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Question number 1-Please identify the words in the following statement that match at least 4 of the HPI (history of present illness)elements identified below:Patient was admitted yesterday with severe asthma exacerbation. She had been trying tomaintain with her inhaler but continued to worsen over the last 24 hours before admit. Shehas had 5 breathing treatments and been on 4Lpm O2 for the last 12 hours and now has astable 90% sats. ORA she decreases to 78-70%. She has been around her boyfriend’s cat alot lately and feels this may have triggered this attack.Quality ____________________ Modifying Factors ___________________Context ___________________ Timing ___________________Duration __________________ Severity __________________________Question number 2-Please identify the Level of Medical Decision Making (MDM) in the following statement:1. Chest pain- new since last visit2. DOE (dyspnea on exertion) – worseningI have discussed this with him, and we will screen for ischemia with stress myocardialperfusion imaging. If Abnl test, then this may represent a high probability for CAD and angioshould be considered. If test is low risk, then may follow syndrome clinically, and seek othercauses of chest pain. The patient was instructed to avoid strenuous physical activity untilcomplete stress test results are known.F/U OV the week after these studies to consolidate eval and recommend further investigationsas indicated.Low __________ Moderate _________ High___________2 | PageQuestion number 3-Please select the level of History (HX) documented in the following statement:Patient comes in today complaining of 4 days history of cough and congestion. No Fever,Chest pain or dyspnea. Cough is mildly productive. He has been using Sudafed and Nyquilwith some relief.Past Medical History-Seasonal allergiesPast Surgical History-tonsillectomyPast Family History- Asthma—Father and BrotherSmoking status: Smokeless tobacco: Alcohol Use:2 drink(s) per weekAllergies-Cephalexin/Penicillin’s- RashReview of systems: Positive for malaise/fatigue. Positive for cough and sputum production(scant, clear). Negative for shortness of breath and wheezing. All remaining 10 point ROS andare negative.HPI- # of Elements__________ PFSH- # reviewed_______ ROS- # of systems ________History Level __________________Question number 4-Please select the level of Exam Both 95 and 97 guidelines documented in the following statement:Constitutional: He is oriented to person, place, and time. He appears well-developed andwell- nourished.Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear:Tympanic membrane normal. Nose: No mucosal edema or rhinorrhea.Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal. Eyes:EOM are normal. Pupils are equal, round, and reactive to light.Neck: Normal range of motion. Neck supple. No thyromegaly present.Cardiovascular: Normal rate, regular rhythm and No murmur heard.Pulmonary/Chest: Effort normal and breath sounds normal.Lymphadenopathy:He has no cervical adenopathy.Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry.No rash noted. Psychiatric: He has a normal mood and affect. His behavior is normal.Judgment and thought content normal.95 Guidelines Detailed________ Comprehensive___________3 | Page97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______Question number 5-Please choose the most accurate way of documenting a Review of System (ROS) in a comprehensive history__________ ROS complete__________ 14 point review of system performed__________ Positive for Shortness of Breath, Negative for Chest Pain. All other systems reviewed and arenegative_________ ROS is not needed for a comprehensive historyQuestion number 6-Please select the level of service documented in the following visit note:CC: Brought by ambulance – evaluate for non- responsiveness44 yo man BIBA from Rockies game after being found slouched over on the ground. Pt reportshaving too much alcohol to drink today and recalls going over to sit against a wall. He thenclosed his eyes and was found by a bystander. no witnessed szr activity. emesis x 1 (NBNB)in route. pt has no complaints at present. Pt denies fall/trauma.PHYSICAL EXAMVital signs reviewed, Patient afebrile, Pulse normal,Blood pressure normal, Respiratory ratenormal, Patient appears non toxic, pain free. Patient alert and oriented to person, place andtime. HEAD: atraumatic, normocephalic. EYES: Pupils equally round and reactive to light,Sclera normal. ENT: Nose exam normal, dried blood left nare, no active bleeding. NECK:Neck exam included findings of normal range of motion, Trachea midline. RESPIRATORYCHEST: no respiratory distress, Breath sounds clear. CARDIOVASCULAR: Regular rateand rhythm, Heart sounds normal, normal S1, normal S2. ABDOMEN: nontender, Bowelsounds normal. BACK: normal inspection, range of motion normal.UPPER EXTREMITY: inspection normal, Range of motion normal BilaterallyLOWER EXTREMITY: bilaterally Range of motion normal, no edema.NEURO: Speech normal. SKIN: warm, dry no abrasions PSYCHIATRIC: intoxicated.(Continued on next page)4 | PageASSESSMENT/PLAN: Acute alcohol intoxication- Breath EtOH 114 on arrival. No evidenceof significant trauma by exam or history. Will obvs until sober then d/c. Pt refused EKG.Disposition: D/C Home.INSTRUCTION: Follow up with your primary care doctor in 1 week. Return to the emergencydepartment for worsening symptoms, including worsening headache, numbness, weakness,tremors, seizure, or any other concerns.A. 99221B. 99222C. 99223D. None of the aboveQuestion number 7-Please select the level of service documented in the following statement:Patient is a 42yr female who presents today with complex migraines since she was a teenager.Now on relpax. No current migraine today but does need refills of relpax. Patient also onProzac and needs a refill of that. Today she is quite depressed and tearful.ROS-Per HPI-All other systems reviewed and negative.Vitals – BP 122/60 Temp- 97.4 Height 5′ 10″ Weight 178 lbsPatient is tearful and upset about a recent breakup with her boyfriend. We discussed in detailtreatment options for her including increased dosage of Prozac, adding Welbutrin, yoga, andstructured counseling. I asked the patient to follow up with my office in a month, unless hersymptoms increase or worsen. I spent 35 minutes in face to face time with the patient 25minutes of which were spent in counseling and coordination of care.If New Patient 99202_______ 99203 _________ 99204 _________If Established Patient 99213 ______ 99214 ________ 99215 ________5 | PageQuestion number 8-For a Level 4 new patient, please choose the proper documentation requirements_______ Detailed History and Comprehensive Exam and Moderate Medical Decision Making_______ Comprehensive History and Comprehensive Exam and High Medical Decision Making_______ Comprehensive History and Comprehensive Exam and Moderate Medical Decision Making________Comprehensive History or Comprehensive Exam and Moderate Medical Decision MakingQuestion number 9-Please select the correct level of service based on the documentation below:I spent 40 minutes in face to face time with the patient and family. 50 % or more was spent in counseling andcoordination of care. We discussed alternative therapies, options for medications, referrals for second opinions,etc. Risks, benefits and considerations were discussed with patient and family. They will let us know what theydecide.If Established Patient 99214 ________ 99215 _________If New Patient 99203_________ 99204 _________Question number 10-Please circle the correct definition of Critical Care:A. High-complexity decision-making to assess, manipulate and support vital system function(s) to treatsingle or multiple organ system failure and/or to prevent further life-threatening deteriorationB. Direct personal management and Frequent personal assessmentC. Record demonstrate the patient has acute impairment of one or more vital organ systems and has a highprobability of imminent or life-threatening deteriorationD. The interventions of a nature that failure to initiate these interventions on an urgent basis would likelyresult in sudden clinically significant or life-threatening deterioration in the patient’s conditionE. All of the Above6 | PageQuestion number 11-Please circle the examples of a correctly documented Chief Compliant:A. Follow up on DM medsB. Left Knee PainC. Follow upD. Annual ExamQuestion number 12-Please circle the correct time documentation for a 99214 if you are doing time based coding:A. 30 minutes was spent with the patient today in my office discussing proper dosage of newmedicationsB. The patient was in my office for two hours receiving hydration and counseling regardingfood poisoning side effectsC. 25 minutes was spent in face to face time with the patient. 50% or more was spent incounseling and coordination of care concerning dosage of new medications and possibleside effects.D. I spent 25 minutes with the patient and 20 minutes were in counseling.7 | PageCoding Quiz Operative Report 1:DATE OF PROCEDURE: 07/01/2017PREOPERATIVE DIAGNOSIS: Lumbar stenosis L4-5.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE: Lumbar laminectomy, bilateral L4-5.SURGEON: Ima Neurosurgeon, MD.ASSISTANT: Hesmy Assistant, PA-C.ANESTHESIA: General.INDICATIONS: The patient is a pleasant 85-year-old woman with symptoms ofneurogenic claudication. Her symptoms were refractory to conservativecare. Her imaging studies revealed severe stenosis at L4-L5, relativelymodest stenosis at ____ level. Given these findings, after a carefulexplanation of risks, benefits, likely outcome, the patient and familyagreed to proceed with surgery.NARRATIVE: The patient was brought to the operating room. After suitableinduction of general anesthetic, the patient was carefully positionedprone on the operative table. All pressure points were padded asconfirmed by me and the anesthesia team. Using surface landmarks and a C-arm, the incision was planned. The patient was prepped and draped in theusual sterile fashion. After infiltration of local anesthetic, incisionwas made with a #10 blade. Hemostasis was obtained with Boviecauterization. The incision was carried down to the level of the lumbardorsal fascia. Ligamentous muscular attachments were elevated at the L4-5region. X-ray once again confirmed our position.Leksell rongeur was then used to remove the spinous processes and portionof the lamina.The operative microscope was brought into the field. High speed drill wasthen used to thin the lamina. A curet was used to then separate thelamina from the ligamentum flavum. With that complete, the remainder ofthe bone was removed.With careful dissection, I was able to then dissect the ligamentum flavumfrom the dura. There is perhaps a small fenestration was made in thedura. This was closed with interrupted 4-0 Nurolon. The facet joints wereundercut laterally on both sides. The remainder of the ligament was alsoremoved.Once I was satisfied that the decompression was adequate, the seal wasplaced over the area where the suture had been placed. The Duragen wasalso placed prior to placement of the Tisseel sealant.The wound was closed with multiple layers of Vicryl followed by a runninglocking Prolene.The patient tolerated the procedure well.Sponge and instrument counts were correct at the end of the case.Of note, at the end of the case, the neural monitoring unit had placedits leads. There were no untoward findings with the neuromonitoring.8 | PageThe patient tolerated the procedure well, was turned over to anesthesiafor awakening.DICTATED BY: Ima Neurosurgeon, MDICD-10 Code(s): ____________________________________________________CPT Code(s): _____________________________________________________Comments:9 | PageCoding Quiz Operative Report 2:DATE OF PROCEDURE: 07/07/2017PREOPERATIVE DIAGNOSIS: Left subtrochanteric femur fracture.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE: Intramedullary nailing of left subtrochanteric femur fracture.SURGEON: Shesa Doctor, MD.ASSISTANT: Hesher Helper, MD. Please note, Mr. Helper was medicallynecessary for this patient to help position the patient, to help holdretractors during the procedure, to help reduce the fracture and toassist with wound closure.ANESTHESIA: General endotracheal anesthesia.ESTIMATED BLOOD LOSS: 250 mL.COMPLICATIONS: None.DISPOSITION: The patient was successfully awakened and extubated in theoperating room and returned to the postanesthesia care unit in stablecondition.BRIEF PREOPERATIVE NOTE: The patient is a 63-year-old gentleman who wasriding his bicycle when he had a terrible accident, landing directly ontohis left hip. He sustained a comminuted complex proximal femur fracturewhich was also complicated by the fact that he was on anticoagulants andhis INR was 3.38. Upon presentation to the hospital. Overnight, he wasgiven vitamin K and prior to surgery given FFP to get him to a morenormalized INR. The risks and benefits of this procedure were explainedto the patient. The patient asked appropriate questions. After allappropriate questions were answered, informed consent was obtained andplaced on the chart. At this time, the patient did agree to proceed tothe operating room for the above listed operative procedure.BRIEF OPERATIVE NOTE: The patient was brought to the operating room,first in his hospital bed general anesthesia was administered. Next, thepatient was transferred to the fracture table where the endotracheal tubewas in placed under the general anesthetic at that time. The left lowerextremity was placed into a well padded longitudinal traction and theright lower extremity was placed into a well padded, well leg holder.Next, image intensifier was brought into the field to ensure that wecould get adequate closed reduction. After significant traction,adduction and internal rotation of the leg, we were able to get anadequate reduction. Next, the left lower extremity was prepped and drapedin the usual orthopedic sterile fashion. Next, a 3.2 mm guidewire for thetrochanteric fixation nail was then passed in an intramedullary position.Next, the opening awl was passed without complication. Next, a balltipped guidewire was passed into the canal and measured to the distalfemur 460, but we placed a 420 mm trochanteric fixation nail with a 130degree helical blade setting. Next, the nail was passed withoutcomplication. Next, the outrigger was placed for placement of the helicalblade. Guide pin was passed for the helical blade in a center-centerposition into the femoral neck and head measured a 105 mm. The outerlateral cortex was drilled without complication, then the triple reamer10 | Pagewas passed. Next, the 105 mm helical blade was passed withoutcomplication and locked into position. Next, the outrigger was removed.Orthogonal x-rays showed near anatomic alignment of the proximal femur.Next, attention was then paid distally to the distal femur for perfectcircles and one 5.0, 52 mm locking bolt was then placed withoutcomplication. Again, orthogonal x-rays showed near anatomic alignment ofthe proximal femur, no evidence of hardware failure. At this time, allwounds were thoroughly irrigated with bacitracin-laden normal saline.Next, the deep layer was closed with a #1 Vicryl in an interruptedfashion. The wound was infiltrated with 30 mL of 0.5% Marcaine withoutepinephrine. The deep subcuticular layer was closed with an 0 Vicryl,skin reapproximated with 2-0 Vicryl and then skin staples. Next, steriledressings were applied.Next, the patient was taken out of traction and returned to the hospitalbed. General endotracheal anesthesia was terminated. The patienttolerated the procedure without complication, was successfully awakenedand extubated in the operating room, returned to the postanesthesia careunit in stable condition.DICTATED BY: Shesa Doctor, MDICD-10 Code(s): ____________________________________________________CPT Code(s): _____________________________________________________Comments:Coding Quiz Operative Report 3:11 | PageDATE OF PROCEDURE: 07/14/2017SURGEON: Fixer Upper, MD.FIRST ASSISTANT: None.PREOPERATIVE DIAGNOSES:1. Symptomatic asymmetrical mammary hypertrophy.2. Cervicalgia.3. Thoracic pain.POSTOPERATIVE DIAGNOSIS: Same.OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.INDICATIONS FOR SURGERY: The patient is a 66-year-old female who requestsreduction mammoplasty for symptoms related to large and heavy breasts.The patient has nod only severe tilt of the shoulder with the rightbreast larger and lower, but has bra strap grooves. The size isconsistent with a 38 G to H size. She has rounded forward anteriordisplaced shoulders, large pendulous ptotic asymmetrical breasts, brastrap grooves and nonfocal, tightness and tenderness in the trapezius,interscapular and paraspinal musculature. The patient requests reductionmammoplasty in an attempt to improve symptoms from large and heavybreasts.PROCEDURE: Markings made preoperatively for a medial pedicle verticaltype reduction mammoplasty accounting for the dyssymmetry. The patienttaken to the operating room, placed on the operating table in the supineposition. All bony prominences were well padded. PAS stockings were inplace and functioning. General anesthesia was induced bilateral upperextremities were abducted to under 80 degrees on arm boards. Prepping anddraping was performed in a sterile fashion.Of note, the patient has severe compromised skin envelope with striateand severe ptosis. Stab incision was made in the area of intendedvertical excision and using a blunt infiltration cannula on each side 500mL of 0.03% lidocaine with adrenalin 1:1 million was infiltrated on eachside. The operation was performed similarly on each side. First,attention was directed to the right side after adequate epinephrineeffect, a 45 mm areola was incised. De-epithelization of the medialpedicle was performed. Incision was made in the upper keyhole in verticalarea, keeping the lower extent of excision 4 cm up from the inframammaryfold. Composite resection was performed after isolating the pedicle bysharp dissection and adequate at least 2 cm vertical pillars wereCoding Quiz Operative Report 3:preserved and further resection laterally was performed removing on theright side 716 grams. Meticulous hemostasis obtained withelectrocauterization. Irrigation was performed with saline. The verticalpillars repaired with #1 Vicryl sutures. The vertical closure for 8 cmwas performed using gathering 4-0 Monocryl deep dermal sutures, running12 | Pagesubcuticular 3-0 V-Loc suture. The nipple areolar complex was sutured tosurrounding flaps using interrupted simple 4-0 Monocryl for the deepdermis, running subcuticular 4-0 Monocryl for the skin. Because of severeskin envelope laxity, the patient’s body habitus, was necessary toperform dog ear excision of skin and subcutaneous tissue in the neo-inframammary fold for contouring purposes. Closure in this area, afterhemostasis obtained with electrocauterization was accomplished usinginterrupted 3-0 Vicryl to deep dermis, running subcuticular 3-0 V-LocMonocryl for the skin. Next, attention was directed to the left sidewhere resection of 757 grams was performed, hemostasis obtained withelectrocauterization, closure and dog ear excision was performed in asimilar fashion. The patient’s areola to neo-inframammary fold was 8 cmon each side with symmetrical mounds created. Specimen was sent topathology. After completion of bilateral reductions, the wounds weredressed with Dermabond and Tegaderm. General anesthesia was thenterminated. The patient went to the recovery room in stable condition.There were no complications. Sponge and instrument counts correct.Estimated blood loss was minimal. The patient was discharged withinstructions to resume usual diet and medications with the exception ofholding aspirin and Advil/ibuprofen. The patient will ambulate q.i.d. Shewill drink plenty of fluids. She will avoid pressure on her chest. Shewill be seen tomorrow in follow up. She will begin Lovenox at 0800 on07/15/2014. The patient will call for problems, questions or concerns.Final pathology is pending at the time of dictation.DICTATED BY: Fixer Upper, MDICD-10 Code(s): ____________________________________________________CPT Code(s): _____________________________________________________Case Study 1:Please select the level of History (HX) documented in the following statement:• HPI: The patient is an 87-year-old white female who lives in a skilled nursing facility. She tellsme that her phone was ringing and she tried to reach over to get the phone but fell out of bed andended up on the floor. She reports yelling for help. She was brought to the emergency room witha facial fracture. She was also found to have a small right frontal intracerebral hemorrhage. Sheis being admitted for observation and treatment. She also has a Colles fracture.• ROS: Constitutional: Denies fevers. Neurologic: She denies a headache. Eyes: She denies anyvision problems. Thinks she has had some cataract surgery. Notes no vision problems right now.ENT: Denies recent cyanosis or respiratory infection or chronic headache problems.13 | PageCardiovascular: Denies heart problems or chest pains. Respiratory: Denies shortness of breath orbreathing problems. Gastrointestinal: Denies nausea or diarrhea. Musculoskeletal: Has chronicback pain mentioned above. Skin: Denies any rashes. Psychiatric: Acknowledges a history oflow-grade depression but has not been problematic recently.• Patient has a past medical history positive for parkinsons, frequent UTIs and chronic low backpain. She does not smoke and rarely drinks alcohol. Both parents are dead.List the HPI elements:List the ROS:List the level of history this documentation supports:For an inpatient admission, would this documentation support a 99221, 99222, or 99223? Pleaseexplain your reasoning.ICD-10 Code(s): ____________________________________________________
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