Lesson 8 Exam Answers



Lesson 8 Coding Scenarios1. List the three goals of Physician Payment Reform.2. Mr. Jones is admitted to the hospital by the orthopedic surgeon for severe hip pain. The ortho surgeon provides an initial hospital visit during which it’s determined that Mr. Jones has a fractured hip that will require surgical intervention. Mr. Jones is taken later that day to the OR, where the doctor performs the surgical procedure to repair Mr. Jones’ hip. Which modifier would you use for the hospital visit?3. List and define the three components of the relative value unit.4. List the three types of persons eligible for Medicare.5. Name the six basic location methods to locate main terms in the index of CPT.6. An initial inpatient consultation with a detailed history, detailed exam, and MDM of lowcomplexity would be coded to what E/M code?7. What are the four elements of history?8. The complexity of medical decision making is based on what three elements?9. Provide the CPT code(s) for the following scenario.A 7-year-old female established patient presents to the pediatrician complaining of ear pain for the last three days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is 99° F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of otitis. Her brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, lungs, and heart. Vital signs were taken in the office. The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic. The MDM is stated to be moderate.CPT Code: ____________________10. What are the three key components that are present in every patient case except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service?11. Provide the CPT code(s) for the following clinic note.Clinic NoteCC: Patient presents for routine examination.SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination.OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without dischargeexcept for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.ASSESSMENT:1. Normal BP.2. Normal pelvic exam.PLAN: Return in 1 year or as needed.CPT Code: ____________________12. Provide the CPT code(s) for the following scenario. Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.CPT Code: ____________________13. What are the four levels of history type?14. Provide the CPT and ICD-9 diagnosis codes for the following Emergency Room scenario.SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the “eye doctor earlier today” and now has a bandage over her eye. Apparently her eye is opened underneath the bandage, and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.CPT Code: ____________________ICD-9-CM Code: ____________________15. Provide the CPT code(s) for the following hospital scenario.PROGRESS NOTE: The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.PLAN: I will continue to follow. From my standpoint, she can mobilize and weight bear as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status II.CPT Code: ____________________16. If a patient were discharged from the hospital with a diagnosis of probable myocardial infarction without a history of MI in the past, what ICD-9 code would the coder document for this stay?17. Provide the CPT and ICD-9 diagnosis codes for the following scenario.INDICATIONS: The patient had a YV advancement flap and advancement of the hamstring muscles about 3 weeks ago, but the wound separated and the muscles retracted over the area of the bone. She has had moderate separation of the wound but not complete separation, and we plan to minimally debride this area and resuture the wound with tension sutures.DIAGNOSIS: Wound dehiscence, left ischial area, partial.SURGICAL FINDINGS: A 6 cm long by about 4 cm deep wound dehiscence.PROCEDURE PERFORMED: Debridement of ischial wound by curettage with secondary wound closure.PROCEDURE: The patient was intubated and turned in the prone position. The area was prepped with Betadine scrub and solution and draped in routine sterile fashion. The area was curettaged and a piece of the tissue was placed in a culture tube. This was curettaged down to bleeding granulation tissue. I was reluctant to restart by complete debridement of all these areas, because there are factors operative in this wound that are probably beyond our control. We nevertheless completed debridement of the granulation down to bleeding tissue and put far/near, near/far tension type sutures in the wound using #2 Ethibond. I then put some Xeroform underneath the sutures that were holding the wound together and put three boxes of Kerlix Fluffs on top of this to cover some of the open areas on the thigh. The thigh sutures were also removed. I then taped the three boxes of Kerlix Fluffs to the ischial area with Elastoplast and taped around the leg to hold this in place, placing an ABD pad over the open areas where the sutures had been present. I then taped the buttock and leg up on the lumbar area with Elastoplast in such a manneras to support the ischial closure. A home health care nurse was in attendance at this time, and she was advised as to how to retape and dress this on a daily basis. The patient had two open areas of the thigh and right lower leg, one of which was a donor site, the other of which was an old skin graft with open areas. We applied Scarlet Red and ABD pads to this area. Estimated blood loss 50 cc. Otherwise, the patient tolerated the procedure well and left the area in good condition.CPT Code: ____________________ICD-9-CM Code: ____________________18. What are the three contributing factors of medical decision-making complexity?19. Steven was able to make an appointment with the orthopedist within a few hours of being seen in the ED for a splint to his left wrist after a fall. The orthopedist reviewed the x-rays from the emergency room and agreed with the emergency room physician that the distal radius was fractured. A short-arm fiberglass cast was applied, and the fracture was expected to heal in 6–8 weeks. Report the CPT code for the closed treatment of this fracture.CPT Code: ____________________20. Name four of the five graft types represented in the musculoskeletal subsection.21. Provide the CPT code(s) for the following operative report from an inpatient hospital.Operative ReportPREOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.POSTOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.PROCEDURE PERFORMED: Placement of halo.ANESTHESIA: General.PROCEDURE: Under general anesthesia, the patient’s head was prepped. The halo was applied. The pins were secured. The vest was secured. The patient was monitored with sensory evoked potentials. There were no changes throughout the case. Films were done post-op, which showed the alignment was acceptable at C6-7.CPT Code: ____________________22. Provide the CPT code(s) for the following scenario, left heart catheterization with coronary angiography and left ventriculogram.PROCEDURE: The right groin was prepped and draped in the usual fashion. Seldinger technique was used, and a 6-French sheath was placed in the right femoral artery. A local anesthetic was used and sublingual nitroglycerin was given; no heparin was used. The left and right coronary arteries were selectively opacified in the LAO and RAO projections using manual injections of Optiray. A ventriculogram was done in the RAO projection with the use of a 6-French pigtail catheter. The catheters were then withdrawn, the sheath was removed and VasoSeal applied, andthe patient was sent to her room in good condition without complications.PRESSURES: Aorta 117/63, LV 110/2-6RIGHT CORONARY ARTERY: This is a dominant vessel. There is a long segment of severe subtotal disease extending from the proximal portion to almost the mid third. The rest of this vessel also appears to be diffusely diseased. The posterior descending branch is identified and this is 80% narrowed at its ostium. There is another 90% lesion in the distal 1/3 of this vessel. The AV branch is diminutive.LEFT CORONARY ARTERY: Left main trunk is calcified and has a 60%–70% distal narrowing. Left anterior descending is severely diseased from its origin, and gives off a diagonal and septal perforator and then the LAD is totally occluded. The circumflex calcification is seen in the main trunk where moderate plaque is seen compromising the lumen about 50%–60%. The circumflex then divides into two branches; the first is the lateral branch and then a second lateral branch. The first lateral branch is severely narrowed in its proximal portion to 90%, and then has another long segment of about 75% narrowing. This does appear to be a diffusely diseased vessel. The second lateral branch also has a long segment of 90% disease distally. The terminal AV branch of the circumflex is completely occluded.LEFT VENTRICLE: End systolic and end diastolic volumes are increased. There is diffuse impairment of contractility indicating diffuse multiwall ischemia. Overall contractility is mild-to-moderately impaired with an ejection fraction of the post PVC beat being around 40% or so. No major wall segment abnormalities are noted. The mitral and aortic valves are normal. The descending aorta is slightly dilated.DIAGNOSES: 1. Coronary atherosclerosis2. Mild-to-moderate impairment of LV Function.CPT Code: ____________________23. Provide the CPT code(s) for the following scenario, placement of a dual-chamber pacemaker.Code the pacemaker placement only.Using a standard technique, the left infraclavicular subcutaneous pacemaker pocket was created with sharp and blunt dissection. The two j-tipped guidewires were advanced through a left subclavian vein using standard left subclavian venotomy under fluoroscopic guidance. The peel-away sheaths and introducers were advanced over the guidewires, and the guidewires were removed. The pacemaker leads were advanced under fluoroscopic guidance into the right ventricular apex and right atrial appendage. The pacemaker leads were seen to function adequately in vivo and were sutured in place with 0 silk. The leads were connected to the pulse generator, which was delivered into the wound in the usual fashion; 2-0 Vicryl suture was used to close the deep tissue layer and a 4-0 running subcuticular suture was used to close the skin. There were no complications of the procedure.CPT Code: ____________________24. Provide the CPT code(s) for the following scenario, replacement of pulse generator in an old pacemaker at the end of its life. After local anesthetic had been infiltrated, an incision was made over the right upper chest where the pacemaker had been implanted. The old pulse generator was removed. The new pulse generator, a Guidant Discovery DR model #1275, serial #abcdefg, was implanted. The atrium sensing was 2 mV, threshold 1.4 V, impedance 500 MHz. In the ventricle our sensing was 7 mV, threshold 1.4 V, and impedance 5600 MHz. There was no VA conduction. The new pulse generator was attached to the old leads. Left and DDD are lower rate 75, upper rate 120 beats per minute. “AV delay” 150 ms and mode switching was on. The wound was closed in layers.CPT Code: ____________________25. Provide the CPT and ICD-9 diagnosis codes for the following inpatient hospital scenario.Operative ReportPRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram.OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region. Otherwise, benign uterine cavity.PROCEDURE: The patient was taken to the operating room and a general anesthetic was administered. The patient was then prepped and draped in the usual manner in lithotomy position and the bladder was emptied with a straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single-toothed tenaculum. The uterus was then sounded to 9 cm in depth. The cervix was dilated to allow for insertion of the diagnostic hysteroscope. The uterine cavity was then inspected. Immediately apparent was a polyp arising from the left cornual region. Remainder of uterine cavity was inspected and appeared to be benign. Minimal endometrial tissue was otherwise present.At this point, the hysteroscope was removed, and polyp forceps was placed within the uterus. Attempt was made to grasp the polyp, but this could not be grabbed with the polyp forceps. Therefore, a sharp curet was used and the polyp was thereby obtained and removed. A small amount of endometrial tissue was also obtained by curettage. Once this had been completed, the hysteroscope was reinserted and the cavity was reinspected. It was confirmed that the polyp was removed. Otherwise, the endometrial canal then appeared normal. At this point, the procedure was terminated. Tenaculum was removed, and good hemostasis was ensured at the cervix. The patient tolerated this procedure well. There were no complications. Fluid in was 325 cc and was equal to fluid out at the end of the procedure. Estimated blood loss was minimal.CPT Code: ____________________ICD-9-CM Code: ____________________26. Provide the CPT code(s) for the following outpatient clinic scenario.Radiology ReportBILATERAL SCREENING MAMMOGRAM:The tissue of both breasts is heterogeneously dense. This may reduce the sensitivity of mammography. No significant masses, calcifications, or other findings are seen in either breast.IMPRESSION: NEGATIVE MAMMOGRAMThere is no mammographic evidence of malignancy. A 1-year screening mammogram is recommended.CPT Code: ____________________27. Provide the CPT code(s) for the following outpatient hospital scenario.Radiology ReportEXAMINATION: MRI of brain with contrastCLINICAL SYMPTOMS: Slurred speech, right arm weaknessMAGNETIC RESONANCE EXAMINATION OF THE BRAIN was performed prior to contrastutilizing T1-weighted sagittal views as well as spin density and T2-weighted sequences in the axial plane. These were supplemented with axial T1-weighted sequence following intravenous infusion of paramagnetic contrast material. Diffusion sequence was also performed. In the spin density and T2-weighted sequences (images 17 and 18 of series 3), there is a small localized area of occipital cortex that shows increased intensity. This is also bright in the diffusion sequence. This area is not hyperintense in the ADC map. I do not appreciate significant abnormal increased or decreased intensity within brain parenchyma of the remainder of the supratentorial brain. However, there is bilateral irregularly shaped increased intensity within the pontine tegmentum. This is not hyperintense in the diffusion sequence. Ventricles are of normal size. Normal gray-white matter delineation. No abnormal contrast enhancement of brain parenchyma.IMPRESSION: Small hyperintense area of the cortex of the right occipital lobe, as described above. This is also hyperintense in the diffusion sequence but not in the ADC map. This would indicate that this represents limited subacute infarction. I do not appreciate other areas of subacute infarction. Remainder of supratentorial portion of the brain is unremarkable. Hazy increased intensity within the pontine tegmentum. This is not unusual in the older age group (8th and 9th decades) and is sometimes thought to represent evidence of microvascular ischemic change. However, it is rarely indeterminate. In this case, I do not appreciate evidence of enlargement of the brainstem, nor is there abnormal enhancement to suggest neoplasm. I cannot elucidate further.CPT Code: ____________________28. Provide the CPT code(s) for the following inpatient hospital scenario.Dialysis Progress NoteThe patient was seen during CAPD while using 1.5% two-liter fill volumes. She is on IV fluids. She appears dry. She doesn’t have much edema, but she is feeling much better. She still has some pain and tenderness on examination, but her spirits are better today and she is eating better. She finished all her breakfast. Her cultures so far are negative. The patient is on vancomycin and gentamicin for peritonitis, and we will continue that with pharmacy. Meanwhile, we will continue current dialysis prescription. We will keep her in the hospital for a couple more days, hopefully discharge either Sunday or Monday. The patient agrees with the plan.CPT Code: ____________________29. Provide the CPT code(s) for the following scenario, pulmonary walking stress test.ENTRANCE DIAGNOSIS: Dyspnea. He gave a board rating of 5 by the time he finished; it was 3 at the beginning and showed some discomfort or effort to do this. He was able to walk 6 minutes at a slow pace without stopping. He did have some wheezing, some coughing, and was able to go 300 feet, which for this age group is relatively poor exercise tolerance. The O2 sats never dropped below 92%. This patient does not need oxygen therapy with this form of exercise.CPT Code: ____________________30. Physical status modifier P3 indicates a patient with _______ disease.31. Assign a CPT anesthesia code and applicable modifiers for anesthesia services for an 81-year-old patient with mild systemic disease who receives anesthesia for revision of total hip arthroplasty.32. Find the main term in the diagnosis of “fractured clavicle.”33. Find the main term in the diagnosis of “globe adhesions.”34. Find the main term in the diagnosis of “urinary retention.”35. Find the main term in the diagnosis of “acute pneumonia.”36. Code “personal history of peptic ulcer.”37. Code “family history of breast cancer, female.”38. Provide the ICD-9-CM codes for preoperative evaluation for elective cholecystectomy due to gallstones. Patient is seen by pulmonologist because of COPD.39. What is the CPT code assignment for simple repair of a superficial wound of the nose measuring 5.2 cm?40. To correctly code lesion excision, what must you know about the lesion(s)?41. Find the CPT code for an unlisted procedure of the neck or thorax.42. Appendix C of the CPT manual contains examples of _______.______________________________________________________________________________Questions 43–44: Using the I-9 to I-10 GEMs file, map the following codes to ICD-10.43. 427.3144. 558.1Questions 45–46: Using the I-10 to I-9 GEMs file, map the following codes to ICD-9.45. N05.846. M81.0 ................
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