2010 Buck Midterm B

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Medical Coding

Assign the appropriate ICD-9-CM code(s) for the following scenario.

Reflux nephropathy of the left kidney.

593.71
Hint: The main term is reflux and subterms vesicoureteral, with, reflux nephropathy, unilateral.

Using Appendix A of the CPT® manual, locate the modifier for bilateral procedure

-50
Hint: See Appendix A of the CPT® manual.

Assign the appropriate Evaluation and Management office visit code for the following scenario. Do not code the diagnosis.

This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
Physical Examination: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)

Impression: Ganglion cyst, right wrist.

Treatment: Refer to Dr. Andrews for further treatment.

99201 Hint: Office and/or Other Outpatient Services, New Patient

According to the CPT® Surgery Guidelines, what is the code for the following unlisted procedure: Unlisted procedure, inner ear?

69949 Hint: Unlisted services and procedures, ear, inner

Missed abortion.

632
Hint: The main term is abortion and subterm missed.

Anesthesia for bilateral vasectomy.

00921 Hint: Anesthesia, vasectomy

Mrs. Smith presented to her physician's office for an office visit for an upper respiratory infection. The physician examines the patient and prescribes antibiotics. The physician notices the patient has a suspicious looking mole. The physician examined the mole and determined that it should be removed. The mole was removed during the same office visit. The physician bills both an E/M code and a procedure code. Which modifier would you use on the E/M code? Do not code the office visit, diagnosis, or procedure.

-25
Hint: The removal of a suspicious mole is considered a separate procedure since Mrs. Smith's office visit is initially for an upper respiratory infection. See page 254 of the textbook or Appendix A of the CPT® manual.

Assign the appropriate ICD-9-CM code(s) for the following scenario.

Dysphagia, oropharyngeal phase, due to previous stroke.

438.82 , 787.22
Hint: The main term is dysphagia and subterm oropharyngeal. Note that in the code description for dysphagia, it states code 438.82 dysphagia due to late effect of cerebrovascular accident must be reported first.

Assign a CPT® anesthesia code and applicable modifiers for anesthesia services for a 9-month-old normal child who received anesthesia for hernia repair in the lower abdomen

00834-P1 Hint: Anesthesia, hernia repair, abdomen, lower. Physical status modifier P1 indicates a normal healthy patient.

Assign the appropriate Evaluation and Management code for the emergency department visit. Do not code the procedure or diagnosis.

Location: Emergency Room

SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling. This patient had right neck lymph node biopsy done 3 days ago. Patient has a dressing in place ever since then. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. She denies any accompanying fever, chills, or sweats.

PAST MEDICAL HISTORY: No known drug allergies. Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy. Medically, she has a history of depression.

REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.

OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress. Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%. HEENT: Conjunctivae and lids normal. Mouth well hydrated. Pharynx normal. Neck is supple. I have removed the dressing. There is a Pen Rose drain in place. The wound seems to be healing well. There is some soft tissue swelling which extends about 3 cm from the wound itself. There is no erythema and no warmth to the area.

ASSESSMENT: Postoperative swelling.

PLAN: I have discussed the case with the ENT surgeon. We have redressed the area. Patient is reassured and will be following up with her doctor tomorrow for drain removal.

99282 Hint: Evaluation and Management, Emergency Department

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. Assign only the home service visit. Do not code Mr. Mayors diabetes.

99341 Hint: Evaluation and Management, Home Services

Assign a CPT® anesthesia code for percutaneous liver biopsy.

00702 Hint: Anesthesia, liver

Assign the appropriate ICD-9-CM code(s) for the following scenario.

Secondary neoplasm of the upper lobe of the lung, primary unknown.

197.0,199.1,
199.1,197.0
Hint: See the Neoplasm Table. The main term for the primary code is lung and subterms upper lobe, malignant, secondary. The main term for the secondary code unknown site or unspecified and subterms primary, malignant. Please note that sequencing will depend on the treatment.

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 is determined that Mr. Jones has a fractured hip that will require surgical intervention. Mr. Jones is taken later that day to the operating room (OR) where Dr. Ortho performs the surgical procedure to repair Mr. Jones' hip. Which modifier would you use for the hospital visit? Do not code the office visit, diagnosis, or procedure.

-57
Hint: Because the decision for surgery was made on the same day Mr. Jones was admitted to the hospital, modifier -57 must be reported. See page 266 of the textbook or Appendix A of the CPT® manual.

Anesthesia for tracheobronchial reconstruction.

00539 Hint: Anesthesia, trachea, reconstruction

Assign ICD-9-CM code(s) to the following scenario.

Head injury (with no loss of consciousness) due to falling object while at a store.

959.01 , E916 , E849.6,E916
Hint: The main term for the primary code is injury and subterm head. See the Index to External Causes to Injury to obtain the E codes. The main term for the secondary code is fall and subterm object. See also hit by, object, falling. To code the place of occurrence, see accident, occurring, store. The E codes can be listed in any order.

According to the CPT® Surgery Guidelines, what is the code for the following unlisted procedure: Unlisted procedure, nervous system?

64999 Hint: Unlisted services and procedures, nervous system surgery

Assign the appropriate Evaluation and Management office visit code for the following scenario. Do not code the diagnosis.

A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101º F yesterday. Mom treated her with Tylenol. The fever this AM is 99º F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. 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.

99214 Hint:
Evaluation and Management, Office and Other Outpatient

With the use of the Surgery Guidelines in the CPT® manual, locate the unlisted code for the following procedure:

Unlisted vascular endoscopy procedure

37501 Hint: Endoscopy, vascular, surgical

The two-digit modifier for a repeat procedure by the same physician is

76.
Hint: See Appendix A of the CPT® manual.

Assign the appropriate Evaluation and Management office visit code. Do not code the diagnoses.

CLINIC NOTE

CC: 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 discharge except 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.

99396 Hint: See Preventive Medicine

Assign ICD-9-CM code(s) to the following scenario.

A multi-gravid patient presents for routine prenatal visit. No complications are noted.

V22.1
Hint: The main term is prenatal and subterm care, normal pregnancy.

Assign the appropriate ICD-9-CM code(s) for the following scenario.

Medial meniscus tear, old.

717.3
Hint: The main term is tear and subterms meniscus, old.

Anesthesia for diagnostic arthroscopic procedure of the knee joint.

01382 Hint: Anesthesia, knee

Mrs. Roberts falls at work. She claims that she is alright, but her employer's workers' compensation policy requires that she see a physician to confirm she was not injured when she fell. The physician files a claim to the Workers' Compensation carrier. Which modifier would you use when reporting the physician's service to the patient? Do not code the office visit or diagnosis.

-32
Hint: Modifier -32 is commonly used by third-party payers (e.g., Workers' Compensation) who require a physical examination be obtained after a patient is injured from his or her job. See page 256 of the textbook or Appendix A of the CPT® manual.

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.

01215-P2, 99100
Hint: To locate the anesthesia code, see anesthesia. Physical status modifier P2 indicates patient with mild systemic disease. A qualifying circumstance code is reported due to the patient's extreme age. To locate this code, see anesthesia, special circumstances, extreme age.

Daily hospital management of epidural, continuous drug administration.

01996 Hint: Anesthesia, other procedures, daily hospital management

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. Assign only the critical care service codes. Do not include 'X1' or 'X2' with the codes.

99291, 99292
Hint: Evaluation and Management, Critical Care

Assign a CPT® anesthesia code for Strayer procedure.

01474 Hint: Anesthesia, Strayer procedure

Assign the appropriate ICD-9-CM code(s) for the following scenario.

Closed fracture right ankle from fall off bicycle while riding his bike in the park.

824.8 , E826.1, E849.4
Hint: The main term for the primary code is fracture and subterm ankle. If a fracture is not indicated as closed or open, it should be classified as closed. The main term for the secondary code (see Index to External Causes of Injury) is fall and subterm from bicycle. The fifth digit '1' indicates pedal cyclist. The main term for the third code (see Index to External Causes of Injury) is accident and subterms occurring, park. The E-codes can be listed in any order.

Assign the appropriate Evaluation and Management office visit code for the following scenario. Do not code the diagnosis.

CHART NOTE

CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration

OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted

ASSESSMENT: Hemorrhoid

PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.

99212
Hint:
Office and/or Other Outpatient Services, Office Visit, Established Patient

Anesthesia for radical hysterectomy.

00846 Hint: Anesthesia, hysterectomy, radical

Assign ICD-9-CM code(s) to the following diagnosis.

Bursitis NOS.

727.3
Hint: See Bursitis NEC

According to the CPT® Surgery Guidelines, what is the code for the following unlisted procedure: Unlisted procedure, cardiac?

33999 Hint: Unlisted services and procedures, cardiac

With the use of the Surgery Guidelines in the CPT® manual, locate the unlisted code for the following procedure:

Unlisted procedure, excision pressure ulcer

15999 Hint: Ulcer, pressure

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