11422 APC: 20 7. EMERGENCY DEPARTMENT VISIT PATIENT: JONATHON OFFICE RECORD NUMBER: 00-15-82 DATE OF SERVICE: 05-06-XX PHYSICIAN: DR. KIM. M. D. Patient is an 11-year-old male who comes in at this time for evaluation of a laceration on his scalp. He apparently was playing in his driveway of a single-family home, on a trampoline, trying to jump up and stuff a basketball through a hoop when, apparently he lost his balance and fell off of the small trampoline and hit his head. He suffered no loss of consciousness. He states he did not hurt his neck, but did note that he was bleeding from his scalp. He generally has been in good health. Is currently on Penicillin, however, for an abscess tooth. He is allergic to no known medicines. According to his mother, his last tetanus injection was 6 years ago. His weight is 66 pounds. EXAM: Blood pressure 114/80, respirations 20, pulse 78, temperature 98.3. Exam of the child reveals a well-developed, well-nourished male in no acute distress. Ears: TMs intact within normal limits bilaterally. Eyes: EOMs intact, PERRL, fundi no hemorrhages, exudates or no papilledema noted. Exam of the neck reveals no tenderness over the dorsal spines of the cervical spine. Exam of the head reveals approximately ¾ inch laceration on the posterior scalp overlying the occiput. Wound was inspected and appears to be through the subcutaneous tissue in one small area. The galea could not be visualized, but wound did not appear to extend to the galea. The wound was thoroughly irrigated with normal saline and subsequently the wound was anesthetized using 1% Xylocaine with epinephrine. Following this, the wound was closed using 4–0 Vicryl and 4–0 Prolene suture. The patient tolerated the procedure well. He was given a tetanus booster as a precaution and the mother was counseled regarding potential side effects. He has been advised to keep the wound clean and dry and his mother has been advised that he should be rechecked should the wound become reddened, increasingly painful or if any purulent drainage should be noted exuding from the wound. The sutures are to be removed in 7–10 days. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S01.01XA, Z23, W11.XXXA, Y93.67, Y92.014 CPT code(s) with modifier, if applicable: 12001, 90460, 90714 APC: 133 8. EMERGENCY DEPARTMENT VISIT PATIENT: ELYSE OFFICE RECORD NUMBER: 00-15-83 DATE OF SERVICE: 08-08-XX PHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This 27-year-old female presents to the emergency room with a small laceration to her right index finger. The patient works in central supply. She cut her digit on a clean razor blade. The patient notes that she is current on her tetanus immunization. OBJECTIVE: Physical exam reveals a well-developed, well-nourished female. She is alert and oriented and in no acute distress. Vital signs are normal. Exam of her right index finger reveals a small 1 cm laceration to the volar fat pad. TREATMENT: The wound was cleaned and injected with 1% plain Xylocaine. It was then sutures with three interrupted 5–0 Nylon sutures. Neosporin ointment and a sterile dressing were placed over the wound. ASSESSMENT: Laceration, right index finger, sutured. PLAN: Wound care instructions include keeping the wound clean and dressed with Neosporin ointment. Sutures are to be removed in approximately 10 days. She is cautioned to watch for any signs of infection. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S61.210A, W27.8XXA, Y99.0 CPT code(s) with modifier, if applicable: 12001-F6 APC: 133 9. EMERGENCY DEPARTMENT VISIT PATIENT: JOSHUA OFFICE RECORD NUMBER: 00-15-90 DATE OF SERVICE: 09-09-XX PHYSICIAN: DR. KIM. M. D. S: The patient comes in complaining of having a large bruise from his mid-upper arm down. He says that he bumps it occasionally on the skid loader and it is quite swollen and tender. It is swollen enough that it is causing a little bit of discomfort. There has been no injury except as described above. The patient is on Coumadin for blood clots that he has had in the past. O: LUNGS: Clear. HEART: Regular rate and rhythm. Unremarkable EXTREMlTTES: There is a large purple ecchymosis from the mid-biceps down to the hand. Distal neurovascular checks in the hand are normal. LABORATORY/DIAGNOSTIC: Blood work shows a protime of 37.1 with an INR of 7.5. A: Hyperanticoagulalion with contusion of left arm. P: We gave him two ampuls of vitamin K. We will have him stop his Coumadin for 2 days and then he will start back at 2.5 mg every other day. He is to have his blood checked in l week and follow up. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S40.022A, S50.12XA, Z79.01, W31.82XA, Y99.0 CPT code(s) with modifier, if applicable: 99281 APC: 609 10. EMERGENCY DEPARTMENT VISIT PATIENT: GREGORY OFFICE RECORD NUMBER: 00-15-91 DATE OF SERVICE: 02-02-XX PHYSICIAN: DR. KIM. M. D. S: The 33-year-old male patient comes in stating that for the last 2 weeks his rectum has been bothering him. It hurts him to have a bowel movement. He occasionally gets blood when he wipes and occasionally has blood in the stool. He has had hemorrhoids before and this kind of feels like it. He has not really had any constipation. He has had no abdominal pain or other problems such as this. It just seems to be bothering him. O: Vital signs as per chart. Abdomen is soft. A: Hemorrhoids. P: We are going to put him on Anusol suppositories one twice a day and given six. We are going to have him use Anusol cream applied four to five times a day as needed. He is to wipe very gently and maybe even just wash with water. He can use witch hazel pads and go that direction. If it is not getting better or if he is having more problems, he is to let us know. Otherwise, he is to follow up, as he feels necessary. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): K64.9 CPT code(s) with modifier, if applicable: 99281 APC: 609