Download 160217123051_Coding_I_II_Project_

1.
Level II codes are not used to report services for patients in this setting?
inpatient
2.
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: E2602
6.
PRE-OPERATIVE DIAGNOSIS: Persistent menorrhagia leading to profound anemia;
submucous uterine fibroidPOST-OPERATIVE DIAGNOSIS: Persistent menorrhagia leading to
profound anemia; submucous uterine fibroidOPERATION: Total abdominal hysterectomy and
bilateral salpingo-oophorectomyANESTHESIA: General with endotracheal intubationGROSS
FINDINGS: Upon entering the abdominal cavity, the lower abdominal wall was greatly distorted
from a previous TRAM flap surgery. Much of the abdominal musculature on the right aspect of
the lower abdomen was missing from the surgery and had been replaced with surgical mesh.
Upon entering the peritoneal cavity, an enlarged, lobulated, approximately 12-week sized uterus
was noted. There was evidence of bilateral tubal ligation in the past. Both ovaries were normal
size. Some ovulatory type cysts were evident. Generalized examination of the abdomen was
otherwise unremarkable.OPERATIVE PROCEDURE: Following administration of general
anesthesic, the patient was positioned frog-legged, a Betadine vaginal preparation performed,
and a Foley catheter inserted. She was then repositioned in the dorsal supine position. Her
abdomen was prepared with Betadine and draped in the usual manner with sterile drapes. Using a
scalpel blade, a 7" transverse lower abdominal incision was made excising the lowest of the
patient’s multiple surgical scars. This was carried down through the subcutaneous tissue and
opening the rectus fascia and transecting through a segment of surgical mesh. The overlying
fascia was then dissected off the underlying musculature using the Bovie. Rectus muscles were
split in the midline, peritoneum elevated, entered, and opened longitudinally. Following a
general examination of the abdomen, an O’Connor-O’Sullivan retractor was placed in the
abdomen and the bowel packed away with moist lap sponges. A Mass General clamp was placed
on the fundus of the uterus and uterus elevated towards the incision. The round ligaments were
then bilaterally clamped, cut, doubly sutured, ligated with #1 chromic, left long, and tagged. A
bladder flap was formed by incising the uterovesical peritoneum with Metzenbaum scissors and
dissecting the bladder downwards using a sponge suck. The infundibulopelvic ligaments were
bilaterally skeletonized a short distance and then were bilaterally clamped, cut and doubly suture
litgated with #1 chromic. At this point, the fundus of the uterus was removed using a scalpel
blade. The cervical stump was then grasped and the procedure continued. Using straight Heaney
clamps, the cardinal ligaments were bilaterally clamped, cut, suture ligated with the #1 chromic
and left long. An additional bite was taken bilaterally piecing up portions of the uterosacral
ligaments and these were similarly cut, ligated , left long and tagged. The vagina was entered
anteriorly using a scapel blade and utilizing Jorgensen scissors and staying within the vaginal
fornices, the cervix was excised off the vaginal cuff. The angles of the cuff were grasped and
then the cuff run with interlocking baseball stitch of #0 chromic. The cardinal ligament and
uterosacral ligaments were then plicated back into the angles of the vagina using free Mayo
needles. The cuff was further reduced in size with several simple sutures of 2-0 chromic. A
Jackson-Pratt T-tube drain was placed in the cuff and brought out through the vagina. Pelvis was
irrigated and suctioned dry and the pelvic peritoneum reapproximated with a continuous running
stitch of 2-0 chromic. Pelvis was reirrigated, bowel replaced into his physiologic position, and all
the counts are correct and instruments were removed from the abdomen. The abdominal
peritoneum was closed with a continuous running stitch of #0 chromic. The rectus musculature
was reapproximated with a continuous running stitch of the same suture material. The rectus
fasciola and mesh were then reapproximated with a continuous running stitch of Prolene.
Subcutaneous tissue was irrigated and suctioned dry and the skin edge was reapproximated with
a series of skin staples followed by a series of vertical mattress sutures of 4-0 Rapide placed
between every staple to maintain good skin eversion. Sterile dressing was applied. Select the
appropriate code for this procedure:
Codes: 58150-22
7.
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.
False
11.
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 painPOSTOPERATIVE 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
14.
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 selfmanagement 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 5cm 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 SteriStrips 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 longarm 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, singleview, 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 carcinomaPOSTOPERATIVE 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 foulsmelling 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:
Codes: 99391