Saturday, December 12, 2009

Medical Coding Test 2

Answer using both 1997 and 1995 guidelines assign all codes and modifiers that apply

On Dec 5, patient fell from a ladder while at work. He was taken to the ER where x-rays were taken noting a comminuted fracture of the distal fibula. Orthopedist, was called in by the ER doctor in consultation to evaluate the patient & discuss treatment options The Orthopedist obtained an expanded problem focused history and performed a detailed examination. His decision making was of moderate complexity identifying the need for immediate surgery. The patient was admitted and taken to the OR where a closed treatment (without manipulation) was performed. Patient is in the postoperative period of an arthroscopy of the shoulder performed 2 weeks ago. The Orthopedist performed both the surgeries. Assign the appropriate ICD-9-CM and CPT codes for the December 5 case by the orthopedist and the ER doctor.



12. Patient presents to her psychiatrist’s office for a 45-minute supportive psychotherapy service that included review of recent lab work and adjustment of her medication. Her diagnosis was noted as: severe bipolar disorder in depressed state displaying psychotic behavior. Assign the appropriate ICD-9-CM and CPT codes for this case.



Patient presents to Outpatient Surgery Department with a suspicious skin lesion involving the upper trunk. Lesion measures 2.8 cm and the margin required to adequately excise the lesion includes 0.2 cm from both sides. Pathology is negative for cancer noting actinic keratosis. Assign the appropriate ICD-9-CM diagnosis code(s) and CPT procedure code(s) for the surgeon.



A six-year old boy fell while riding his bike in his backyard. He had numerous cuts and was brought to the ER by his mother. The ER physician obtained a brief HPI, pertinent ROS and pertinent past medical, social & family history. He performed an expanded problem focused examination. Medical decision making was of low complexity. Physician performed a layered closure of a 5.0 cm laceration of the forehead, a 1.5 cm layered closure of the left external ear and a simple repair of a 2.5 cm laceration of the lip. Assign the appropriate ICD-9-CM diagnosis code(s) and CPT procedure code(s).



An established patient with known diagnosis of hypertension returns to the office for a blood pressure check by the nurse. The physician did not see the patient during this visit. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



A doctor is requested by another doctor to evaluate his patient that is hospitalized. He. sees the patient on 1/5 . He obtains a detailed history, performs a comprehensive examination and medical decision making was of moderate complexity. He has ordered several tests to be performed and will schedule a follow-up appointment with the patient in his office to go over the results. The patient was discharged home on 1/7. The patient sees the. doctor in his office on 1/12 to discuss the results of the tests. He obtains an expanded problem focused history, performs an expanded problem focused examination and provides medical decision making of moderate complexity.

Identify the E&M code for the 1/5 visit in the hospital

Identify the E&M code for the 1/12 visit in the office


Patient presents to OP surgery for insertion of a dual chamber pacemaker into the right atrium and ventricle including transvenous placement of electrodes. A subcutaneous pocket for the pulse generator was also created. Patient has long-standing atrial fibrillation with minimal improvement from medications. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



Patient has recently moved to the area and presents to Dr. Peters office to establish care and for evaluation of long-standing diabetes and hypertension, currently doing well per patient. A detailed history was obtained and a detailed exam was performed. Medical decision making was of moderate complexity, including renewal of medications. Doctor ordered a baseline EKG, which was performed by the nurse. The results were interpreted by Dr. Peters as normal. The patient requested evaluation of several skin tags that were rubbing against his shirt collar. Following examination, patient agreed to have them removed. Eight skin tags were successfully removed. Assign the appropriate ICD-9-CM diagnosis and CPT procedure codes.



A patient had a biopsy of skin lesion performed on 10/2/05. Results were positive for malignant melanoma and patient was taken back to the operating room on 10/5/05 for a wide excision with adjacent tissue transfer to ensure no further tumor is present. What two-digit modifier should be appended to the surgical procedure?


CT scan of the cervical spine without contrast material followed by contrast material with additional sections taken. You are the biller for the radiologist who supervised, interpreted & dictated the report for this test. Assign only the appropriate CPT procedure code.


Via femoral approach, an arch aortogram and bilateral selective common carotid arteriogram were performed. Assign the CPT codes for both the surgery and the radiologic (professional component only) portions of the procedure.



Patient was taken to the Operating Room for a repeat excision of Baker’s cyst from the popliteal space of the right knee. Assign the appropriate ICD-9-CM diagnosis and CPT procedure code for the second procedure.


Anesthesiologist personally provided anesthesia service for patient undergoing spinal surgery including laminectomy and insertion of Harrington rods. The patient is relatively healthy other than the spinal condition. Assign only the CPT code along with the appropriate physical status modifier and modifier identifying the provider.


Patient was admitted on January 10 for planned surgical repair of left carotid artery stenosis. He was taken to the OR where Dr Peters performed a thromboendarterectomy of the left carotid artery with patch graft. He was stable while in recovery and was transferred to the surgical ward when a bed was available Dr Peters stopped by to see the patient later in the evening on the 10th. He stopped by the morning of the 1/11 and noted that the patient was doing well and could be discharged later in the day. The patient was discharged home on the 11th with instructions to follow-up with Dr. Peters on the 18th. Assign the appropriate ICD-9-CM and CPT codes for the following:

January 10:

January 11:


Dr. Peters sees an established patient in his office for evaluation of end-stage renal disease due to insulin-dependent diabetes mellitus. In addition to a problem focused history, he performs an expanded problem focused exam that includes a limited exam of the genitourinary, immunologic, skin and musculoskeletal systems and documents all positive and negative findings. The patient’s status does not seem to have changed and medical decision making is of a low complexity. Dr. Hawthorne discusses with the patient his insulin dosage, diet, exercise and will see patient again in 6 months. Assign the appropriate ICD-9-CM and CPT codes.



Patient was brought to the ER following a car accident yesterday evening in which she was a passenger. The accident was minor and she and her husband drove home with no complaints noted at the time of the accident. When she woke up this morning, she complained of neck pain especially with movement. She tried a heating pad for an hour with no relief. She has no complaints of dizziness or headache, abdominal or other musculoskeletal pain or nausea. The patient has no known allergies and takes Zocor for her hypercholesterolemia. Doctor performed an expanded problem focused examination. The ER doctor, Dr. Smith, ordered complete cervical spine x-rays including oblique & flexion views. Radiologist, Dr. Jones completed the x-ray report noting cervical sprain. Dr. Smith instructed the patient to apply heat to alleviate the cervical sprain. Assign the appropriate ICD-9-CM and CPT codes for both Dr. Smith & Dr. Jones (professional component only).

Dr. Smith:

Dr. Jones:
Patient presents to her doctor’s office with complaint of dizziness and headache for the past week. Her regular doctor is on vacation and she is seen by his partner, Dr. Sullivan. Doctor obtains a problem focused history and performs an expanded problem focused exam noting tachycardia. Patient has a history of atrial fibrillation and has been on Digoxin for the past year. Venipuncture is done to assess the quantity of Digoxin in the blood. Results showed elevated Digoxin. Patient was called and dosage was adjusted. Patient will return to the office in one week for follow-up. Final diagnosis: Digoxin toxicity and atrial fibrillation. Assign the appropriate ICD-9-CM and CPT codes.



Patient presents to the lab department for the following blood tests: serum potassium, calcium, carbon dioxide, chloride, creatinine, serum sodium, BUN & glucose. Assign the appropriate CPT code(s) for these tests.



Patient is status post right hip replacement and presents to the outpatient physical therapy department for rehab as per the treatment plan approved by the physician. The following services were provided by the PT assistant under the direction of the physical therapist: 15 minutes of whirlpool therapy, 8 minutes of ice packs and 10 minutes of therapeutic massage. The patient is doing very well and able to complete 5 minutes more therapeutic exercises compared to last week. Patient is instructed to continue with home exercises until next visit. Assign the appropriate ICD-9-CM and CPT codes.



Patient presents with spinal stenosis. He was taken to the OR where a laminectomy with exploration and decompression of spinal cord at L1, L2 and L3. Assign the appropriate CPT code(s) only.

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