This is an \u201copen book\u201d test with regard to CPT and ICD-10 coding books.<\/p>\n
Question number 1-
\nPlease identify the words in the following statement that match at least 4 of the HPI (history of present illness)
\nelements identified below:
\nPatient was admitted yesterday with severe asthma exacerbation. She had been trying to
\nmaintain with her inhaler but continued to worsen over the last 24 hours before admit. She
\nhas had 5 breathing treatments and been on 4Lpm O2 for the last 12 hours and now has a
\nstable 90% sats. ORA she decreases to 78-70%. She has been around her boyfriend\u2019s cat a
\nlot lately and feels this may have triggered this attack.
\nQuality ____________________ Modifying Factors ___________________
\nContext ___________________ Timing ___________________
\nDuration __________________ Severity __________________________<\/p>\n
Question number 2-
\nPlease identify the Level of Medical Decision Making (MDM) in the following statement:
\n1. Chest pain- new since last visit
\n2. DOE (dyspnea on exertion) – worsening
\nI have discussed this with him, and we will screen for ischemia with stress myocardial
\nperfusion imaging. If Abnl test, then this may represent a high probability for CAD and angio
\nshould be considered. If test is low risk, then may follow syndrome clinically, and seek other
\ncauses of chest pain. The patient was instructed to avoid strenuous physical activity until
\ncomplete stress test results are known.
\nF\/U OV the week after these studies to consolidate eval and recommend further investigations
\nas indicated.
\nLow __________ Moderate _________ High___________<\/p>\n
2 | Page
\nQuestion number 3-<\/p>\n
Please select the level of History (HX) documented in the following statement:
\nPatient comes in today complaining of 4 days history of cough and congestion. No Fever,
\nChest pain or dyspnea. Cough is mildly productive. He has been using Sudafed and Nyquil
\nwith some relief.
\nPast Medical History-Seasonal allergies
\nPast Surgical History-tonsillectomy
\nPast Family History- Asthma—Father and Brother
\nSmoking status: Smokeless tobacco: Alcohol Use:2 drink(s) per week
\nAllergies-Cephalexin\/Penicillin\u2019s- Rash
\nReview of systems: Positive for malaise\/fatigue. Positive for cough and sputum production
\n(scant, clear). Negative for shortness of breath and wheezing. All remaining 10 point ROS and
\nare negative.
\nHPI- # of Elements__________ PFSH- # reviewed_______ ROS- # of systems ________
\nHistory Level __________________
\nQuestion number 4-
\nPlease select the level of Exam Both 95 and 97 guidelines documented in the following statement:
\nConstitutional: He is oriented to person, place, and time. He appears well-developed and
\nwell- nourished.
\nHead: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear:
\nTympanic membrane normal. Nose: No mucosal edema or rhinorrhea.
\nMouth\/Throat: Oropharynx is clear and moist and mucous membranes are normal. Eyes:
\nEOM are normal. Pupils are equal, round, and reactive to light.
\nNeck: Normal range of motion. Neck supple. No thyromegaly present.
\nCardiovascular: Normal rate, regular rhythm and No murmur heard.
\nPulmonary\/Chest: Effort normal and breath sounds normal.
\nLymphadenopathy:He has no cervical adenopathy.
\nNeurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry.
\nNo rash noted. Psychiatric: He has a normal mood and affect. His behavior is normal.
\nJudgment and thought content normal.
\n95 Guidelines Detailed________ Comprehensive___________<\/p>\n
3 | Page
\n97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______
\nQuestion number 5-
\nPlease choose the most accurate way of documenting a Review of System (ROS) in a comprehensive history
\n__________ ROS complete
\n__________ 14 point review of system performed
\n__________ Positive for Shortness of Breath, Negative for Chest Pain. All other systems reviewed and are<\/p>\n
negative<\/p>\n
_________ ROS is not needed for a comprehensive history<\/p>\n
Question number 6-
\nPlease select the level of service documented in the following visit note:
\nCC: Brought by ambulance \u2013 evaluate for non- responsiveness
\n44 yo man BIBA from Rockies game after being found slouched over on the ground. Pt reports
\nhaving too much alcohol to drink today and recalls going over to sit against a wall. He then
\nclosed his eyes and was found by a bystander. no witnessed szr activity. emesis x 1 (NBNB)
\nin route. pt has no complaints at present. Pt denies fall\/trauma.
\nPHYSICAL EXAM
\nVital signs reviewed, Patient afebrile, Pulse normal,Blood pressure normal, Respiratory rate
\nnormal, Patient appears non toxic, pain free. Patient alert and oriented to person, place and
\ntime. HEAD: atraumatic, normocephalic. EYES: Pupils equally round and reactive to light,
\nSclera normal. ENT: Nose exam normal, dried blood left nare, no active bleeding. NECK:
\nNeck exam included findings of normal range of motion, Trachea midline. RESPIRATORY
\nCHEST: no respiratory distress, Breath sounds clear. CARDIOVASCULAR: Regular rate
\nand rhythm, Heart sounds normal, normal S1, normal S2. ABDOMEN: nontender, Bowel
\nsounds normal. BACK: normal inspection, range of motion normal.
\nUPPER EXTREMITY: inspection normal, Range of motion normal Bilaterally
\nLOWER EXTREMITY: bilaterally Range of motion normal, no edema.
\nNEURO: Speech normal. SKIN: warm, dry no abrasions PSYCHIATRIC: intoxicated.
\n(Continued on next page)<\/p>\n
4 | Page
\nASSESSMENT\/PLAN: Acute alcohol intoxication- Breath EtOH 114 on arrival. No evidence
\nof significant trauma by exam or history. Will obvs until sober then d\/c. Pt refused EKG.
\nDisposition: D\/C Home.
\nINSTRUCTION: Follow up with your primary care doctor in 1 week. Return to the emergency
\ndepartment for worsening symptoms, including worsening headache, numbness, weakness,
\ntremors, seizure, or any other concerns.
\nA. 99221
\nB. 99222
\nC. 99223
\nD. None of the above<\/p>\n
Question number 7-
\nPlease select the level of service documented in the following statement:
\nPatient is a 42yr female who presents today with complex migraines since she was a teenager.
\nNow on relpax. No current migraine today but does need refills of relpax. Patient also on
\nProzac and needs a refill of that. Today she is quite depressed and tearful.
\nROS-Per HPI-All other systems reviewed and negative.
\nVitals \u2013 BP 122\/60 Temp- 97.4 Height 5′ 10″ Weight 178 lbs
\nPatient is tearful and upset about a recent breakup with her boyfriend. We discussed in detail
\ntreatment options for her including increased dosage of Prozac, adding Welbutrin, yoga, and
\nstructured counseling. I asked the patient to follow up with my office in a month, unless her
\nsymptoms increase or worsen. I spent 35 minutes in face to face time with the patient 25
\nminutes of which were spent in counseling and coordination of care.
\nIf New Patient 99202_______ 99203 _________ 99204 _________
\nIf Established Patient 99213 ______ 99214 ________ 99215 ________<\/p>\n
5 | Page
\nQuestion number 8-
\nFor a Level 4 new patient, please choose the proper documentation requirements
\n_______ Detailed History and Comprehensive Exam and Moderate Medical Decision Making
\n_______ Comprehensive History and Comprehensive Exam and High Medical Decision Making
\n_______ Comprehensive History and Comprehensive Exam and Moderate Medical Decision Making
\n________Comprehensive History or Comprehensive Exam and Moderate Medical Decision Making<\/p>\n
Question number 9-
\nPlease select the correct level of service based on the documentation below:
\nI spent 40 minutes in face to face time with the patient and family. 50 % or more was spent in counseling and
\ncoordination of care. We discussed alternative therapies, options for medications, referrals for second opinions,
\netc. Risks, benefits and considerations were discussed with patient and family. They will let us know what they
\ndecide.<\/p>\n
If Established Patient 99214 ________ 99215 _________
\nIf New Patient 99203_________ 99204 _________<\/p>\n
Question number 10-
\nPlease circle the correct definition of Critical Care:
\nA. High-complexity decision-making to assess, manipulate and support vital system function(s) to treat
\nsingle or multiple organ system failure and\/or to prevent further life-threatening deterioration
\nB. Direct personal management and Frequent personal assessment
\nC. Record demonstrate the patient has acute impairment of one or more vital organ systems and has a high
\nprobability of imminent or life-threatening deterioration
\nD. The interventions of a nature that failure to initiate these interventions on an urgent basis would likely
\nresult in sudden clinically significant or life-threatening deterioration in the patient\u2019s condition
\nE. All of the Above<\/p>\n
6 | Page
\nQuestion number 11-
\nPlease circle the examples of a correctly documented Chief Compliant:
\nA. Follow up on DM meds
\nB. Left Knee Pain
\nC. Follow up
\nD. Annual Exam<\/p>\n
Question number 12-
\nPlease circle the correct time documentation for a 99214 if you are doing time based coding:
\nA. 30 minutes was spent with the patient today in my office discussing proper dosage of new
\nmedications
\nB. The patient was in my office for two hours receiving hydration and counseling regarding
\nfood poisoning side effects
\nC. 25 minutes was spent in face to face time with the patient. 50% or more was spent in
\ncounseling and coordination of care concerning dosage of new medications and possible
\nside effects.
\nD. I spent 25 minutes with the patient and 20 minutes were in counseling.<\/p>\n
7 | Page
\nCoding Quiz Operative Report 1:
\nDATE OF PROCEDURE: 07\/01\/2017
\nPREOPERATIVE DIAGNOSIS: Lumbar stenosis L4-5.
\nPOSTOPERATIVE DIAGNOSIS: Same.
\nPROCEDURE: Lumbar laminectomy, bilateral L4-5.
\nSURGEON: Ima Neurosurgeon, MD.
\nHelpANT: Hesmy Helpant, PA-C.
\nANESTHESIA: General.
\nINDICATIONS: The patient is a pleasant 85-year-old woman with symptoms of
\nneurogenic claudication. Her symptoms were refractory to conservative
\ncare. Her imaging studies revealed severe stenosis at L4-L5, relatively
\nmodest stenosis at ____ level. Given these findings, after a careful
\nexplanation of risks, benefits, likely outcome, the patient and family
\nagreed to proceed with surgery.
\nNARRATIVE: The patient was brought to the operating room. After suitable
\ninduction of general anesthetic, the patient was carefully positioned
\nprone on the operative table. All pressure points were padded as<\/p>\n
confirmed by me and the anesthesia team. Using surface landmarks and a C-
\narm, the incision was planned. The patient was prepped and draped in the<\/p>\n
usual sterile fashion. After infiltration of local anesthetic, incision
\nwas made with a #10 blade. Hemostasis was obtained with Bovie
\ncauterization. The incision was carried down to the level of the lumbar
\ndorsal fascia. Ligamentous muscular attachments were elevated at the L4-5
\nregion. X-ray once again confirmed our position.
\nLeksell rongeur was then used to remove the spinous processes and portion
\nof the lamina.
\nThe operative microscope was brought into the field. High speed drill was
\nthen used to thin the lamina. A curet was used to then separate the
\nlamina from the ligamentum flavum. With that complete, the remainder of
\nthe bone was removed.
\nWith careful dissection, I was able to then dissect the ligamentum flavum
\nfrom the dura. There is perhaps a small fenestration was made in the
\ndura. This was closed with interrupted 4-0 Nurolon. The facet joints were
\nundercut laterally on both sides. The remainder of the ligament was also
\nremoved.
\nOnce I was satisfied that the decompression was adequate, the seal was
\nplaced over the area where the suture had been placed. The Duragen was
\nalso placed prior to placement of the Tisseel sealant.
\nThe wound was closed with multiple layers of Vicryl followed by a running
\nlocking Prolene.
\nThe patient tolerated the procedure well.
\nSponge and instrument counts were correct at the end of the case.
\nOf note, at the end of the case, the neural monitoring unit had placed
\nits leads. There were no untoward findings with the neuromonitoring.<\/p>\n
8 | Page
\nThe patient tolerated the procedure well, was turned over to anesthesia
\nfor awakening.
\nDICTATED BY: Ima Neurosurgeon, MD<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Comments:<\/p>\n
9 | Page
\nCoding Quiz Operative Report 2:
\nDATE OF PROCEDURE: 07\/07\/2017
\nPREOPERATIVE DIAGNOSIS: Left subtrochanteric femur fracture.
\nPOSTOPERATIVE DIAGNOSIS: Same.
\nPROCEDURE: Intramedullary nailing of left subtrochanteric femur fracture.
\nSURGEON: Shesa Doctor, MD.
\nHelpANT: Hesher Helper, MD. Please note, Mr. Helper was medically
\nnecessary for this patient to help position the patient, to help hold
\nretractors during the procedure, to help reduce the fracture and to
\nHelp with wound closure.
\nANESTHESIA: General endotracheal anesthesia.
\nESTIMATED BLOOD LOSS: 250 mL.
\nCOMPLICATIONS: None.
\nDISPOSITION: The patient was successfully awakened and extubated in the
\noperating room and returned to the postanesthesia care unit in stable
\ncondition.
\nBRIEF PREOPERATIVE NOTE: The patient is a 63-year-old gentleman who was
\nriding his bicycle when he had a terrible accident, landing directly onto
\nhis left hip. He sustained a comminuted complex proximal femur fracture
\nwhich was also complicated by the fact that he was on anticoagulants and
\nhis INR was 3.38. Upon presentation to the hospital. Overnight, he was
\ngiven vitamin K and prior to surgery given FFP to get him to a more
\nnormalized INR. The risks and benefits of this procedure were explained
\nto the patient. The patient asked appropriate questions. After all
\nappropriate questions were answered, informed consent was obtained and
\nplaced on the chart. At this time, the patient did agree to proceed to
\nthe operating room for the above listed operative procedure.
\nBRIEF OPERATIVE NOTE: The patient was brought to the operating room,
\nfirst in his hospital bed general anesthesia was administered. Next, the
\npatient was transferred to the fracture table where the endotracheal tube
\nwas in placed under the general anesthetic at that time. The left lower
\nextremity was placed into a well padded longitudinal traction and the
\nright lower extremity was placed into a well padded, well leg holder.
\nNext, image intensifier was brought into the field to ensure that we
\ncould get adequate closed reduction. After significant traction,
\nadduction and internal rotation of the leg, we were able to get an
\nadequate reduction. Next, the left lower extremity was prepped and draped
\nin the usual orthopedic sterile fashion. Next, a 3.2 mm guidewire for the
\ntrochanteric fixation nail was then passed in an intramedullary position.
\nNext, the opening awl was passed without complication. Next, a ball
\ntipped guidewire was passed into the canal and measured to the distal
\nfemur 460, but we placed a 420 mm trochanteric fixation nail with a 130
\ndegree helical blade setting. Next, the nail was passed without
\ncomplication. Next, the outrigger was placed for placement of the helical
\nblade. Guide pin was passed for the helical blade in a center-center
\nposition into the femoral neck and head measured a 105 mm. The outer
\nlateral cortex was drilled without complication, then the triple reamer<\/p>\n
10 | Page
\nwas passed. Next, the 105 mm helical blade was passed without
\ncomplication and locked into position. Next, the outrigger was removed.
\nOrthogonal x-rays showed near anatomic alignment of the proximal femur.
\nNext, attention was then paid distally to the distal femur for perfect
\ncircles and one 5.0, 52 mm locking bolt was then placed without
\ncomplication. Again, orthogonal x-rays showed near anatomic alignment of
\nthe proximal femur, no evidence of hardware failure. At this time, all
\nwounds were thoroughly irrigated with bacitracin-laden normal saline.
\nNext, the deep layer was closed with a #1 Vicryl in an interrupted
\nfashion. The wound was infiltrated with 30 mL of 0.5% Marcaine without
\nepinephrine. The deep subcuticular layer was closed with an 0 Vicryl,
\nskin reapproximated with 2-0 Vicryl and then skin staples. Next, sterile
\ndressings were applied.
\nNext, the patient was taken out of traction and returned to the hospital
\nbed. General endotracheal anesthesia was terminated. The patient
\ntolerated the procedure without complication, was successfully awakened
\nand extubated in the operating room, returned to the postanesthesia care
\nunit in stable condition.
\nDICTATED BY: Shesa Doctor, MD
\nICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Comments:<\/p>\n
Coding Quiz Operative Report 3:<\/p>\n
11 | Page
\nDATE OF PROCEDURE: 07\/14\/2017
\nSURGEON: Fixer Upper, MD.
\nFIRST HelpANT: None.
\nPREOPERATIVE DIAGNOSES:
\n1. Symptomatic asymmetrical mammary hypertrophy.
\n2. Cervicalgia.
\n3. Thoracic pain.
\nPOSTOPERATIVE DIAGNOSIS: Same.
\nOPERATIVE PROCEDURE: Bilateral reduction mammoplasty.
\nINDICATIONS FOR SURGERY: The patient is a 66-year-old female who requests
\nreduction mammoplasty for symptoms related to large and heavy breasts.
\nThe patient has nod only severe tilt of the shoulder with the right
\nbreast larger and lower, but has bra strap grooves. The size is
\nconsistent with a 38 G to H size. She has rounded forward anterior
\ndisplaced shoulders, large pendulous ptotic asymmetrical breasts, bra
\nstrap grooves and nonfocal, tightness and tenderness in the trapezius,
\ninterscapular and paraspinal musculature. The patient requests reduction
\nmammoplasty in an attempt to improve symptoms from large and heavy
\nbreasts.
\nPROCEDURE: Markings made preoperatively for a medial pedicle vertical
\ntype reduction mammoplasty accounting for the dyssymmetry. The patient
\ntaken to the operating room, placed on the operating table in the supine
\nposition. All bony prominences were well padded. PAS stockings were in
\nplace and functioning. General anesthesia was induced bilateral upper
\nextremities were abducted to under 80 degrees on arm boards. Prepping and
\ndraping was performed in a sterile fashion.
\nOf note, the patient has severe compromised skin envelope with striate
\nand severe ptosis. Stab incision was made in the area of intended
\nvertical excision and using a blunt infiltration cannula on each side 500
\nmL of 0.03% lidocaine with adrenalin 1:1 million was infiltrated on each
\nside. The operation was performed similarly on each side. First,
\nattention was directed to the right side after adequate epinephrine
\neffect, a 45 mm areola was incised. De-epithelization of the medial
\npedicle was performed. Incision was made in the upper keyhole in vertical
\narea, keeping the lower extent of excision 4 cm up from the inframammary
\nfold. Composite resection was performed after isolating the pedicle by
\nsharp dissection and adequate at least 2 cm vertical pillars were<\/p>\n
Coding Quiz Operative Report 3:<\/p>\n
preserved and further resection laterally was performed removing on the
\nright side 716 grams. Meticulous hemostasis obtained with
\nelectrocauterization. Irrigation was performed with saline. The vertical
\npillars repaired with #1 Vicryl sutures. The vertical closure for 8 cm
\nwas performed using gathering 4-0 Monocryl deep dermal sutures, running<\/p>\n
12 | Page
\nsubcuticular 3-0 V-Loc suture. The nipple areolar complex was sutured to
\nsurrounding flaps using interrupted simple 4-0 Monocryl for the deep
\ndermis, running subcuticular 4-0 Monocryl for the skin. Because of severe
\nskin envelope laxity, the patient’s body habitus, was necessary to<\/p>\n
perform dog ear excision of skin and subcutaneous tissue in the neo-
\ninframammary fold for contouring purposes. Closure in this area, after<\/p>\n
hemostasis obtained with electrocauterization was accomplished using
\ninterrupted 3-0 Vicryl to deep dermis, running subcuticular 3-0 V-Loc
\nMonocryl for the skin. Next, attention was directed to the left side
\nwhere resection of 757 grams was performed, hemostasis obtained with
\nelectrocauterization, closure and dog ear excision was performed in a
\nsimilar fashion. The patient’s areola to neo-inframammary fold was 8 cm
\non each side with symmetrical mounds created. Specimen was sent to
\npathology. After completion of bilateral reductions, the wounds were
\ndressed with Dermabond and Tegaderm. General anesthesia was then
\nterminated. The patient went to the recovery room in stable condition.
\nThere were no complications. Sponge and instrument counts correct.
\nEstimated blood loss was minimal. The patient was discharged with
\ninstructions to resume usual diet and medications with the exception of
\nholding aspirin and Advil\/ibuprofen. The patient will ambulate q.i.d. She
\nwill drink plenty of fluids. She will avoid pressure on her chest. She
\nwill be seen tomorrow in follow up. She will begin Lovenox at 0800 on
\n07\/15\/2014. The patient will call for problems, questions or concerns.
\nFinal pathology is pending at the time of dictation.
\nDICTATED BY: Fixer Upper, MD
\nICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Case Study 1:
\nPlease select the level of History (HX) documented in the following statement:
\n\u2022 HPI: The patient is an 87-year-old white female who lives in a skilled nursing facility. She tells
\nme that her phone was ringing and she tried to reach over to get the phone but fell out of bed and
\nended up on the floor. She reports yelling for help. She was brought to the emergency room with
\na facial fracture. She was also found to have a small right frontal intracerebral hemorrhage. She
\nis being admitted for observation and treatment. She also has a Colles fracture.
\n\u2022 ROS: Constitutional: Denies fevers. Neurologic: She denies a headache. Eyes: She denies any
\nvision problems. Thinks she has had some cataract surgery. Notes no vision problems right now.
\nENT: Denies recent cyanosis or respiratory infection or chronic headache problems.<\/p>\n
13 | Page
\nCardiovascular: Denies heart problems or chest pains. Respiratory: Denies shortness of breath or
\nbreathing problems. Gastrointestinal: Denies nausea or diarrhea. Musculoskeletal: Has chronic
\nback pain mentioned above. Skin: Denies any rashes. Psychiatric: Acknowledges a history of
\nlow-grade depression but has not been problematic recently.
\n\u2022 Patient has a past medical history positive for parkinsons, frequent UTIs and chronic low back
\npain. She does not smoke and rarely drinks alcohol. Both parents are dead.
\nList the HPI elements:
\nList the ROS:
\nList the level of history this documentation supports:
\nFor an inpatient admission, would this documentation support a 99221, 99222, or 99223? Please
\nexplain your reasoning.<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n","protected":false},"excerpt":{"rendered":"
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