Physical examination is one of the:
A. Documentation Guidelines.
B. outpatient services.
C. content of service.
D. nature of presenting problem.
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Q. 2) __________ identification of an appropriate clinical treatment for the purpose of promoting the patient's health, recovery, and wellness
Fill in the blank with correct word.
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Q. 3) What does the term unique listed code mean?
A. The medical documentation of the provided healthcare service
B. The documentation guidelines that provide oversight for evaluation and management services
C. The specific numeric code listing in the CPT book which represents the provided healthcare service
D. The amount of time the clinician has spent providing care for the patient
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Q. 4) SAME DAY SURGERY
Directions:
Code the following cases for outpatient facility purposes using ICD-9-CM, 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.
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 40 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-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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Q. 5) __________ the record of healthcare provided for the patient, which may be in the form of handwritten or typed narratives, reported diagnostic results, diagnostic images or scans, or any other record of the healthcare received by the patient at the healthcare facility
Fill in the blank with correct word.
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Q. 6) Medical decision making is one of the:
A. typical time.
B. content of service.
C. outpatient services.
D. place of service.
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Q. 7) When a patient presents to the physician's clinic office, this place of service is referred to as:
A. outpatient/office.
B. hospital/inpatient.
C. emergency department.
D. nursing facility.
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Q. 8) A physical examination of the ______ typically includes trill, rhythm, friction, and apical impulse.
A. heart
B. lungs
C. abdomen
D. neurological system
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Q. 9) _________ His mid and forefoot are painful and quite swollen.
Fill in the blank with correct word.
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Q. 10) Comorbidities and complications are conditions that are thought to increase the length of stay at least _____ day(s) for 75 of patients.
A. 1
B. 2
C. 5
D. 7
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