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A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 6.docx

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A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 6: ADVANCED PHYSICIAN OFFICE CODING Directions: Code the following physician encounters using ICD-10-CM, and CPT. Sequence the codes in the correct order. Assign any needed modifiers. 1. PHYSICIAN OFFICE VISIT PATIENT: DALE OFFICE RECORD NUMBER: 02-68-23 DATE OF SERVICE: 03-15-XX PHYSICIAN: DR. KIM, M.D SUBJECTIVE: This 22-month-old female patient is seen in consultation, new, in my office for a diagnosis of fever of uncertain etiology by request of the patient's pediatrician. The patient had a workup with a blood count, CRP, and blood culture. He was treated with Motrin and Tylenol. It is significant to note that his blood count was elevated at 23,000 with 76% SBGS, 13.4% lymphocytes. He also had an elevated CRP, which was 7.11. Blood culture has not been read yet and will not be read until late this afternoon. Mother notes that the child has improved considerably. The mother notes that his temperature has come down and he seems to be more playful and acting more like himself. The child does have a history of asthma and tachycardia. She tells me she is treating him with albuterol, Tylenol, ibuprofen, and Zyrtec elixir. Mother also notes the child is taking fluids today quite well. She tells me he seems to be very thirsty, drinking lots of f1uid and he has been eating today. She notes that he has developed sort of a barky bronchial cough but that is not unusual with his history of asthma. OBJECTIVE: General exam reveals a happy, smiling two-year-old. Temperature 97.1, heart rate 140, respiratory rate 28. I reviewed his chart from yesterday. His temperature yesterday was 105. His respiratory rate was 26. His heart rate was 200. His O2 sat was only 93% on room air. HEENT: TMs are dear. Pharynx is minimally injected. No exudates. The neck is supple. The lungs demonstrate somewhat tubular breath sounds but I do not hear any significant wheezes, and he is moving air freely. He does have a deep bronchial cough. ASSESSMENT: Acute febrile illness, uncertain etiology pending blood culture results. PLAN: At this point, the child is improved. I would not change the treatment. I do not think he needs antibiotics. We discussed getting a chest x-ray, however, with his O2 saturation improved and his temperature down and pulse down; I really do not think that is indicated at this time. Mother is advised to follow up with primary care pediatrician if she becomes concerned and pending findings of blood culture. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): R50.9 CPT code(s) with modifier, if applicable: 99243 2. PHYSICIAN OFFICE VISIT PATIENT: ALICE OFFICE RECORD NUMBER: 03-68-3 DATE: 03-15-XX PHYSICIAN: Dr. KIM, M.D. SUBJECTIVE: This is 43-year-old black female new patient presents to the physician office complaining of severe pain in her low back. The patient recently moved into the community. The patient notes she has had a long history of back problems somewhat over 2 years. She notes that she was thoroughly evaluated by her previous physician to include MRl studies and numerous other x-rays. She was diagnosed as having two slipped disks in her lower back. She notes that they were not severe enough to require surgery. She was treated with muscle relaxants and was hospitalized briefly with traction. The patient notes she has been getting along fairly well until today. Today, she was in church and had a sudden sharp pain in her lower back, she notes it felt like someone hit her in the back on the right side, with pain radiating down her right leg. The patient describes pains down the lateral aspect of her right leg all the way to the foot. She notes that in the past when her back has started to hurt, she has just been able to lie down for several days, takes Flexeril and Motrin, and gradually it improves. OBJECTIVE: Physical examination reveals a well-developed, well-nourished, black female. She is very meticulously dressed. She is however, wincing occasionally as she gives me this history, stating that these are muscle spasms in her lower back. Temperature is 97.8, pulse 88, respirations 16. blood pressure 112/80. ALLERGIES: MORPHINE AND PENICILLIN. She is currently taking Inderal 40 mg daily and Dyazide for high blood pressure. Exam is limited to the low back. The patient is quite tender along the paraspinous muscles in the lumbar region. She is able to flex only about 10 degrees at the lumbar spine without experiencing pain. She moves very slowly up onto the gurney. She actually walks with a slight limp in her right leg. The patient has pain on straight leg raising of the right leg of 25 degrees. The left leg is pain free until 45 degrees. She has severe pain in the right lumbar region with elevation of the left leg at 45 degrees, however. The patient has intact deep tendon reflexes in her knees. There is an absent ankle jerk on the right side. The patient's legs are quite thin and although I do not see any asymmetrical muscle wasting. The patient also notes there is an area of decreased sensation in the lateral aspect of her right side. Grossly, her muscle strength is symmetrical in both lower extremities, however. No x-rays were obtained. ASSESSMENT: Exacerbation of low back pain. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): M54.5 CPT code(s) with modifier, if applicable: 99202 3. PHYSICIAN OFFICE VISIT PATIENT: SHELBY OFFICE RECORD NUMBER: 04-68-23 DATE OF SERVICE: 03-15-XX PHYSICIAN: DR. KIM, M.D. SUBJECTIVE: The patient is a 34-year-old female established patient who presents with several days of malaise, generalized abdominal pain, and nausea. She states that for about 3 days now, she has had an achy feeling associated with a headache and some chills. She has had transient intermittent abdominal pain as well in multiple areas, no one area. She has had some loose bowel movements. She was nauseated somewhat and vomited once. OBJECTIVE: On examination, she is noted to have normal vital signs with the exception of a low-grade fever of 100.6. She is noted to have clear lung fields bilaterally. Examination of the abdomen reveals hyperactive bowel sounds but no tenderness and there is no organomegaly. There is no costovertebral angle tenderness. HEENT: The throat is no erythematous. Mouth shows normal mucosa with adequate saliva. The neck is supple. Extremities are unremarkable. ASSESSMENT: Viral gastroenteritis PLAN: Fluid, clear liquid diet with increased amounts of clear liquids frequently. Tylenol or aspirin as needed for malaise or fever. Darvocet-N 100 small prescription of 10 is written to take as needed for abdominal pain. Recheck if not improving after the next three or so days. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): A08.4 CPT code(s) with modifier, if applicable: 99213 4. PHYSICIAN OFFICE VISIT PATIENT: KAREN OFFICE RECORD NUMBER: 05-68-23 DATE OF SERVICE: 03-15-XX PHYSICIAN: DR. KIM, M.D. SUBJECTIVE: This 42-year-old female new patient presents to the physician office complaining of pain in her right ear. The patient notes she has been ill now for a little over 2 weeks. It started with what she thought was an influenza-like illness with cough and upper respiratory congestion. She has not been running a fever; however, in the last 2 days she has developed pain in her right ear, pain in the right facial area above and behind her right eye. She notes that she still has greenish nasal discharge as well and thinks that she may have developed a sinus infection. The patient notes that she is not allergic to any antibiotics. OBJECTIVE: Physical exam reveals a well-developed, well-nourished female. Temperature is 97.8, respiratory rate 20, heart rate 72, blood pressure slightly elevated at 114/99. O2 sat 97% on room air. HEENT: Left TM is read and somewhat retracted. The right TM is dull. The pharynx shows minimal injection. No exudates. The neck is supple with no significant adenopathy. The patient is tender to percussion over her right maxillary sinus; however, her right ear is not nearly as red as her left ear. Nasal mucosa is moderately injected. The lungs were not examined. She does not have any significant cervical adenopathy. ASSESSMENT: Left acute otitis media and acute sinusitis. PLAN: The patient was treated with Augmentin 875 bid for 10 days. I recommend she take Sudafed 60 mg - 120 mg daily for her sinus symptoms and if she is not improving or develops new symptoms should be reevaluated. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): H66.92, J01.90 CPT code(s) with modifier, if applicable: 99202 5. URGENT CARE VISIT PATIENT: RUTH OFFICE RECORD NUMBER: 06-68-23 DATE OF SERVICE: 04-26-XX PHYSICIAN: DR. KIM, M.D. HISTORY OF PRESENT ILLNESS: This 66-year-old female established patient presents to the urgent care with complaints of epigastric and chest pain. The patient has felt sick in general today, she has suspected coronary artery disease. She has also had a headache, been nauseated and has had some shortness of breath and dizziness. Patient's husband died about a week ago. ALLERGIES: Codeine, morphine and compazine. CURRENT MEDICATIONS: Cardizem 60 tid, Xanax 0.25mg prn, Premarin 0.3 and Proloid 0.15 mg Lasix prn. PREVIOUS ILLNESS: Kidney stones in 1989. SUBJECTIVE: PHYSICAL EXAMINATION: Alert and cooperative. Patient is afebrile, pulse 73, respiration 20, blood pressure 196/84. HEENT: Noncontributory. NECK: Supple. SKIN: Normal for age. LUNGS: Clear. HEART: Regular rhythm. ABDOMEN: Tender in the high epigastrium, no guarding or rebound. Bowel tones are present. The abdomen is soft. EXTREMITIES: No edema. EKG: Poor R wave progression precordial leads; no acute changes. No ectopies, sinus rhythm. IMPRESSION: Chest and epigastric pain. Consider the possibility of a cardiac origin. Also, consider peptic origin. PLAN: The patient was advised to proceed to the local emergency department for evaluation of her chest pain with consideration that pain is cardiac in origin. Patient's husband stated that since the local hospital was only 2 miles that he would drive the patient immediately there. The patient was stable and not experiencing any chest pain at the time and refused ambulance. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): R07.9, R10.13, Z88.5, Z88.8 CPT code(s) with modifier, if applicable: 99214 6. PHYSICIAN OFFICE VISIT PATIENT: BRADY OFFICE RECORD NUMBER: 07-68-23 DATE OF SERVICE: 04-16-XX PHYSICIAN: DR. KIM, M.D. SUBJECTIVE: This 8-year-old male established patient presents to the physician office with the chief complaint of a cough that has been productive of brown sputum. The patient is brought in by his parents. He has no significant fever that he has noted, but did vomit yesterday. The cough has become worse recently, so he has come in for evaluation. The mother believes he has had a night fever as well, and has seemed to be ornery more than normal. No known allergies. No current medication. Patient has recently been treated for pneumonia. OBJECTIVE: Physical examination reveals a healthy young male. Blood pressure is 102/54, temperature 97.9, pulse 104, respirations 28. HEENT: Normocephalic. Right TM is slightly inflamed. Left TM appears normal. Pupils are PERRL and EOMI. Oropharynx is mildly inflamed posteriorly, but no exudate or petechiae. Neck is supple without thyromegaly or adenopathy. LUNGS: Some congestion heard in the left lung fields, with some diffuse rales and rhonchi. He has no associated coughing, no retractions or cyanosis. The heart has regular rate and rhythm without murmur. The abdomen is soft without organomegaly, nontender to palpation. Extremities show no clubbing, cyanosis or edema. A chest x-ray was done, which showed infiltrate in the right lower lobe, also in what appears to be the retrocardiac region. This is consistent with pneumonia. IMPRESSION: 1. Pneumonia. 2. Early right otitis media. PLAN: I discussed my findings with the family. The family was concerned about the recurrence of pneumonia in this child, and whether he will have this chronically. I have advised the family that he may have a tendency toward it, but the father's smoking does not help things, and have advised the father that he might best quit if possible. The patient on erythromycin 400 mg tid for 10 days. The patient is to be seen in follow up in 2 days to be sure x-ray is clearing and then follow up after the course of antibiotics. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): J18.9, H66.91, Z77.22 CPT code(s) with modifier, if applicable: 99214 7. PHYSICIAN OFFICE VISIT PATIENT: JULIE OFFICE RECORD NUMBER: 09-68-23 DATE OF SERVICE: 01-10-XX PHYSICIAN: DR. KIM. M.D. SUBJECTIVE: This 53-year-old female established patient presents with a chief concern of several week history of stuffy nose with nasal congestion and blowing brown stuff out of her nose. She has also had some plugging of her ears. She is not having any wheezing or difficulty breathing. She also wanted to talk about getting Reclast for osteoporosis, which is once a year injection intravenously. OBJECTIVE: Temperature is 97.5, blood pressure 120/60, pulse 80, and respirations 16. GENERAL: She is a pleasant women resting in no acute distress. EYES: Mild conjunctival injection. No discharge. ENT: The nasal mucosa is beefy red with greenish-brown rhinorrhea. Mild posterior pharyngeal erythema. The tympanic membranes are normal in color and landmarks. NECK: Supple. No lymphadenopathy. No meningismus. LUNGS: Completely clear to auscultation. No crackles or wheezes. She is breathing comfortably. ASSESSEMENT: 1. Acute sinusitis with a history of methicillin-resistant Staphylococcus aureus on nasal cultures. 2. Osteoporosis. PLAN: Prescription for clindamycin 150 mg four times daily, 10 days #40 with no refills. We will make arrangements for her to get Reclast infusions once yearly. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): J01.90, M81.0, Z86.14 CPT code(s) with modifier, if applicable: 99214 8. PHYSICIAN OFFICE VISIT PATIENT: JEFFREY OFFICE RECORD NUMBER: 10-68-23 DATE OF SERVICE: 03-23-XX PHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This established patient came in today for administrative purposes. A letter was dictated on his behalf to a claims examiner who is determining employability for the patient. The patient has not been employable for more than a decade due to chronic pain issues. He is having increased pain in his right leg now above and beyond the chronic nerve pain in his left leg, which has had an amputation. OBJECTIVE: On examination today, it looks as though he has got some evidence of partial quadriceps tearing in the right thigh. Right now, he does not want to pursue that further. I agreed, and we can wait and see what happens. This man has a hard enough time getting around now as it is, and I think he is just slowly but surely wearing his knees out. He has partially torn his quadriceps on the right thigh with neurologic effects. He has had some chronic back pain, and at some point he may need further workup. ASSESSMENT: 1. Chronic nerve pain due to right leg amputation 11 years ago. 2. Partially torn quadriceps right thigh. 3. Chronic back pain. PLAN: For now, I simply recommend that he continue with his chronic pain management as he is. Recheck is planned from our viewpoint on an as-needed basis. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): Z02.71, T87.89, M79.604, Z89.511, M54. 9, S76.111A, Z56.0 CPT code(s) with modifier, if applicable: 99455 9. PHYSICIAN OFFICE VISIT PATIENT: ROBERT OFFICE RECORD NUMBER: 11-68-23 DATE OF SERVICE: 09-1-XX PHYSICIAN: DR. KIM. M.D. SUBJECTIVE: This is a 77-year-old new patient who presents to the office to have a lesion checked on his right forearm. He has noticed it in the last 2 months or so, and it has been growing fairly rapidly. It has not bled and does not bother him at all. No other recent skin issues. The patient does have a history of basal cell skin cancers on his nose and check 4 years ago, which were treated with recurrence. The patient feels well and has no other issues or concerns. OBJECTIVE: Alert male in no distress. SKIN: Examination of his right foream shows a lesion on the radial aspect of the proximal part of the forearm. It is 2 cm in size and is raised about 4 mm. It is slightly red and irritated appearing, though there is no ulceration. It was noted that the patient's blood pressure is a bit elevated today. The patient is to follow up with me in the next month or two to recheck elevated blood pressure and address if necessary. ASSESSMENT: Abnormal skin lesions right forearm, probably keratoacanthoma. PLAN: After verbal informed consent was obtained, the lesion was prepped with alcohol, anesthetized with 2% lidocaine with epinephrine. Shave biopsy was then performed. Tissue was sent to pathology. Hemostasis was with 35% aluminum chloride. The patient tolerated the procedure well. The skin was covered with a bandage. PATHOLOGY returned as keratoacanthoma. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): L85.8, R03.0, Z85.828 CPT code(s) with modifier, if applicable: 11302 10. PHYSICIAN OFFICE VISIT PATIENT: KRIS OFFICE RECORD NUMBER: 20-68-23 DATE OF SERVICE: 07-16-XX PHYSICIAN: DR. KIM. M. D. SUBJECTIVE: This 73-year-old female established patient returns today for follow up regarding her Parkinson’s disease with associated motor function difficulties. The patient reports that she is having increasing difficulties with motor function. She states that the Sinemet seems to wear off and then she has a lot of trouble with freezing and ambulation. She also reports a new problem of pain in the left elbow with some numbness and impaction of the left fourth and fifth fingers. OBJECTIVE: General: An older female with obvious physical manifestations of Parkinson’s disease. CONSTITUTIONAL: 112/74, pulse 72, and respiration 16. MOTOR: Moderate bradykinesia and rigidity are present on examination. There is also a resting tremor. GAIT: The patient has a hard time rising from sitting to standing position. She ambulates with a scooped shuffling posture and tends to carry her arms flexed when she walks. ASSESSMENT: 1. Parkinson’s disease with gait difficulty, bradykinesia, rigidity, and resting tremors. 2. Possible entrapment neuropathy left elbow. PLAN: Patient is to hold Sinemet CR or perhaps take it at bedtime. A prescription for standard Sinemet (25/100) is given. Patient is to take this medication tid to qid. It is hopeful that the patient will tolerate the Sinemet at this point. We have tried to adjust the Mirapex in times past but the patient reports hallucinations. I am also going to order an EMG to evaluate for possible entrapment neuropathy at the left elbow. Patient is to call us back in a couple of weeks to let us know how she is doing with the standard Sinemet. Follow up in office as needed. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ Answers: ICD-10-CM diagnosis code(s): G20, M79.632 CPT code(s) with modifier, if applicable: 99213

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