A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 4.docx

A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 4: INTERMEDIATE OUTPATIENT HOSPITAL CODING MATCHING Directions: Identify the portion of the medical record in which the following statements would MOST likely be found. QUESTIONS ANSWERS Service Type: Emergency Room. D Pharyngitis with some sinus infection. C Esophagogastroduodenoscopy. G I reduced the hernia and then inspected the defect after I freshened up the edges of the fascia. I No mass or organomegaly was noted. A Multiple (2) hyperplastic pharyngeal tonsils and fragments of adenoidal tissue. J I told her to lie in a prone position with her legs up on a couch. B Schatzki’s ring. F The patient underwent umbilical hernia repair and went home that afternoon. H Sodium 137 L. E CHOICES: Physical examination Plan Impression Face sheet Laboratory results Postoperative diagnosis Operative procedure Discharge summary Operative note procedure Pathology report MULTIPLE CHOICE Directions: Select the word or phrase that best completes each sentence or best answers the question. QUESTION ANSWER ER evaluation and management and procedure codes are assigned using what code set? CPT ICD--10-CM ICD-10-PCS HCPCS A Which of the following are permissible to code for SDS diagnoses? All lab result flagged as abnormal Diagnoses documented on the nursing progress notes Pre-operative diagnoses Past conditions that relate to the current visit D ______ is a common abbreviation for no known allergies. NAL NKAL NKA NAG C What report is the definitive authority on specimens taken out during surgery? Specimen report Discharge summary Pathology report Operative report C What codes do ER coders report? CPT codes beginning with 7, 8 and 9 ICD-10-CM ICD-10-PCS HCPCS B When is it appropriate to use non-physician notes as a source document for coding? To code BMI for a patient with documented obesity. To code all nursing diagnoses. To code abnormal laboratory results. To code IVs. A Which of the following procedures would likely be hard coded by the chargemaster? 31276 54500 73500 99281 C ____ is a common abbreviation for the oral route of medication administration. OAM PO OP ORA B Which condition should be documented as to whether or NOT the condition is “reducible”? Crush injury to the right hand Pharyngitis with sinus infection Cephalgia Umbilical hernia D Coagulation and serology tests help determine: the presence of blood in the urine. the amount of drug present in the blood. the amount of time it takes for bleeding to stop. which antibiotic is most effective against an infectious organism. C The Caldwell-Luc procedure is an eponym for a specific type of: tonsillectomy. sinusotomy. hernia repair. esophagogastroduodenoscopy. B When does an ER coder report EM codes? For all professional physician services When the physician is employed by the hospital When critical care is provided When the hospital does not use APCs B Which of the following is NOT a characteristic of a critical access hospital? It provides at least 50% critical care services. It is located more than 35 miles from another hospital. It typically has 25 or fewer inpatient beds. It provides 24-hour emergency care. A When coding CPT procedures, coders should check whether a _______ is needed. modifier diagnosis lab test follow up visit A Outpatient coding conventions state that _____ diagnoses may NOT be coded. possible multiple past confirmed A What report is the official summary of the procedure performed, pre-operative and post-operative diagnosis, and step-by-step details for the actual procedure and or surgery performed? Pathology report Physician progress note Discharge summary Operative report D Documentation of “EBL 20cc” refers to: the amount of anesthetic agent. blood loss during a procedure. a post-procedure medication. O2 saturation. B Where would you expect to find the following statement? “A C-shaped flap was made in a small fashion below the transverse sinus with the base on the transverse sinus overlying the cerebellum.” Physical examination Pathology report Operative report Discharge summary C EGD is a: diagnosis. laboratory test. medication. procedure. D Which setting uses APCs for Medicare reimbursement? Physician offices Inpatient hospitals Same-day surgery Critical access hospitals C CASES 1. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Questionable stenosis of rectal anastomosis. POSTOPERATTVE DIAGNOSIS: Stenosis of rectal anastomosis. PROCEDURE: Flexible sigmoidoscopy with dilatation of rectal anastomosis. ANESTHESIA: Intravenous. PROCEDURE: This 7-year-old female patient was brought to the endoscopy suite and placed in the left lateral decubitus position. A pediatric colonoscope was passed without difficulty though the anus. At 10 cm on the scope, the patient was found to have stenosis at the site of a previous rectal anastomosis. The anastomosis was very gently dilated until it could admit the scope. The scope was then passed through the anastomosis to the sigmoid colon where evaluation noted fairly normal anatomical features. The scope was then slowly withdrawn and the procedure terminated. The patient was returned to the recovery room is satisfactory condition. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): K62.4 CPT code(s) with modifier, if applicable: 45340 APC: 146 2. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Mass of the left upper outer breast. POSTOPERATIVE DIAGNOSIS: Mass of the left upper outer breast. PROCEDURE: Left breast biopsy. ANESTHESIA: Local plus sedation. PROCEDURE: The 42-year-old female patient is brought to the operating room where she was positioned, prepped and draped in the usual fashion for left breast biopsy. The patient was anesthetized utilizing intravenous administration of 75 mg of Demerol and 3 mg of Versed. The left upper outer breast was injected with 0.5% Marcaine with epinephrine. A curvilinear incision was made overlying the mass. The incision was carried down through the subcutaneous tissue. The mass was excised along with approximately a nice 2 mm margin. Hemostasis was obtained utilizing a Bovie and electrocauterization. The specimen was sent to pathology for identification. The wound was copiously irrigated. Attention was turned to the dermis which was approximated with continuous 3–0 Dextron with closure of the epidermis achieved utilizing Steri-Strips. The patient was taken to the recovery room in satisfactory condition. The patient was returned to her room where she arrived in satisfactory condition. Pathology report reported returned as sebaceous cyst of the left upper outer breast. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): N60.82 CPT code(s) with modifier, if applicable: 19120-LT APC: 28 3. EMERGENCY ROOM REPORT HISTORY OF PRESENT ILLNESS: This 18-year-old white male presents to the emergency room by private vehicle for evaluation of abrasion injuries. The patient states that last night he was riding a motorcycle when he slipped on some gravel. He was not wearing a helmet but denies any loss of consciousness or neck injury. His only complaint is of the right forearm and right knee area being deep abrasions. He, in addition, suffered minor abrasions to his right cheek and to his chest/abdomen area. He denies any shortness of breath. No numbness, tingling, weakness to an arm or a leg. Tetanus is up to date being two years ago. ALLERGIES: NONE KNOWN. CURRENT MIDDICATIONS: None. PAST MEDICAL HISTORY: Unremarkable. PHYSICAL EXAM: Blood pressure 140/64, temperature 99.6 F, pulse 100, respirations 24. In general appears a well-developed alert male who appears in minimal discomfort. HEENT: Shows mild amount of abrasions to the right cheekbone area. There is no evidence of bony tenderness in this area. Funduscopic exam and pupil exam are normal. Ears normal. NECK: Soft, supple. No thyromegaly or lymphadenopathy. Cervical spine is nontender to firm palpation and range of motion. Skull was nontender either. NEUROLOGIC: Normal for light touch sensation and muscle strength testing. EXTREMITIES: Exam of the right forearm area shows deep abrasions about the forearm itself, not about the elbow. Elbow range of motion was quite good. There is no evidence of elbow effusion. No evidence of bony tenderness to the forearm. Examination of the right knee revealed deep abrasions anteriorly, some gravel foreign body present. None of these abrasions appears to be full skin thickness in nature. Knee itself showed no evidence of effusion. The patient was tender only about the abrasions. Knee range of motion and full extension to 90 degrees of flexion and ligamentous testing was normal. DISCUSSION: I told the patient I would recommend a knee x-ray given the amount of trauma that was sustained to the skin of the area and the decreased range of motion. The patient refused a knee x-ray though. For treatment of his abrasions, I wanted to send him to physical therapy for whirlpool treatment and debridement as needed. The patient refused to do this, citing financial concerns as a reason why. Therefore, I had our emergency nurse thoroughly debride all of these wounds as best as possible. The patient was instructed to follow up with a private physician as soon as possible. I am still giving him a note for physical therapy that he may follow up with them if he so chooses. The patient is to return for any sign of infection or other problems. IMPRESSION: Deep abrasions to right forearm and right knee area. PLAN: General wound care instructions given. He is told to return to the emergency department if any problems or sign of infection or other complaints. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S80.251A, S50.851A, V28.4XXA CPT code(s) with modifier, if applicable: 99282 APC: 613 4. EMERGENCY DEPARTMENT VISIT SUBJECTIVE: This 12-year-old female was driving a three-wheeler while her family was recreating in hills this afternoon with her smaller sister when she flipped the three-wheeler over. She did not have any helmet on at the time of the accident. She denies any loss of consciousness. She did strike her head on the ground and has an abrasion on her forehead but her main complaint is pain in the left posterior iliac crest region. This patient denies any recent illness. She has not had any cough, sore throat, fever or chills. She denies any urinary tract symptoms. She does not have any nausea or vomiting. The patient is having considerable pain and discomfort when she walks; most of this pain is in the left posterior aspect of her back extending from the lower rib cage to the iliac crest. She has several abrasions including a fairly deep abrasion on the left hip. The patient is current on her tetanus immunization. OBJECTIVE: Physical examination reveals a well-developed, well-nourished young woman. Vitals include initially a temperature of 100.9, pulse of 79, respirations of 18, blood pressure 114/56. Subsequently, her temperature was rechecked, it remained at 100.4. Her vitals remained stable. Head is nontender although she does have some abrasions on her forehead. TMs are clear bilaterally. Pharynx is clear. There is no tenderness over her maxillary sinuses. Her neck is supple with full range of motion and no tenderness. Lungs are clear to auscultation. The patient is tender in the left flank and posterior rib cage. She is also tender over the left posterior iliac crest. Her abdomen is soft. She has active bowel sounds. There are no peritoneal signs. There is no tenderness in the area of the spleen in the left upper quadrant. Her pelvis is actually quite stable and nontender to anterior lateral or pubic compression. She has full range of motion in all of her extremities. She does have some pain in the left hip with flexion of the hip. X-rays were obtained of the pelvis, which appear to be within normal limits. Additionally urine was obtained which reveals 4–5 epithelial cells, 15–20 red cells, 8–10 white cells, and 1+ bacteria. In view of the patient's fever, which I am unable to explain by any physical findings at this time nor can it be explained by any complaints, a urine culture was set up. ASSESSMENT: 1. Three-wheeler accident with contusion to the back, head, and left hip. 2. Fever of uncertain etiology. PLAN: The patient is given Darvocet N for pain as Tylenol with Codeine makes her sick to her stomach. She is given some Robaxin for a muscle relaxant. She is given 2 days school excuse. She is advised to return to the ER if she develops any new symptoms. I particularly caution the patient to watch for any fever or chills. I will contact the patient and her family if we grow any bacteria of significant number on the urine culture. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S70.02XA, S30.0XXA, S00.83XA, R50.9, V86.59XA, Y92.828 CPT code(s) with modifier, if applicable: 99284 APC: 615 5. EMERGENCY ROOM REPORT CHIEF COMPLAINT: Left hand injury. HISTORY OF PRESENT ILLNESS: This 25-year-old male was carrying groceries in plastic bags approximately 10 - 15 pounds in each hand and felt sudden pain in the dorsum of his left hand. He put down the bag and noticed there was some swelling along his left fourth MCP on the dorsal side. Patient notes that last week he was brought to the ER after being in an MVA with question of a hand injury from holding onto the steering wheel. He was discharged from the ER being told he had a strain. There were no fractures or ligament damage, this is per patient and no old records are available. Patient is not having any numbness, tingling, or feeling of weakness right now. PAST MEDICAL HISTORY: Unremarkable except for the MVA. CURRENT MEDICATIONS: Amoxicillin for an ear infection. He occasionally takes ibuprofen as well. ALLERGIES: NONE KNOWN. PHYSICAL EXAM: Patient is a WN, WD, white male in no acute distress right now. Vital signs: BP 120/70, P 64, R 16. LEFT ARM: Full range of motion at shoulder and elbow without pain. Left wrist with full range of motion and normal strength. He has good distal radial and ulnar pulses. Good capillary refill in all digits and good sensation to light touch and pinprick in distal phalanges. There is some swelling over the fourth MCP and there is some tenderness over the dorsum of the fifth MCP. He has normal DIP and PIP flexion in all left phalanges and normal MCP flexion and extension. There is no tenderness and normal strength throughout as well. He has normal interosseous motion. X-rays revealed no fractures or dislocations. DIAGNOSIS: Left fourth and fifth interosseous strain at the metacarpophalangeal joint. PLAN: Patient was sent home with ibuprofen 400 mg tid times 5 days, ice for 20 minutes on and off for 48 hours and rest the left hand. No lifting. His fourth and fifth fingers were buddy-taped. He is advised to follow up if pain persists. ICD-10-CM diagnosis code(s): _____________________ CPT code(s) with modifier, if applicable: _____________________ APC: _____________________ Answers: ICD-10-CM diagnosis code(s): S63.655A, S63.657A, V49.9XXA CPT code(s) with modifier, if applicable: 99283 APC: 614