AH 213 Grantham University Basic Procedure Coding Worksheet

230Chapter 18
ASSIGNMENT 18.2 – C.ODING MEDICINE REPORTS
Instructions
Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT medicine code(s) and the
appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes.
1. CAROTID ULTRASOUND
DIAGNOSIS: Screening exam, risk factors for cardiovascular disease.
Multiple real-time images were made of both carotid arteries from the supraclavicular area to the bifurcation.
The common carotid arteries are of normal caliber bilaterally with no evidence of any plaque formation or
stenosis. The bifurcations are well demonstrated bilaterally and are normal. There is a very tiny calcified
plaque involving the posterior wall of the left carotid artery just proximal to the bifurcation. This is only
about 2 mm in size, and I do not think it is significant.
CONCLUSION: Normal carotid ultrasound.
2. ELECTROENCEPHALOGRAM (EEG)
COMPLAINT: Seizure.
CURRENT MEDICATIONS: Phenobarbital, Theo-Dur, Peri-Colace.
STATE OF PATIENT DURING RECORDING: Awake.
DESCRIPTION OF EEG: The background is not well developed. Much muscle tension artifact is
superimposed; electrode artifact also present at times. No spike-wave discharges, paroxysmal slowing, or
focal abnormality present. Hyperventilation procedure was not done. Sleep did not occur. Total recording
time was 35 minutes.
EEG INT ERPRETATION: Normal EEG.
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CPT Medicine
231
3. SPEECH LANGUAGE EVALUATION
Patient was administered a complete Boston Diagnostic Aphasia Examination test for aphasia and was placed
in the 41st percentile of all aphasics. Individual test scores were characterized with a severe involvement in
graphic abilities, a marked involvement in gestural abilities, a moderate involvement in verbal abilities, and a
mild to moderate involvement in auditory and visual receptive abilities. During the testing, many responses
were repeated and cued. Patient showed a moderate involvement in reading abilities. Patient also
demonstrated a severe involvement in graphic abilities. However, this is misleading because patient refused
to do any graphic tests. I am uncertain at this point as to how well this patient can do graphically. The test
results on the graphic tests also dropped her overall score a great deal.
However, a positive high/low gap was noted between the scores. This suggests that speech therapy will benefit
this patient. Patient was given an oral exam, and no abnormalities were noted. Patient refused a hearing test.
Patient was very, very nervous during the whole testing, and it was very hard to relax her. This may also have
affected her test scores and helped in the refusing of the graphic part. Speech therapy is recommended daily
for the patient.
4. STRESS TEST (OUTPATIENT)
FINDINGS: The patient is a 62-year-old female who has paroxysmal atrial tachycardia and takes Inderal
40 mg four times a day and Lanoxin 0.25 mg daily for this. She has also complained of some chest discomfort
and has had some mild hypertension for which she takes Dyazide once a day. She is referred to take an
outpatient stress test to rule out coronary artery disease.
The patient was prepared in the usual fashion. Electrodes were applied to the chest. She was taken at
1.6 metabolic equivalents (METs), 3 METs, 6 METs, and 9 METs during her exercise on the treadmill. During
that time, her pulse rate increased linearly from 60 up to 150. The systolic blood pressure increased from
140 to 160. The blood pressure at the final MET level apparently was not recorded. During the course of the
test, the patient did not really complain of chest pain, but she did become quite noticeably tired and short of
breath, complaining of some tightness in her chest and feelings of weakness and dizziness. The rhythm strips
at 1.6, 3, and 6 METs did not show any real ST segment depression. However, at the 6-MET level, there was
noted about a 1/2-mm horizontal ST segment depression. At 9 METs, the changes were somewhat more
pronounced with about a 1-2 mm. ST segment depression was actually horizontal to downward sloping.
With these changes at 9 METs, I would think that this is sort of a borderline test with indeed some signs of
positive at 9 METs. At this point, I would think this lady probably could be watched. She is essentially
asymptomatic at rest and at low levels of exercise. I will continue her medications and see her frequently in
the office if her, symptoms increase. It may be that she should be restressed or at any rate that she should have
yearly stress tests to keep tabs on the status of her coronary arteries. If the symptoms worsen and so forth, it
might be worth referral for further studies.
DIAGNOSES: Paroxysmal atrial tachycardia. Chest pain. Hypertension. Rule out coronary artery disease.
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232
Chapter 18
5. RESPIRATORY THERAPY
SUBJECT: Patient was seen in the office with complaints of shortness of breath.
OBJECTIV E: Patient received one hour of continuous inhalation treatment with 0.3 cc Alupent/2 cc NS via
mask at 6 LPM aerosol medication for acute airway obstruction. Bilateral sounds very coarse with fair
aeration and severe upper airway congestion with audible stridor. Good respiratory effort with severe
suprasternal and substernal and intercostal retractions. CPAP initiated during this encounter to improve
breathing.
ASSESSMENT: Slight changes with nebulizer.
PLAN: Copious amounts of thick beige secretions from patient. Fair aeration on CPAP with moist rales and
rhonchi at right base. Ambulance was called and patient is being transported to the hospital for direct
admission to the ICU.
6. PHYSICAL THERAPY
INITIAL EVALUATION AND BEHAVIOR/MAIN COMPLAINT: Patient has history of back pain off and
on for five years. Recently, patient had severe back pain radiating down right lower extremity (RLE). Pain
is worse when rising after lying; it is also severe upon sitting for more than a few minutes and when bending
while sitting.
JOINT EVALUATION: Pain upon straight leg raising right leg at 45 degrees. Pain is in right buttock and
down posterior right thigh and leg. Pain also when flexing trunk on hips in same areas.
MUSCLE/MOTOR EVALUATION: Not evaluated for muscle power. Patient has muscle spasms of moderate
degree in the right lower quadrant (RLQ) of the back.
FUNCTIONAL EVALUATION: Moves about easily in no apparent discomfort. When ambulating, no limp;
but patient states pain is immediate upon coming to sitting or standing position.
SENSATION: Burning pain, sometimes numbness down RLE from buttock to ankle. Pain is present unless
patient lies reclined.
OTHER COMMENTS: Patient had myelogram on 09/11/YY. This has not definitely concluded that she has a
ruptured disc. Moist heat applied to back provides no relief according to patient.
PLAN: Modalities to be used; whirlpool and hot packs for six weeks, twice per week for 30 minutes.
DIAGNOSES: Severe back pain. Muscle spasms, RLQ of back. Burning pain with numbness, RLE.
7. HAIR ANALYSIS
DIAGNOSIS: Rule out alopecia or hair shaft abnormality.
The patient is a 45-year-old female who has been diagnosed with hypothyroidism. She is seen in the office
today with complaints of hair loss. Hair was removed from the patient’s scalp and examined under the
microscope. Extracted hairs show that 20 percent are in telogen. This level is within the expected
normal range.
DIAGNOSIS: Alopecia (unrelated to hypothyroidism).
8. Lisa Morales is a type 1 diabetic patient who presents for the refilling of her insulin pump. The pump is
identified as a Paradigm model number 515/715, and 250 units per milliliter of insulin was placed in the
pump. The patient is discharged.
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Current Procedural Terminology© 2016 American Medical Association. All Rights Reserved.
Basic Procedure Coding Systems – Week 7 Assignment 1
Medicine Section Coding Practice
Assignment 18.2 – Coding Medicine Reports Chapter 18
ICD Codes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
CPT Codes
CPT Evaluation and Management
135
ASSIGNMENT 9.2 – ASSIGNING EVALUATION AND MANAGEMENT 1:0DES
At the conclusion of this assignment, the student should be able to:
• Interpret the use of key components when locating evaluation and management codes.
• Assign CPT evaluation and management codes.
Overview
The levels of evaluation and management (E/M) services code descriptions include seven components.
• History
•
Coordination of care
• Examination
• Nature of presenting problem
• Medical decision making
• Time
• Counseling
The key components of history, examination, and medical decision making are required when an E/M level of
service code is selected. For new patients, all three key components must be considered when codes are assigned.
For established patients, two of the three key components must be considered when codes are assigned. This
means that documentation in the patient’s chart must support the key components used to determine the E/M
code selected.
Contributory components include counseling, coordination of care, nature of presenting problem, and time;
they are used to select the appropriate E/M service code when patient record documentation indicates that they
were the focus of the visit. Counseling and/or coordination of care components drive CPT code selection only
when they dominate the encounter (e.g., office visit), requiring that more than 50 percent of the provider’s time
be spent on such components. In such circumstances, the provider must be sure to document these elements
carefully so as to support the higher-level code selected. (Some E/M code descriptions include notes about time
and nature of the presenting problem to assist in determining the appropriate code number to report.)
Instructions
Assign the ICD-10-CM code(s) according to outpatient coding guidelines (e.g., assign codes to signs and
symptoms when a diagnosis has not been established), and assign the CPT evaluation and management code(s)
and appropriate modifier(s). Do not assign ICD-10-CM external cause codes.
1. Jim Davis (age 28) was admitted to the hospital by his primary care provider, Dr. Jackson. During the
hospitalization, Dr. Jackson asked Dr. Morales to provide consultation services for the patient to rule out a
rash due to an allergy. (Dr. Morales is an ENT doctor who specializes in allergies and sinus problems.)
Dr. Morales provided inpatient consultation services to Mr. Davis during his inpatient admission for a total
body rash. Dr. Morales documented a comprehensive history, a comprehensive examination, and medical
decision making of moderate complexity. Dr. Morales ordered allergy blood tests, which were negative.
2. Gerry Smith w’as seen in the emergency department (ED) following a house fire. The patient sustained third­
degree burns over 20 percent of his body and second-degree burns over 10 percent of his body, resulting in a
total of 30 percent of his body being burned. Based on information obtained from the patient’s Medic Alert
bracelet, the patient has type 2 diabetes mellitus and a heart condition. The ED physician documented a
detailed examination and medical decision making of high complexity. The patient was unable to provide any
history due to severe pain, which made it impossible for him to speak. Therefore, the ED physician obtained a
detailed history from the patient’s spouse. The ED physician documented a total of 80 minutes spent with this
patient before the patient was transferred to the hospital’s inpatient burn unit. During the 80 minutes, the
patient had an episode of ventricular tachycardia, which converted with medication. The patient’s blood sugar
was closely monitored in the ED.
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136
Chapter 9
3. Kate Martin is a long-time patient of Dr. Hardy’s office, and she presents to the office today with the
complaint of “feeling very tired all of the time even after sleeping for eight hours:’ The patient reports that she
has been feeling this way for the past three weeks. The physician documented a detailed history, an expanded
problem focused exam, and medical decision making of low complexity.
4. New patient Daniel Cook presented to Dr. Lowell’s office today because he is new to the area and needs to
establish himself with a physician. He explained that he has asthma for which he takes a prescription
medication and that he is almost out of his medication. No medical history other than asthma is reported,
and old health records from his previous primary care physician are unavailable. The review of systems is
positive for asthma. During today’s visit, the patient complained of a sore throat and loss of appetite. These
symptoms have been present for four days, per the patient. The patient describes the sore throat pain as on
and off with worsening in the morning and late at night. The patient has taken only his prescribed asthma
medication. He has not taken any over-the-counter medications in an attempt to relieve the sore throat. The
patient stated that he needs a refill of his asthma medications, which the physician provided. The physician
also instructed the patient to take Tylenol to relieve his sore throat symptoms and to eat foods that will not
irritate his throat, such as soup. The patient was further instructed that if the sore throat and loss of appetite
did not abate in five to seven days, the patient should contact the office to obtain a follow-up appointment.
The physician documented a detailed examination and medical decision making of moderate complexity.
(NOTE: Use the E/M CodeBuilder in Appendix I of your textbook to determine the level of history
performed.)
5. The patient is a 52-year-old female presenting to the emergency department (ED) after falling down an
embankment while hiking on her single-family private residential 25-acre property with her dog. (The patient
reminded me that her residential 25-acre property is considered her yard for the purpose of assigning an
external cause “place of occurrence” code.) The patient complains of left wrist pain. The ED physician
diagnosed left wrist sprain and wrapped the wrist with an Ace bandage. The physician documented an
expanded problem focused history, a detailed examination, and medical decision making of moderate
complexity.
6. Mrs. Austin has been a resident of a nursing facility for the past year due to Alzheimer’s disease. Today during
this month’s follow-up visit by her primary care physician, she was seen for a chief complaint of difficulty
sleeping. The patient states that she is sleeping only a few hours each night and often awakens around 3 AM
and is unable to go back to sleep. The primary care physician prescribed medication to treat the patient’s
inability to sleep, and he reviewed the patient’s Alzheimer’s disease prescription medications to ensure that no
adverse reaction would result from her taking the prescribed sleep medication. He documented a problem­
focused history, a detailed examination, and medical decision making of low complexity.
7. A patient was seen by her primary care physician for an initial inpatient visit. She was admitted to the hospital
for an intestinal obstruction. The patient was previously diagnosed with bone cancer, which was treated last
year. The attending physician documented a detailed history, comprehensive examination, and medical
decision making of high complexity.
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CPT Evaluation and Management
137
8. Ms. Hardy was seen in Dr. Stockwell’s office. This patient was referred by her primary care physician due to
complaints of muscle weakness and diplopia. The consulting physician, Dr. Stockwell, documented a
comprehensive history, a detailed examination, and medical decision making of moderate complexity.
9. A patient presented to her family physician’s office with the chief complaint of aching muscles. The patient
has fibromyalgia and was last seen two months ago for exacerbation of her symptoms. The physician
documented a detailed history, a comprehensive examination, and medical decision making of moderate
complexity.
10. The attending physician was preparing to discharge a patient for an inpatient hospital stay, during which time
the patient’s acute bronchitis was treated. The physician examined the patient and reviewed discharge
instructions with the patient and the family. The physician also contacted home health services for the
patient’s continued care. The total time spent discharging the patient was 45 minutes.
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Current Procedural Terminolog y© 2016 American Medical Association. All Rights Reserved.
Basic Procedure Coding Systems – Week 8 Assignment 1
Assigning Evaluation & Management Codes
Assignment 9.2 – Assigning Evaluation and Management Codes Chapter 9
ICD Codes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
CPT Codes