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?

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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?

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?
Advanced Medical Coding / Nursing
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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