1. Level II codes are not used to report services for patients in this setting? inpatient

Level II codes are not used to report services for patients in this setting?

Subjective: Six-year-old girl had her arm twisted on the play ground. She is seen in the ED complaining of pain in her wrist.Objective : Vital Signs: stable. Wrist: A lot of tenderness laterally. X-ray is normalAssessment: Wrist sprainPlan: Anaprox. Give twice daily with hot packs. Recheck if no improvement.What would the E/M code be for this visit?

Codes: 99281


3.

Which of the following would be used to code drugs?

Codes: J codes
4.

Margaret has a cholecystoenterostomy with a Roux-en-Y; five hours later she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and peritonitis was setting in. What is the correct coding for the subsequent services on this date of service? The same surgeon who performed the original operation took her back to the OR.

Codes: 49402-78


5.

A patient is issued a 22-inch seat cushion for his wheelchair.

Codes: 58150-22

A 65-year-old male Medicare patient presents for a digital rectal examination and a total prostate-specific antigen (PSA) screening test. His father and brother had prostate cancer.

Codes: G0102, G0103, V76.44, V16.42


8.

A 46-year-old white male suffered back pain after heavy lifting and was found to have bilateral disk herniation. The patient was placed prone and general anesthesia given. Incision was then made with a 10-blade knife and dissection was carried downward through the thick adipose tissue to the fascia in a subperiosteal plane. The paraspinous muscles were reflected off L5 and S1. A laminotomy was drilled with the Midas Tex AMB on the inferior end of L5 on both sides. The thecal sac was retracted medially. A microscope was brought in, direct with microdissection. There was a massive disk herniation on the right side underneath the nerve root as well as the left. The disk was incised with an 11-blade knife and was cleaned out first on the right and then on the left with a series of straight and angled curets and rongeurs. The disk was intertwined with the posterior longitudinal ligament. The space was cleaned out, the foramina were checked and no further compression was found on any of the neural elements. What are the correct codes for this procedure?

Codes: 63030-50


9.

Dr. Smith is treating a 72-year-old female with a ureteral obstruction caused by a stricture from post operative and post radiation scarring from treatment of transitional cell cancer. The patient requires removal and replacement of an internal dwelling ureteral stent. Dr. Smith advances a diagnostic catheter under conscious sedation into the bladder and injects contrast to opacity the bladder. A guide wire is advanced into the bladder and the diagnostic catheter is exchanged for a larger catheter to allow the use of a snare device. Under the fluoroscopic guidance the snare device is negotiated into the bladder through the sheath and used to grasp the pigtail portion of the double-J ureteral stent tube within the bladder and the indwelling stent tube is pulled out of the bladder and urethra far enough to allow retrograde introduction of a guide wire through the stent, directed into the renal pelvis. Using fluoroscopic guidance to negotiate the wire through the inner lumen of the ureteral stent tube rather than through side holes a diagnostic catheter is positioned over the wire into the renal pelvis, allowing opacification of the renal pelvis. The guide wire is repositioned into the renal pelvis and the diagnostic catheter removed. A new double-J ureteral stent tube is introduced and positioned. The guide, sheath and safety wire are removed after appropriate position is confirmed with fluoroscopy and a permanent image is obtained for the medical record.What code would be used to describe the exchange?

Codes: 50385


10.

All third-party payers require the use of HCPCS codes in submissions for service provided to any patient.

A 27-year-old triathelete is thrown from his bike on a steep downhill ride. He suffered a severely fractured vertebra at C5. An anterior approach is used to dissect out the bony fragments and strengthen the spine with titanium cages and arthrodesis. The surgeon places the patient supine on the OR table and proceeds with an anterior corpectomy at C5 with diskectomies above and below. Titanium cages are placed in the resulting defect and morselized allograft bone is placed in and around the cages. Anterior synthes plates are placed across C2-C3 and C3-C5, and C5-C6. What is the best way to code for this?

Codes: 63081, 22554-51, 22846, 22851, 20930
12.

A 45-year-old male with a previous biopsy positive for malignant melanoma, presents for definitive excision of the lesion. After induction of general anesthesia the patient is placed supine on the OR table, the left thigh was prepped and draped in the usual sterile fashion. IV antibiotics are given as patient had previous MRSA infection. The previous excisional biopsy site on the left knee had measured approximately 4 cm and was widely elipsed with a 1.5 cm margin.. The excision was taken down to the underlying patellar fascia. Hemostasis was achieved via electrocautery. The resulting defect was 11cm x 5cm. Wide advancement flaps were created inferiorly and superiorly using electrocautery. This allowed the skin edges to come together without tension. The wound was closed using interrupted 2-0 monocryl and 2 retention sutures were placed using #1 Prolene. Skin was closed with a stapler. Choose the correct code(s) for this note.

Codes: 14301


13.

PRE-OPERATIVE DIAGNOSIS: Esophageal reflux; dysphagia; epigastric painPOST-OPERATIVE DIAGNOSIS: Acute gastritis; hiatal herniaOPERATION: EGD with biopsy using forceps.SPECIMEN: Biopsy from GE junctionGROSS FINDINGS: No evidence of esophageal strictures or narrowing or varicosities but there was some inflammation noted at the GE junction on the stomach side. Representative biopsies were performed. Remaining part of the stomach and duodenum were unremarkable. She had moderated hiatal hernia. OPERATIVE PROCEDURE: Once the patient was properly identified and consent reviewed, the patient was brought to the endoscopy suite. Patient was placed in the supine semi-seated position. Flexible endoscope was passed under direct visualization into the esophagus. Esophagus was insufflated. Scope was advanced. Esophagus and GE junction were normal appearing. Right at the GE junction just distal to it on the stomach side, there were inflammatory changes and area of inflammation. No evidence of active bleeding or ulceration. Representative biopsies were performed of this locale. Stomach was insufflated. Scope passed through the GE junction into the stomach. Stomach was insufflated. Scope was retroflexed. Cardia, fundus and antrum remaining parts were unremarkable. Scope was then advanced through the pylorus to the duodenum and passed duodenal sweep. Duodenum was unremarkable. What are the code(s) for this encounter? Codes: 43239, 535.00, 553.3

Which HCPCS modifier indicates the great toe of the right foot?

Codes: T5


15.

Mrs. Mertz goes to the procedure room to have a permanent pacemaker implanted. She is given a mild sedative and the area just under the right clavicle is prepped and draped in a sterile manor. An incision is made to create a pocket for the pulse generator. A venogram is shot through an indwelling antecubital IV and a catheter is threaded from the pocket into the right subclavian vein. The catheter is then advanced into the right atrium under fluoroscopic guidance. Using the Seldinger technique the catheter is withdrawn over a guide wire and a 32 FR Medtronic pacing wire is threaded back over the guide wire and into the right atrium under fluoroscopy. The guide wire is removed and the pacing tip is screwed into the myocardium. Thresholds are tested for sensing and capture. The lead is then attached to the pulse generator and placed into the pocket. The pocket is closed with interrupted 4-0 Prolene. Choose the correct code(s).

Codes: 33206, 71090-26, 75820 - 26
16.

A 72-year-old male Medicare patient receives 30 minutes of individual diabetes outpatient self-management training session. The patient is a newly diagnosed type II diabetic.

Codes: G0108, 250.00


17.

Dr. Smith sees a patient referred by his partner who is also an orthopedic surgeon regarding the ongoing treatment of a tibial fracture that happened 3 weeks ago. The patient’s mom is concerned that it may not be healing. Dr. Smith reviews and updates the patient’s complete PFSH and performs a problem focused exam and makes no changes to the existing fracture care. What is the CPT code for this encounter?

Codes: 99024


18.

Date: 02/01/XXSurgeon:PRE-OPERATIVE DIAGNOSIS: MenorrhagiaPOST-OPERATIVE DIAGNOSIS: MenorrhagiaOPERATION: D&C; hysteroscopyANESTHESIA: IV sedationGROSS FINDINGS: Evaluation under anesthesia revealed a normal sized and shaped uterus. No adnexal masses were palpated. No cervical, vaginal or external genitalia lesions. Hysterscopic visualization of the endocervix revealed no lesions. Hysteroscopic visualization of the endometrial cavity revealed a normal sized and shaped cavity with a homogenous light yellow pinkish endometrium. There was an approximately 1 cm polyp in the left fundal area.OPERATIVE PROCEDURE: After adequate IV sedation, the patient was placed in the dorsal lithotomy position. The vaginal area was prepped with Betadine and aseptically draped. The anterior cervical lip was grasped with a Behr’s clamp. A hysteroscope was passed using normal saline to expand the cavity. The above findings were noted. The hysteroscope was removed. Endocervical curettage was performed with a small sharp curet. Tissue sent: laveled endocervical curettings. Cervical os was progressively dilated with #29 Pratt dilator. Sharp curettage of the endometrium was performed. Polyp forceps were passed. It appeared the polyp had been produced. The hysteroscope was reinserted and the cavity appeared empty. Tissue was sent labled endometrial curettings. Instruments were removed from the vagina. Good hemostatsis was noted. Estimated blood loss was 10cc. Patient to recovery room in satisfactory condition.

Codes: 58558, 626.1
19.

A 52-year-old male has scheduled a colonoscopy due to a strong family history for colon CA. He is on the table and the physician finds multiple polyps in the transverse colon. The physician removes two of the polyps with a snare and a third with hot biopsy forceps. What are the correct CPT and ICD-9-CM codes for this encounter?

Codes: 45385, 45384-59; 211.3, V16.0


20.

OPERATIVE REPORTOPERATIVE PROCEDURE: Excision of back lesion.INDICATIONS FOR SURGERY: The patient has an enlarging lesion on the uppermidback.FINDINGS AT SURGERY: There was a 5-cm, upper midback lesion.OPERATIVE PROCEDURE: With the patient prone, the back was prepped anddraped in the usual sterile fashion. The skin and underlying tissues wereanesthetized with 30 mL of 1% lidocaine with epinephrine.Through a 5-cm transverse skin incision, the lesion was excised. Hemostasis wasensured. The incision was closed using 3-0 Vicryl for the deep layers and running3-0 Prolene subcuticular stitch with Steri-Strips for the skin.The patient was returned to the same-day surgery center in stable postoperativecondition. All sponge, needle, and instrument counts were correct. Estimatedblood loss is 0 mL.PATHOLOGY REPORT LATER INDICATED: Dermatofibroma, skin of back.Assign code(s) for the physician service only.

Codes: 11406, 12032, 216.5



21.

A patient sees Dr. Smith for a consult at the request of his PCP, Dr. L for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The patient agrees that he would like to be tested to possibly have better control on his allergies and ongoing care for them. Dr. Smith sends a report back to Dr. L thanking him for the referral and the date the patient is set up for allergy testing along with his findings from the encounter. What is the E/M code?

Codes: 99242



22.

OPERATIVE REPORTPREOPERATIVE DIAGNOSIS: Open fracture, left humerus, with possible loss ofleft radial pulse.PROCEDURE PERFORMED: Open reduction internal fixation, left open humerusfracture.PROCEDURE: While under a general anesthetic, the patient's left arm wasprepped with Betadine and draped in sterile fashion. We then created alongitudinal incision over the anterolateral aspect of his left arm and carried thedissection through the subcutaneous tissue. We attempted to identify the lateralintermuscular septum and progressed to the fracture site, which was actuallyfairly easy to do because there was some significant tearing and rupturing of thebiceps and brachialis muscles. These were partial ruptures, but the bone wasrelatively easy to expose through this. We then identified the fracture site andthoroughly irrigated it with several liters of saline. We also noted that the radialnerve was easily visible, crossing along the posterolateral aspect of the fracturesite. It was intact. We carefully detected it throughout the remainder of theprocedure. We then were able to strip the periosteum away from the lateral sideof the shaft of the humerus both proximally and distally from the fracture site. Wedid this just enough to apply a 6-hole plate, which we eventually held in place withsix cortical screws. We did attempt to compress the fracture site. Due to somecomminution, the fracture was not quite anatomically aligned, but certainly it wasfelt to be very acceptable.Once we had applied the plate, we then checked the radial pulse with a Doppler.We found that the radial pulse was present using the Doppler, but not withpalpation. We then applied Xeroform dressings to the wounds and the incision.After padding the arm thoroughly, we applied a long-arm splint with the elbowflexed about 75 degrees. He tolerated the procedure well, and the radial pulsewas again present on Doppler examination at the end of the procedure.

codes: 24515-LT, 812.31, E887
23.

The patient’s mom presents to the pediatrician with her 12-month-old daughter for ongoing chronic otitis media. The patient’s otitis has failed to respond to the most recent antibiotic therapy prescribed by the pediatrician. The patient’s mom is concerned about hearing loss. The tympanogram done in office reveals a slight loss and the eardrum is still red and inflamed on the right ear. The left ear also has impacted cerumen. After performing a problem focused history and exam, Dr. Smith decides to send the patient to an ENT for evaluation and possible insertion of tubes. In the interim, the physician prescribes electronically a new prescription of antibiotics to the local pharmacy. What are the correct codes for this encounter, assuming the physician is participating in an e-prescribing pay for performance program and has a qualifying system?

Codes: 99212, 92567, 382.9, 380.4

24.

A 55-year-old man with an elevated PSA of 6.5 presents for a biopsy of his prostate. Dr. Smith documents the patient is placed in the left lateral position. Prostate volume was determined at 50.7g. Some calcifications were found in the right lobe, with no obvious hypoechogenic abnormality. The base of the prostate was infiltrated and under ultrasonic guidance random biopsies were performed. The pathology report later showed benign prostate tissue. The physician performed the procedure in his office. What are the correct code(s) for this encounter?

Codes: 55700, 76942

Mrs. Mertz has severe atrial fibrillation. She presents today for an EPS study. Dr. H. Throb performs the professional component of a comprehensive EPS study, which includes right atrial and ventricular pacing/recording, bundle of His recording and induction of atrial fibrillation. How should this service be coded?

Codes: 93620 – 26

26.

After reading the following operative report, select the best coding solution.The patient was taken to the operating room, identified and the procedure verified. She was placed on the operating table and IV sedation was given. She was placed in a dorsal lithotomy position, prepped and draped in the usual sterile fashion. The right vulvar lesion was anesthetized with 1% lidocaine with epinephrine. The excision measured 2.1 x 1.6 cm with the underlying tissue measuring 0.3 cm in thickness. A horizontal oval incision was made around this, and it was dissected sharply off the underlying fatty tissue. It was oriented at 12 o’clock with a stitch and sent for pathologic evaluation. The perineal skin defect was closed in layers, first with an interrupted stitch of 2-0 Vicryl, then an interrupted stitch of 3-0 Vicryl. The skin was then approximated with 2 mattress sutures of 3-0 nylon. The remaining skin was closed with 3-0 chromic in a running subcuticular stitch. Neosporin and sterile dressing was applied. The patient was awakened then and transferred to the recovery in stable and satisfactory condition. Final diagnosis was condyloma acuminatum with mild squamous dysplasia.

Codes: 11423, 12041-51
27.

A patient with chronic lumbar pain previously purchased a TENS and now needs replacement batteries.

Codes: A4630

28.

SAME-DAY SURGERYDIAGNOSIS: Inverted nipple with mammary duct ectasia, left.OPERATION: Excision of mass deep to left nipple.With the patient under general anesthesia, a circumareolar incision was madewith sharp dissection and carried down into the breast tissue. The nipple complexwas raised up using a small retractor. We gently dissected underneath to free upthe nipple entirely. Once this was done, we had the nipple fully unfolded, andthere was some evident mammary duct ectasis. An area 3 × 4 cm was excisedusing electrocautery. Hemostasis was maintained with the electrocautery, andthen the breast tissue deep to the nipple was reconstructed using sutures of 3-0chromic. Subcutaneous tissue was closed using 3-0 chromic, and then the skinwas closed using 4-0 Vicryl. Steri-Strips were applied. The patient tolerated theprocedure well and was returned to the recovery area in stable condition. At theend of the procedure, all sponges and instruments were accounted for.

Codes: 19120-LT, 610.4

29.

OPERATIVE REPORTCode only the operative procedure and diagnosis.PREOPERATIVE DIAGNOSIS:1. Hypoxia2. PneumothoraxPOSTOPERATIVE DIAGNOSIS:1. Hypoxia2. PneumothoraxPROCEDURE: Chest tube placementDESCRIPTION OF PROCEDURE: The patient was previously sedated withVersed and paralyzed with Nimbex. Lidocaine was used to numb the incisionarea in the midlateral left chest at about nipple level. After the lidocaine, anincision was made, and we bluntly dissected to the area of the pleural space,making sure we were superior to the rib. On entrance to the pleural space, therewas immediate release of air noted. An 18-gauge chest tube was subsequentlyplaced and sutured to the skin. There were no complications for the procedure,and blood loss was minimal.DISPOSITION: Follow-up, single-view, chest x-ray showed significant resolutionof the pneumothorax except for a small apical pneumothorax that was noted.

Codes: 32551, 512.8, 799.02


30.

A patient presents for trimming of 10 dystrophic toenails.

Codes: G0127, 703.8


31.

An 82-year-old female Medicare patient has a single energy x-ray absorptiometry (SEXA) bone density study of two sites of the wrist. The patient has osteopenia and is complaining of wrist pain.

Codes: G0130, 733.90, 719.43


32.

A Medicare patient presents for an influenza vaccination and pneumococcalvaccination. This is the only service rendered.

Codes: G0008, G0009, V06.6


33.

PRE-OPERATIVE DIAGNOSIS: Change in bowel habits, family Hx of colon carcinomaPOST-OPERATIVE DIAGNOSIS: multiple colon polypsOPERATION: Colonoscopy with polypectomy using snareANESTHESIA: MACOPERATIVE PROCEDURE: Once patient was properly identified, consent reviewed, patient was brought to endoscopy suite where procedure was verified by patient as well as surgeon. Patient was placed in the Sims position. On rectal exam, he had good sphincter tone. No masses palpable. No evidence of any external anal disease. Normal external genitalia. He does have a urinary catheter in. He had very poor prep; significant amount of irrigation was needed to irrigate out his colon to help facilitate the examination but once that was done, good visualization was then obtained. Patient had multiple polyps of the sigmoid colon, another polyp removed at 55 cm and another polyp removed from the right colon. All polyps were removed by snare and sent to pathology for opinion. Code this procedure.

Codes: 45385, 211.3, V16.0


34.

A 14-year-old boy was thrown against the window of the car on impact. The resulting injury was a star shaped pattern cut into the top of his head. On presentation to the ER the MD on call for plastic surgery was asked to evaluate the injury and repair it. The surgeon performed an expanded problem focused H&P. Medical Decision Making was moderate. The total length of the intermediate repair was 5+ 4+ 4+ 5 cm. The star like shape allowed the surgeon to pull the wound edges together nicely in a natural Y plasty in two spots. What is the best way to code this?

Codes: 14040


35.

A 59-year-old male suffering from degenerative disc disease at the L4-L5, L5-S1 was placed under general anesthesia. Using an anterior approach, the L5-S1 disc space was exposed. Using blunt dissection the disc space was cleaned. The disc space was then sized and trialed. Further disc material was removed, a bilateral discectomy was performed and neural elements were decompressed. Excellent placement and insertion of the artificial disc at L5-S1 was noted. The area was inspected and there was no compression of any nerve roots. Peritoneum was then allowed to return to normal anatomic position and the entire area was copiously irrigated. The wound was closed in a layered fashion.

Codes: 22857, 63030-50


36.

A patient with chronic obstructive pulmonary disease is issued a medicallynecessary nebulizer with a compressor and humidifier for extensive use withoxygen delivery.

Codes: E0575, E0550



37.

OPERATIVE REPORTPREOPERATIVE DIAGNOSIS: Left thigh abscess.PROCEDURE PERFORMED: Incision and drainage of left thigh abscess.OPERATIVE NOTE: With the patient under general anesthesia, he was placed inthe lithotomy position. The area around the anus was carefully inspected, and wesaw no evidence of communication with the perirectal space. This appears tohave risen in the crease at the top of the leg, extending from the posteriorbuttocks region up toward the side of the base of the penis. In any event, the areawas prepped and draped in a sterile manner. Then we incised the area influctuation. We obtained a lot of very foul-smelling, almost stool-like material (itwas not stool, but it was brown and very foul-smelling material). This was not thetypical pus one sees with a Staphylococcus aureus–type infection. The incisionwas widened to allow us to probe the cavity fully. Again, I could see no evidenceof communication to the rectum, but there was extension down the thigh andextension up into the groin crease. The fascia was darkened from the purulentmaterial. I opened some of the fascia to make sure the underlying muscle wasviable. This appeared viable. No gas was present. There was nothing to suggesta necrotizing fasciitis. The patient did have a very extensive inflammation withinthis abscess cavity. The abscess cavity was irrigated with peroxide and saline andpacked with gauze vaginal packing. The patient tolerated the procedure well andwas discharged from the operating room in stable condition.

Codes: 27301-LT, 682.6


38.

Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain radiating down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes helping them and when they finally arrive in the emergency room Mr. Trumph is in full arrest with torsades de pointes. Dr. H. Art spends another hour stabilizing the patient and performing CPR. Defibrillation is performed with 250 joules to a NSR. What is/are the appropriate procedure code(s) for this encounter?

Codes: 99288, 99291, 92950
39.

A 55–year-old is seen by her physician for a routine six month follow up appointment to monitor her chronic arthritis in multiple joints. During the visit, the patient reports pain in both knees that is not alleviated by her current medication regiment. The physician performs an expanded problem focused history, an exam of the musculoskeletal system, cardiovascular system and 3 vitals signs, and low MDM. The physician makes changes to her current medications and orders a DEXA scan. He also recommends injections of Depomedrol into both knees, which he has time to perform today. Both knees are prepped with betadine and local anesthesia. Both knees are injected with ½ cc Depomedrol and ½ cc Xylocaine.

Codes: 99213-25, 20610-50


40.

Patient comes in today at four months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump, but hasn’t seemed to produce enough milk.PHYSICAL EXAM: Weight 12 lbs 11 oz, Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says that there was a diaper rash there earlier in the week.ASSESSMENT1. Four month well check2. Cold3. Mild thrush4. Diaper rashPLAN:1. Okay to advance baby foods2. Okay to supplement with Similac3. Nystatin suspension for the thrush and creams for the diaper rash if it recurs4. Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polioCode this visit: