(Test Bank) GEOG BIOL250- QUIZ 7-comprehensive-with verified answers-2022

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GEOG BIOL250- QUIZ 7-comprehensive-with verified answers-2022 George McKeown, a 65-year-old male, presents with pain around his right eye and sensitivity to bright light. Dr. Zabawa notes redness of the eye and sagging skin around the lower eyelid. George is diagnosed with entropion of the right eye, lower eyelid……H02.002 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Entropion What is the anatomical site – Eye What is the laterality – Right Do any of the following apply to the condition – Lower eyelid Do any of the following apply to the condition – Unspecified Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H02.002 Overall Feedback: H02.002: Entropion>right>lower Rosa Fuller, a 24-year-old female, presents with ear pain. Dr. Rider documents a thick greyish-white matter. After a thorough examination, Rosa is diagnosed with diffuse otomycosis, external ear. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Otomycosis What is the location – external Do any of the following apply to the condition – None of these Is there a manifestation code - Yes Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B36.9 What is the manifestation code – H62.40 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Otitis What is the location – Externa In – Mycosis NEC Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H62.40 Overall Feedback: B36.9: Otomycosis H62.40: Otitis>externa>in>mycosis NEC John Di Toma, a 10-month-old male, was diagnosed with congenital bilateral cataracts several weeks ago. John is admitted today for the surgical removal of the cataracts. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Cataract Do any of the following apply to the condition – Congential Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Q12.0 Overall Feedback: Q12.0: index>cataract>congenital Latoya Simpkins, a 36-year-old female, presents with the complaint of right ear pain. Dr. Herauf also documents a low-grade fever, cough, and nasal drainage. Dr. Herauf completes an examination with otoscope, which visualizes a cloudy bulging eardrum with blisters. Latoya is diagnosed with bullous myringitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Myringitis Do any of the following apply to the condition – Acute What type – Bullous What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H73.011 Overall Feedback: H73.011: Myringitis>acute>bullous>right PATIENT: OLDENBERG, KYLE ACCOUNT/EHR #: OLDEKY001 DATE: 10/17/18 Attending Physician: Renee O. Bracker, MD Kyle Oldenberg, 65-year-old male, presents today with the complaints of gradual loss of vision OD of a 2-month duration. Kyle states it doesn’t hurt, “just getting to where I can’t see.” Kyle saw his ophthalmologist and was diagnosed with angle closure glaucoma and was referred to us for treatment. PMH: Healthy, no medications FH: Noncontributory with no history of glaucoma SH: Drinks alcohol socially and denies use of tobacco. Eye Exam: • Best corrected visual acuities: 20/20 OS, barely hand motion vision OD. • Pupils: >2.9 LU RAPD OD • EOM: full OU • IOP: 17 mmHg OS, 66 mmHg OD • DFE: retina exam—normal macula, vessels, and periphery OU. Optic nerves: 0.3 C/D OS, complete cup OD. Gonioscopy: moderately open angles OD. (+) Sampaolesi’s line OD. Dx: Pseudoexfoliation glaucoma, moderate stage P: Selective laser trabeculoplasty (ALT or SLT). ROB/pw D: 10/17/18 09:50:16 T: 10/19/18 12:55:01 Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Glaucoma What type – Open angle Do any of the following apply to the condition - Primary Do any of the following apply to the condition – Capsular What it the laterality – Right What stage - Moderate Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H40.1412 Overall Feedback: H40.1412: Glaucoma>open angle>primary>capsular>right>moderate stage PATIENT: SEQUEN, EUGENE ACCOUNT/EHR #: SEQUEU001 DATE: 09/16/18 Attending Physician: Oscar R. Prader, MD Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium swallow fluoroscopy, esophageal pH probe, esophageal manometry, and esophagoscopy were completed. He presents today to discuss the results of those tests. I explain that the test results indicate that he has GERD. The first course of treatment is to adopt a lowfat, high-fiber diet. The second course would be surgical repair. Patient was instructed not to eat at least 2 hours before going to bed, and the head of the bed should be elevated 6 to 8 inches while in supine position. Patient was informed that surgery may be necessary if diet and positioning do not relieve symptoms. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Reflux What type – Gastroesophageal Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – K21.9 Overall Feedback: K21.9: Reflux>gastroesophageal PATIENT: BARDARO, LYNNE ACCOUNT/EHR #: BARDLY001 DATE: 10/16/18 Attending Physician: Renee O. Bracker, MD S: Lynne, a 37-year-old female, presents today with the complaint that her right ear is throbbing. O: T: 101, BP: 137/83, R: 21, P: 78. PERRLA. Lynne is in moderate discomfort. She admits to a pain level of 4 on a scale of 0–10. Past medical history: noncontributory. Review of systems: negative. Medications: none. Ear exam: Left is within normal range. Right pinna: a lump is noted, as well as swelling and inflammation. It appears to be a localized pool of blood. Dr. Bracker evacuates the blood and applies a pressure bandage. A: Auricle hematoma P: Rx: antibiotics Follow up with patient in 10–14 days. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disorder What is the anatomical site – Pinna Do any of the following apply to the condition - Hematoma What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – No Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – H61.121 Overall Feedback: H61.121: Hematoma>auricle tells us to see disorder, pinna>hematoma Disorder>pinna>hematoma>right PATIENT: STEEVANG, BRANDON ACCOUNT/EHR #: STEEBR001 DATE: 10/16/18 Attending Physician: Oscar R. Prader, MD S: This is a 39-year-old male with advanced human immunodeficiency virus infection who has presented to the emergency department with severe itching with a duration of approximately 10 days. On a scale of 1 to 10, he rates the itching as 10 of 10 in severity. Patient states he has been compliant with his antiretroviral therapy. He has been drinking excessively and taking diphenhydramine every 4 hours for the last several days. O: H: 6’1”, Wt: 176, T: 98.9, R: 19, P: 66, BP: 132/76. On examination, he is constantly scratching his skin. There are spots of blood on his clothing. Xerosis is noted as well as several brown patches on his extremities. The scrotum appears leathery and thickened. A skin scraping for scabies mite is performed and sent to the lab for analysis. A: Scabies, HIV Rx: Permethrin, 5% cream, apply to all skin surfaces. Leave on for at least 9 hours, then wash off with warm water. P: Follow-up appointment with PCP Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Scabies Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – Yes Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B86 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Human What type – Immunodeficiency Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes Is there a Code first notation - Yes Is there a Code also notation – No Is there a Use additional code notation – Yes Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B20 Overall Feedback: B86: Scabies B20: Human>immunodeficiency PATIENT: INGER, TERRENCE ACCOUNT/EHR #: INGETE001 DATE: 09/29/18 Procedure Performed: Tissue, skin, head, mutation identification Pathologist: Peter Havner, MD Referring Physician: Oscar R. Prader, MD INDICATIONS: Suspected melanoma IMPRESSIONS: Abnormal cells present, by surgical pathology, gross and microscopic examination Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the correct section of the CPT manual - Pathology and laboratory What type - Surgical pathology What type - Gross and micro What level - IV What anatomical site - Skin Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there an additional notation - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 88305 Overall Feedback: 88305: Index>pathology and laboratory>surgical pathology>gross and micro>Level IV>skin PATIENT: CHABANNI, LORI ACCOUNT/EHR #: CHABLO001 DATE: 09/16/18 Attending Physician: Renee O. Bracker, MD S: This 46-year-old female with a 3-month history of ulcerations and abscesses involving both breasts was admitted today. Patient states the ulcerations began to appear after breast reduction surgery, approximately 2 weeks postop. The patient had no history of ulcerations before the breast reduction surgery. She also states that her muscles and joints ache. O: VS: T: 102 F, all other VS are within normal range; patient is in obvious distress. PMH: remarkable for hypertension and quiescent ulcerative colitis. FH: Noncontributory. Deep ulcers under breast, bilaterally, are noted with well-defined borders. Ulcer edges are worn and surrounding skin is red. Coloration of ulcers is violet to blue. Incision and drainage of breast abscesses is scheduled. A: Pyoderma gangrenosum. P: Pulse IV methylprednisolone, 500 mg daily for 3 consecutive days Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Pyoderma What type – gangrenosum Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L88 Overall Feedback: L88: Pyoderma>gangrenosum PATIENT: MASHEN, CYRUS ACCOUNT/EHR #: MASHCY001 DATE: 11/25/18 Attending Physician: Oscar R. Prader, MD S: This new Pt is a 57-year-old male complaining of a stabbing chest pain and shortness of breath. Patient states the pain is worse when he breathes in. PMH: Noncontributory PFH: Noncontributory O: VS: within normal range. Chest: Pleural rub on auscultation. Dullness upon percussion. Chest x-ray shows approximately 2.75 liters of fluid in the pleural space. A: Interlobar pleurisy P: Schedule aspiration of pleural fluid Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Pleurisy Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No Is there a Code first notation - No Is there a Code also notation – No Is there a Use additional code notation – No Is there an Excludes1 notation – Yes Is there an Excludes2 notation - Yes Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – R09.1 Overall Feedback: R09.1: Pleurisy PATIENT: HOUGH, BETH DATE OF ADMISSION: 05/30/18 DATE OF DISCHARGE: 06/01/18 ADMITTING DIAGNOSIS: Acute pyelonephritis caused by E. coli DISCHARGE DIAGNOSIS: Acute pyelonephritis caused by E. coli The patient is a 29-year-old female suffering with burning on urination. She stated she also noticed a fishy odor after urination. The urinalysis and culture lab results showed positive for acute pyelonephritis caused by E. coli. She was referred to me. I then admitted her to the hospital for treatment with Ceftazidime-Avibactam Anti-infective, peripheral vein introduction. Benjamin Johnston, MD—2222 Principal Procedure: Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index What is the type of procedure - New technology What is the procedure performed - Introduction What is the body part - Peripheral vein What is the approach - Percutaneous What is the substance - Ceftazidime-Avibactam Anti-infective What is the character 1: Section Character - X What is the character 2: Section Qualifier Character - W What is the character 3: Root Type Character - 0 What is the character 4: Qualifier Character - 3 What is the character 5: Qualifier Character - 3 What is the character 6: Qualifier Character - 2 What is the character 7: Qualifier Character - 1 What is the correct code: XW03321 Overall Feedback: XW03321: ICD-10-PCS index>Ceftazidime-Avibactam Anti-infective>peripheral vein>percutaneous PATIENT: HARRINGTON, ROSA DATE OF ADMISSION: 01/15/18 DATE OF DISCHARGE: 01/17/18 DIAGNOSIS: Appendicitis Attending Physician: Dennis Beckham, MD HISTORY OF PRESENT ILLNESS: This is a 39-year-old previously healthy female. She awoke this morning with pain in her abdomen. Her pain continued, periumbilical, and apparently now has traversed to the right lower quadrant. On a 1 to 10 pain scale she states a 7 for pain. She has had some nausea and vomiting. No history of inflammatory bowel disease, colon cancer, abdominal operations, or bleeding. No urinary tract symptomatology. PAST MEDICAL HISTORY: Noncontributory. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: No smoking. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: As per ER intake chart. PHYSICAL EXAMINATION: HEENT: No scleral icterus. NECK: Unremarkable. HEART: No findings. LUNGS: No findings. ABDOMEN: Exquisite right lower quadrant tenderness. Positive focal rebound. No masses. RECTAL: Unremarkable. EXTREMITIES: Unremarkable. LABORATORY AND DIAGNOSTIC STUDIES: White blood count is 25, otherwise unremarkable. An ultrasound of the appendix was performed. The patient has clear-cut possible retrocecal appendicitis. RECOMMENDATIONS/PLAN: The patient has received antibiotics. The patient has consented to a laparoscopic, possible open, appendectomy. She was counseled concerning the benefits and risks of the surgery, including but not limited to bleeding, infection, death, and injury. All questions were answered and she agreed to the procedure. We will place bilateral sequential compression devices and call the operating room to have her scheduled as soon as possible. Principal Procedure: Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index What is the type of procedure - Ultrasonography What is the anatomical site - Appendix What is the character 1: Section Character - B What is the character 2: Body System Character - D What is the character 3: Root Type Character - 4 What is the character 4: Body Part Character - 8 What is the character 5: Contrast Character - Z What is the character 6: Qualifier Character - Z What is the character 7: Qualifier Character - Z What is the correct code: BD48ZZZ Overall Feedback: BD48ZZZ: ICD-10-PCS Manual>index>ultrasonography>appendix PATIENT: WHEATON, MARLA ACCOUNT/EHR #: WHEAMA001 Admission Date: 09/18/18 Discharge Date: 09/18/18 DATE: 09/18/18 Preoperative DX: High-grade squamous intraepithelial lesion of the cervix Postoperative DX: Same Operation: Loop electrosurgical excision procedure (LEEP) and ECC (endocervical curettage) Surgeon: Ralph L. Goff, MD Assistant: None Anesthesia: General by LMA Findings: Large ectropion, large nonstaining active cervix essentially encompassing the entire active cervix Specimens: To pathology Disposition: Stable to recovery room PROCEDURE: The patient was taken to the OR, where she was placed in the supine position and administered general anesthesia. She was then placed in candy cane stirrups and prepped and draped in the usual fashion. Her vaginal vault was not prepped. The coated speculum was then placed and the cervix exposed. It was then painted with Lugol and the entire active cervix was nonstaining with the clearly defined margins where the stain began to be picked up. The cervix was injected with approximately 7 cc of lidocaine with 1% epinephrine. Using a large loop, the anterior cervix was excised, and then the posterior loop was excised in separate specimens. Because of the size of the lesion, one piece in total was not accomplished. Prior to the excision, the endocervical curettage was performed, and specimens were collected. All specimens were sent to pathology. The remaining cervical bed was cauterized and then painted with Monsel for hemostasis. The case was concluded with this. Instruments were removed. The patient was taken down from candy cane stirrups, awakened from the anesthesia, and taken to the recovery room in stable condition. Principal Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What type of procedure - LEEP What type of excision - Loop electrode excision What else do we know about it - With ECC Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No Is there an additional notation - No Do you need to add a modifier - No Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 57522 Overall Feedback: 57522: Index>LEEP procedure>loop electrode excision Benjamin Fulkenbury, a 46-year-old male, comes in today with cough, runny nose, sneezing, and body aches. Dr. Pruessner completes a thorough examination and notes a temperature of 104 F. Ben is admitted, where a CXR and laboratory tests confirm the diagnosis of influenza virus A/H5N1 with pleural effusion. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Influenza What type – A/H5N1 With - Effusion Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - Yes Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J09.X2 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Effusion What type – Pleural Do any of the following apply to the condition – In other conditions classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – No If so does the Excludes1 note apply to the case study – No Excludes1 notation Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J91.8 Overall Feedback: J09.X2: Influenza>A J91.8: Effusion>pleural>in other conditions classified elsewhere Larry Crosstree, a 29-year-old male, presents today concerned about vocal pitch changes he has been experiencing for approximately 2 weeks. Dr. Leonard notes the frequent need for breath while Larry is speaking as well as hoarseness. Larry is admitted to the hospital, where an MRI scan of the neck and chest confirms a diagnosis of complete bilateral paralysis of the laryngeal nerve. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term –Paralysis What is the location–Laryngeal nerve What is the laterality – Bilateral Do any of the following apply to the condition –None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation –No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation –Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation –Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J38.02 Overall Feedback: J38.02: Paralysis>laryngeal nerve>bilateral Dale Hunter, a 52-year-old male, was diagnosed with chronic bronchitis 3 months ago and is on medication. This morning, he came to see Dr. Teasdale because he began to cough and is having difficulty breathing. Dr. Teasdale admitted him into the hospital with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Disease What type – Pulmonary What type – Chronic obstructive Do any of the following apply to the condition – With acute exacerbation Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – Yes If so does the Code also note apply to the case study – No Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J44.1 Overall Feedback: J44.1: Disease>pulmonary>chronic obstructive>with> exacerbation Allison Mabry, a 6-year-old female, is brought in by her parents with a fever and hoarseness. Allison says it hurts when she swallows and it’s hard to breath. Dr. Macon completes an examination noting drooling; culture is positive for haemophilus influenza. Allison is diagnosed with acute epiglottitis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Epiglottitis Do any of the following apply to the condition – Acute Due to – Haemophilus influenza Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – J05.10 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Infection What type – Haemophilus influenza Do any of the following apply to the condition – As cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B96.3 Overall Feedback: J05.10: Epiglottitis>acute B96.3: Infection>haemophilus>influenza>as cause of disease classified elsewhere Archie Blume, a 41-year-old male, presents with the complaint of swollen tender gums and bleeding after he brushes his teeth. Dr. Day notes Archie uses tobacco. After an examination and x-rays, Archie is diagnosed with acute gingivitis, non-plaque induced. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Gingivitis Do any of the following apply to the condition – Acute What type – Non-plaque induced Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – K05.01 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Tobacco What type – Use Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – Z72.0 Overall Feedback: K05.01: Gingivitis>acute>non-plaque induced Z72.0: Tobacco>use Kent Rhodes, a 28-month-old male, is brought in by his parents for a checkup. Dr. Washington notes Kent’s deciduous teeth are smaller than normal and widely spaced with notches on the biting surface. Kent is diagnosed with Hutchinson’s teeth. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Hutchinson’s What type – teeth Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – A50.52 Overall Feedback: A50.52: Hutchinson’s>teeth Jonathan Stutts, a 41-year-old male, comes in today with the complaint of abdomen pain with some diarrhea and bloating. Dr. Dresdner completes a thorough examination with the appropriate laboratory tests. Jonathan is diagnosed with idiopathic sclerosing mesenteric fibrosis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Fibrosis What type – Sclerosing mesenteric Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – K65.4 Overall Feedback: K65.4: Fibrosis>sclerosing mesenteric Robert Thomas, an 82-year-old male, presents today with severe epigastric pain. Robert also has been experiencing sharp chest pain that radiated to the left side of the neck and arm. Robert is admitted to the hospital, where an upper GI series confirms the diagnosis of volvulus of the colon with perforation. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Volvulus Do any of the following apply to the condition – With perforation Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – K56.2 Overall Feedback: K56.2: Volvulus>with perforation Aaron Ragin, a 17-year-old male, presents today with a painful red lump on his chest. Dr. Godwin completes an examination and the appropriate laboratory tests. Aaron is diagnosed with a furuncle due to staphylococcus. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Furuncle What is the anatomical site – Chest wall Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L02.223 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Infection What type – Staphylococcal Do any of the following apply to the condition – As cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify – Yes Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – No Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – B95.8 Overall Feedback: L02.223: Furuncle>chest wall B95.8: Infection>staphylococcal>as cause of disease classified elsewhere Gary Sanders, a 78-year-old male, comes in today with the complaint that the mole on his right ankle has begun to rapidly change in shape and color. Dr. Jones completes an examination noting ABCD - asymmetry, elevation above skin surface with an irregular border, blue-grey in color, firm to the touch, and a diameter of 8 mm and thickness of 1.63 mm. Gary is admitted to Weston Hospital. Skin and lymph node biopsies were ordered as well as imaging studies and blood tests. After reviewing the results of the pathology report and other tests, Gary is diagnosed with a malignant nodular melanoma. Excision of lesion is scheduled. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Melanoma What is the anatomical site – Skin What is the location – Ankle What is the laterality - Right Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – C43.71 Overall Feedback: C43.71: Melanoma>skin>ankle>right Eugene Sanford, a 49-year-old male, comes in today with the complaint of a small red prickly rash under his scrotum. Dr. Kimrey completes an examination and the appropriate tests. Eugene is diagnosed with apocrine miliaria. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Miliria What is the anatomical site – Apocrine Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L75.2 Overall Feedback: L75.2: Miliria>apocrine Matt Kicklighter, an 18-year-old male, presents today with fluid-filled blisters on his back. Matt states that the blisters are easily broken. After an examination and testing, Dr. Gardener diagnoses Matt with staphylococcal scalded skin syndrome with 14% exfoliation due to erythematosis. Principal diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Syndrome What type – Staphylococcal scalded skin Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study – No Code first notation Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – Yes If so does the Use additional code note apply to the case study – Yes Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - No Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L00 Second diagnosis: Where should you begin to look up the code in the coding manual – Index to Diseases and Injuries What is the key term – Exfoliation Due to – Erythematous What percentage – 10-19 percent Do any of the following apply to the condition – None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify – No Includes notation Is there a Code first notation - Yes If so does the Code first note apply to the case study – Yes Is there a Code also notation – No If so does the Code also note apply to the case study – No Code also notation Is there a Use additional code notation – No If so does the Use additional code note apply to the case study – No Use additional code notation Is there an Excludes1 notation – Yes If so does the Excludes1 note apply to the case study – No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study – No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code – L49.1 Overall Feedback: L00: Syndrome>staphylococcal scalded skin L49.1: Exfoliation>due to erythematous>14% Rykia Huffman, a 21-year-old female, presents today with the complaint of uneven hips and leg length. Dr. Gamble completes a physical examination and orders a weight-bearing, full-length spine x-ray, AP, which confirms the diagnosis of idiopathic scoliosis, lumbosacral region. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Scoliosis What type - Idiopathic What is the anatomical site - Lumbosacral region Do any of the following apply to the condition - None of these Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M41.27 Overall Feedback: M41.27: Scoliosis>idiopathic>lumbosacral region Sharron Webster, a 3-year-old female, was brought in by her parents to see her pediatrician, Dr. Surrant, 4 days ago. Sharron had a boil on her left thigh that Dr. Surrant incised and drained. Sharron is now running a fever of 102 F. Dr. Surrant decides to admit Sharron to Weston Hospital. The MRI scan revealed abscess of the vastus intermedius muscle. A wound culture grew Staphylococcus aureus. Sharron is diagnosed with pyomyositis. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Myositis What type - Infective What is the anatomical site - Lower limb What is the location - Thigh Do any of the following apply to the condition - None of these What is the laterality - Left Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - Yes Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M60.052 Second diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Infection What type - Staphylococcal Do any of the following apply to the condition - As cause of disease classified elsewhere Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - Yes If so does the Includes note help to clarify - Yes Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - Yes If so does the Use additional code note apply to the case study - No Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - B95.61 Overall Feedback: M60.052: Pymyositis ~ redirects us ~ Myositis>infective>lower limb>thigh>left B95.61: Infection>Staphylococcus>as cause of disease classified elsewhere>aureus Valerie Halsey, a 51-year-old female, complains of lower back pain and numbness. Valerie also admits it is sometimes difficult to control her left leg. Dr. Spratt completes a physical examination and history of the symptoms. Dr. Spratt has Valerie perform the straight leg raise test, which was positive for Lasegue’s sign. Valerie is diagnosed with wallet sciatica, left side. Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Sciatica What type - Wallet Do any of the following apply to the condition - None of these What is the laterality - Left Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - M54.32 Overall Feedback: M54.32: Sciatica>wallet>left side Nancy Nottingham, a 52-year-old female, presents today with a severe burning pain and swelling in her upper right arm and fingers. Dr. Olden notes edema and allodynia. After a thorough examination, Nancy is diagnosed with reflex sympathetic dystrophy (RSD). Principal diagnosis: Where should you begin to look up the code in the coding manual - Index to Diseases and Injuries What is the key term - Syndrome What type - Pain What type - Complex region What is the anatomical site - Upper limb Do any of the following apply to the condition - None of these What is the laterality - Right Begin to code the encounter Did you verify the code in the Tabular List of Diseases and Injuries - Yes Is there an Includes notation - No If so does the Includes note help to clarify - No Includes notation Is there a Code first notation - No If so does the Code first note apply to the case study - No Code first notation Is there a Code also notation - No If so does the Code also note apply to the case study - No Code also notation Is there a Use additional code notation - No If so does the Use additional code note apply to the case study - No Use additional code notation Is there an Excludes1 notation - Yes If so does the Excludes1 note apply to the case study - No Is there an Excludes2 notation - Yes If so does the Excludes2 note apply to the case study - No Is there a symbol indicating additional characters are required - Yes Do you need to use the placeholder “X” - No Did you code to the highest level of specificity - Yes What is the correct diagnosis code - G90.511 Overall Feedback: G90.511: Dystrophy> reflex sympathetic ~redirects us ~ Syndrome>pain>complex region I>upper limb>right Samantha DaVita, a 74-year-old female, has a permanent subcutaneous implanted defibrillator system, which is not functioning properly. Samantha is taken to the OR, where Dr. Meetze removes and replaces the implanted defibrillator pulse generator and subcutaneous electrode; 25 minutes of moderate sedation was achieved. The new defibrillator system is tested and is working within normal limits. The nurse monitored Samantha’s vital signs during the procedure. Samantha tolerated the procedure well. Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Implantable defibrillator Which apply - Replacement system Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Out of numerical sequence code Is there an additional notation - Yes If so does the notation apply - Yes Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 33270 Second Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Implantable defibrillator Which apply - Removal Removal of what - Electrodes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Out of numerical sequence code Is there an additional notation - Yes If so does the notation apply - Yes Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 33272 Third Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Implantable defibrillator Which apply - Removal Removal of what - Pulse generator Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Revised code Is there an additional notation - Yes If so does the notation apply - Yes Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 33241 Fourth Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Sedation What type - Moderate What is the age of the patient - 74 What is the total time of sedation - 25 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - New code and modifier 51 exempt Is there an additional notation - No If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99152 Fifth Procedure: Where should you begin to look up the code in the coding manual - Alphabetic Index What is the key term - Sedation What type - Moderate What is the age of the patient - 74 What is the total time of sedation - 25 minutes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - New code and add-on code Is there an additional notation - No If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 99153 Overall feedback: 33270: Index>implantable defibrillator>replacement>system 33272: Index>implantable defibrillator>removal>electrodes 33241: Index>implantable defibrillator>removal>pulse generator 99152: Index>sedation>moderate>patient older than age 5 years (initial 15 minutes) 99153: Index>sedation>moderate>patient>additional 10 minutes Jack Friedman, a 41-year-old male, was in a fight at a soccer game and was hit in the head with a bottle, which caused some deep lacerations in his scalp. Dr. Girald performed a layered closure of the wounds: one 2.0 cm, one 4.5 cm, and two lacerations that were 1.0 cm each in length. Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What is the key term - Wound What is the procedure - Repair What is the anatomic site - Scalp What type of repair - Intermediate What is the total size of the lacerations for this anatomical group - 8.5 cm Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there an additional notation - No If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 12034 Overall Feedback: 12034: Index>wound>repair>scalp>intermediate>7.6 cm to 12.5 cm 2.0 + 4.5 + 1.0 + 1.0 = 8.5 cm Hannah Lopez, a 53-year-old female, hurt her eye in an accident. Dr. Dawson examined her and noticed that her cornea was scratched. It was not a perforating laceration. Dr. Dawson repaired the laceration of the cornea in the office. Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What type of procedure - Repair What type of repair - Wound What is the anatomic site - Cornea What else do we know about it - Nonperforating Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there an additional notation - No If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 65275 Overall Feedback: 65275: Index>cornea>repair>wound>non-perforating Dr. Macintosh performed the backbench preparation of a cadaver donor heart allograft prior to Dr. Gantt’s performing the transplantation. Code for Dr. Mackintosh’s work. Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What type of procedure - Transplantation What is the anatomic site - Heart What type of graft - Allograft preparation What is the component phase - Backbench standard preparation Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there an additional notation - Yes If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 33944 Overall Feedback: 33944: Index>transplantation>heart>allograft preparation>backbench standard preparation of cadaver donor heart allograft prior to transplantation Alice Milton, a 39-year-old female, was diagnosed with an abdominal wall incisional hernia, which was repaired using prosthetic mesh. Alice has had recurrent infections. Alice is taken to the OR, where Dr. Gilroy debrides the infected subcutaneous tissue and removes the prosthetic mesh. Principal Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What type of procedure - Debridement What is the anatomic site - Skin, abdominal wall What level - Subcutaneous tissue Was there an infection - Yes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - No If so what does the symbol mean - Does not apply Is there an additional notation - No If so does the notation apply - Does not apply Do you need to add a modifier - No If so what is the modifier - Does not apply Did you check the guidelines - Yes Did you code to the highest level of specificity - Yes What is the correct procedure code - 11005 Second Procedure: Where should you begin to look up the code in the coding manual - CPT Alphabetic Index What type of procedure - Removal Removal of what - Mesh What is the anatomic site - Abdominal wall Was there an infection - Yes Begin to code the encounter Did you verify the code in the numerical listing - Yes Is there a symbol for this code - Yes If so what does the symbol mean - Add-on code Is there an additional notation - Yes If so does the notation apply - Yes