Advanced Medical Coding

1. A 61-year-old female patient is seen for a complaint of

severe heartburn, lightheadedness, skin reddening, and

shortness of breath. The physician renders a diagnosis of

GERD, sickle cell anemia, lymphangitis, and diaphragmatic

paralysis. What code(s) should be assigned?

ICD-10: __________________________________________

2. A 37-year-old patient comes in complaining of swollen

joints and headaches. The physician’s diagnosis is SLE.

The patient also has rheumatoid arthritis and asthma

with status asthmaticus. What code(s) are assigned?

ICD-10: __________________________________________

3. A 52-year-old patient is seen for mouth pain, knee pain,

and fluid buildup in the chest. The physician renders a

diagnosis of pulp degeneration, old disruption of the posterior

cruciate ligament, and pleural effusion. The

physician also performed a chest tube insertion (draining

the right pleural cavity with a drainage device using a

percutaneous approach) prior to diagnosing the patient’s

pleural effusion. What diagnosis and procedure code(s)

are assigned?

ICD-10: __________________________________________

4. A 30-year-old male is admitted to the hospital with

lymphadenitis, acute lymphoid leukemia in relapse, and

von Willebrand disease. What code(s) are reported?

ICD-10: __________________________________________

5. A 47-year-old male is involved in a motor vehicle accident.

He was driving on the highway when his car

collided with another vehicle. He was brought to the hospital

with a lower arm injury. The physician obtained an

x-ray of the arm and, after careful review and interpretation

of the x-ray, rendered a diagnosis of lower arm

fracture. The physician repaired the arm fracture using

open reduction and internal fixation (reposition of the

right radius with internal fixation using a percutaneous

endoscopic approach). What diagnosis and procedure

code(s) are reported?

ICD-10: __________________________________________

Review each of the following medical coding scenarios. Assign

the CPT code for the services and procedures indicated in

each scenario.

1. A 48-year-old male patient comes to the emergency room

with complaints of GERD. The physician performs a

laparoscopic fundoplasty with a Collis gastroplasty. What

CPT code(s) should be assigned?

CPT: _________________________________________________

2. A 40-year-old female patient is diagnosed with cervical

cancer. She also complains about difficulty breathing.

She is admitted to the hospital, where the physician

begins to perform a bronchoscopy after anesthesia

administration. However, the procedure is discontinued

due to unforeseen complications. Later the same day, a

bilateral cervical lymphadenectomy is performed to

address the patient’s cervical cancer. What CPT code(s)

are assigned?

CPT: _________________________________________________

3. A 50-year-old patient is admitted for a repair of a laceration

to the diaphragm resulting from an accident

involving a bus that ran into a ditch. She also received

eight trigger point injections into the transverse abdominus

muscle due to pain resulting from the accident.

What CPT code(s) are assigned?

CPT: _________________________________________________

4. A 23-year-old patient comes to the emergency room after

being physically assaulted by her boyfriend. She complains

of nasal pain and bleeding from the left nostril.

The physician obtains an x-ray of the nasal cavity, and

the x-ray confirms a nasal septum fracture. The physician

performs an open treatment of the nasal fracture

with a concomitant open treatment of the fractured septum.

What CPT code(s) should be assigned?

CPT: _________________________________________________

5. A 33-year-old patient is seen in the emergency room due

to complaints of headaches and congestion. The final

diagnosis is maxillary sinus infection. The physician performs

a nasal endoscopy with a maxillary antrostomy.

She also removes some tissue from the maxillary sinus.

What CPT code(s) should be assigned?

CPT: _________________________________________________

Review each of the following medical coding scenarios. Assign

the HCPCS code(s) required for each coding scenario.

1. A 49-year-old patient is admitted to the hospital for

repair of an ankle fracture. On the day of discharge, the

physician prescribes a dynamic ankle extension and flexion

device with a soft interface material. The ankle device

is adjustable. What HCPCS code(s) are assigned?

HCPCS: ______________________________________

2. A 26-year-old patient was admitted to the hospital with

acute exacerbation of allergic asthma. During the course

of the hospitalization, the patient received 5 mg of omalizumab

administered subcutaneously. What HCPCS

code(s) are assigned?

HCPCS: ______________________________________

3. A 58-year-old patient is admitted to the hospital due to

severe anemia. He receives six units of fresh frozen

plasma on the first day of admission. What HCPCS

code(s) should be assigned?

HCPCS: ______________________________________

4. A 26-year-old patient comes to the emergency room complaining

of watery diarrhea for five days. She receives 25

mcg of octreotide acetate administered

intravenously. What HCPCS code(s) are assigned?

HCPCS: ______________________________________

5. A patient is brought to the emergency room after ingesting

a bottle of verapamil as a suicide attempt. The

physician ordered 10mg of glucagon HCL to be administered

as an antidote mixed in 100 ml of D5W in an IV

over 2 minutes. What HCPCS code(s) should be

assigned?

HCPCS: ______________________________________

Review the following medical coding scenario. Assign all of

the ICD-10 and CPT codes for the diagnoses and procedures

indicated in the scenario.

After being evaluated by his gastroenterologist, Mr. Jackson

was sent to the hospital for a diagnostic esophagogastroduodenoscopy.

He is having several symptoms that indicate a

potential gastrointestinal condition. As a result, he was admitted

in observation. His symptoms include vomiting, weight

loss, and dysphagia. The esophagogastroduodenoscopy reveals

that the patient has low-grade Barrett’s esophagus, GERD

with reflux esophagitis and a non-obstructing hiatal hernia.

Patient was also incidentally diagnosed with Crest Syndrome

(CRST), which correlates with his complaint of dysphagia.

After the procedure, the patient was noted to have several

PVC’s on his EKG. These resolved shortly after the patient

arrived in the recovery room. Based on the results of the

detailed history, detailed, exam, and straight forward medical

decision making, it was decided that the patient could be discharged

home on the same day with instructions for a follow

up office appointment in 2 days. Code this scenario.

ICD-10: ____________________________________________________

CPT: ____________________________________________________

 

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