<\/p>\n
This is an \u201copen book\u201d test with regard to CPT and ICD-10 coding books.<\/p>\n
Question number 1-<\/p>\n
Please identify the words in the following statement that match at least 4 of the HPI (history of present illness)<\/p>\n
elements identified below:<\/p>\n
Patient was admitted yesterday with severe asthma exacerbation. She had been trying to<\/p>\n
maintain with her inhaler but continued to worsen over the last 24 hours before admit. She<\/p>\n
has had 5 breathing treatments and been on 4Lpm O2 for the last 12 hours and now has a<\/p>\n
stable 90% sats. ORA she decreases to 78-70%. She has been around her boyfriend\u2019s cat a<\/p>\n
lot lately and feels this may have triggered this attack.<\/p>\n
Quality ____________________ Modifying Factors ___________________<\/p>\n
Context ___________________ Timing ___________________<\/p>\n
Duration __________________ Severity __________________________<\/p>\n
Question number 2-<\/p>\n
Please identify the Level of Medical Decision Making (MDM) in the following statement:<\/p>\n
1. Chest pain- new since last visit<\/p>\n
2. DOE (dyspnea on exertion) – worsening<\/p>\n
I have discussed this with him, and we will screen for ischemia with stress myocardial<\/p>\n
perfusion imaging. If Abnl test, then this may represent a high probability for CAD and angio<\/p>\n
should be considered. If test is low risk, then may follow syndrome clinically, and seek other<\/p>\n
causes of chest pain. The patient was instructed to avoid strenuous physical activity until<\/p>\n
complete stress test results are known.<\/p>\n
F\/U OV the week after these studies to consolidate eval and recommend further investigations<\/p>\n
as indicated.<\/p>\n
Low __________ Moderate _________ High___________<\/p>\n
2 | Page<\/p>\n
Question number 3-<\/p>\n
Please select the level of History (HX) documented in the following statement:<\/p>\n
Patient comes in today complaining of 4 days history of cough and congestion. No Fever,<\/p>\n
Chest pain or dyspnea. Cough is mildly productive. He has been using Sudafed and Nyquil<\/p>\n
with some relief.<\/p>\n
Past Medical History-Seasonal allergies<\/p>\n
Past Surgical History-tonsillectomy<\/p>\n
Past Family History- Asthma—Father and Brother<\/p>\n
Smoking status: Smokeless tobacco: Alcohol Use:2 drink(s) per week<\/p>\n
Allergies-Cephalexin\/Penicillin\u2019s- Rash<\/p>\n
Review of systems: Positive for malaise\/fatigue. Positive for cough and sputum production<\/p>\n
(scant, clear). Negative for shortness of breath and wheezing. All remaining 10 point ROS and<\/p>\n
are negative.<\/p>\n
HPI- # of Elements__________ PFSH- # reviewed_______ ROS- # of systems ________<\/p>\n
History Level __________________<\/p>\n
Question number 4-<\/p>\n
Please select the level of Exam Both 95 and 97 guidelines documented in the following statement:<\/p>\n
Constitutional: He is oriented to person, place, and time. He appears well-developed and<\/p>\n
well- nourished.<\/p>\n
Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear:<\/p>\n
Tympanic membrane normal. Nose: No mucosal edema or rhinorrhea.<\/p>\n
Mouth\/Throat: Oropharynx is clear and moist and mucous membranes are normal. Eyes:<\/p>\n
EOM are normal. Pupils are equal, round, and reactive to light.<\/p>\n
Neck: Normal range of motion. Neck supple. No thyromegaly present.<\/p>\n
Cardiovascular: Normal rate, regular rhythm and No murmur heard.<\/p>\n
Pulmonary\/Chest: Effort normal and breath sounds normal.<\/p>\n
Lymphadenopathy:He has no cervical adenopathy.<\/p>\n
Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry.<\/p>\n
No rash noted. Psychiatric: He has a normal mood and affect. His behavior is normal.<\/p>\n
Judgment and thought content normal.<\/p>\n
95 Guidelines Detailed________ Comprehensive___________<\/p>\n
3 | Page<\/p>\n
97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______<\/p>\n
Question number 5-<\/p>\n
Please choose the most accurate way of documenting a Review of System (ROS) in a comprehensive history<\/p>\n
__________ ROS complete<\/p>\n
__________ 14 point review of system performed<\/p>\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-<\/p>\n
Please select the level of service documented in the following visit note:<\/p>\n
CC: Brought by ambulance \u2013 evaluate for non- responsiveness<\/p>\n
44 yo man BIBA from Rockies game after being found slouched over on the ground. Pt reports<\/p>\n
having too much alcohol to drink today and recalls going over to sit against a wall. He then<\/p>\n
closed his eyes and was found by a bystander. no witnessed szr activity. emesis x 1 (NBNB)<\/p>\n
in route. pt has no complaints at present. Pt denies fall\/trauma.<\/p>\n
PHYSICAL EXAM<\/p>\n
Vital signs reviewed, Patient afebrile, Pulse normal,Blood pressure normal, Respiratory rate<\/p>\n
normal, Patient appears non toxic, pain free. Patient alert and oriented to person, place and<\/p>\n
time. HEAD: atraumatic, normocephalic. EYES: Pupils equally round and reactive to light,<\/p>\n
Sclera normal. ENT: Nose exam normal, dried blood left nare, no active bleeding. NECK:<\/p>\n
Neck exam included findings of normal range of motion, Trachea midline. RESPIRATORY<\/p>\n
CHEST: no respiratory distress, Breath sounds clear. CARDIOVASCULAR: Regular rate<\/p>\n
and rhythm, Heart sounds normal, normal S1, normal S2. ABDOMEN: nontender, Bowel<\/p>\n
sounds normal. BACK: normal inspection, range of motion normal.<\/p>\n
UPPER EXTREMITY: inspection normal, Range of motion normal Bilaterally<\/p>\n
LOWER EXTREMITY: bilaterally Range of motion normal, no edema.<\/p>\n
NEURO: Speech normal. SKIN: warm, dry no abrasions PSYCHIATRIC: intoxicated.<\/p>\n
(Continued on next page)<\/p>\n
4 | Page<\/p>\n
ASSESSMENT\/PLAN: Acute alcohol intoxication- Breath EtOH 114 on arrival. No evidence<\/p>\n
of significant trauma by exam or history. Will obvs until sober then d\/c. Pt refused EKG.<\/p>\n
Disposition: D\/C Home.<\/p>\n
INSTRUCTION: Follow up with your primary care doctor in 1 week. Return to the emergency<\/p>\n
department for worsening symptoms, including worsening headache, numbness, weakness,<\/p>\n
tremors, seizure, or any other concerns.<\/p>\n
A. 99221<\/p>\n
B. 99222<\/p>\n
C. 99223<\/p>\n
D. None of the above<\/p>\n
Question number 7-<\/p>\n
Please select the level of service documented in the following statement:<\/p>\n
Patient is a 42yr female who presents today with complex migraines since she was a teenager.<\/p>\n
Now on relpax. No current migraine today but does need refills of relpax. Patient also on<\/p>\n
Prozac and needs a refill of that. Today she is quite depressed and tearful.<\/p>\n
ROS-Per HPI-All other systems reviewed and negative.<\/p>\n
Vitals \u2013 BP 122\/60 Temp- 97.4 Height 5′ 10″ Weight 178 lbs<\/p>\n
Patient is tearful and upset about a recent breakup with her boyfriend. We discussed in detail<\/p>\n
treatment options for her including increased dosage of Prozac, adding Welbutrin, yoga, and<\/p>\n
structured counseling. I asked the patient to follow up with my office in a month, unless her<\/p>\n
symptoms increase or worsen. I spent 35 minutes in face to face time with the patient 25<\/p>\n
minutes of which were spent in counseling and coordination of care.<\/p>\n
If New Patient 99202_______ 99203 _________ 99204 _________<\/p>\n
If Established Patient 99213 ______ 99214 ________ 99215 ________<\/p>\n
5 | Page<\/p>\n
Question number 8-<\/p>\n
For a Level 4 new patient, please choose the proper documentation requirements<\/p>\n
_______ Detailed History and Comprehensive Exam and Moderate Medical Decision Making<\/p>\n
_______ Comprehensive History and Comprehensive Exam and High Medical Decision Making<\/p>\n
_______ Comprehensive History and Comprehensive Exam and Moderate Medical Decision Making<\/p>\n
________Comprehensive History or Comprehensive Exam and Moderate Medical Decision Making<\/p>\n
Question number 9-<\/p>\n
Please select the correct level of service based on the documentation below:<\/p>\n
I spent 40 minutes in face to face time with the patient and family. 50 % or more was spent in counseling and<\/p>\n
coordination of care. We discussed alternative therapies, options for medications, referrals for second opinions,<\/p>\n
etc. Risks, benefits and considerations were discussed with patient and family. They will let us know what they<\/p>\n
decide.<\/p>\n
If Established Patient 99214 ________ 99215 _________<\/p>\n
If New Patient 99203_________ 99204 _________<\/p>\n
Question number 10-<\/p>\n
Please circle the correct definition of Critical Care:<\/p>\n
A. High-complexity decision-making to assess, manipulate and support vital system function(s) to treat<\/p>\n
single or multiple organ system failure and\/or to prevent further life-threatening deterioration<\/p>\n
B. Direct personal management and Frequent personal assessment<\/p>\n
C. Record demonstrate the patient has acute impairment of one or more vital organ systems and has a high<\/p>\n
probability of imminent or life-threatening deterioration<\/p>\n
D. The interventions of a nature that failure to initiate these interventions on an urgent basis would likely<\/p>\n
result in sudden clinically significant or life-threatening deterioration in the patient\u2019s condition<\/p>\n
E. All of the Above<\/p>\n
6 | Page<\/p>\n
Question number 11-<\/p>\n
Please circle the examples of a correctly documented Chief Compliant:<\/p>\n
A. Follow up on DM meds<\/p>\n
B. Left Knee Pain<\/p>\n
C. Follow up<\/p>\n
D. Annual Exam<\/p>\n
Question number 12-<\/p>\n
Please circle the correct time documentation for a 99214 if you are doing time based coding:<\/p>\n
A. 30 minutes was spent with the patient today in my office discussing proper dosage of new<\/p>\n
medications<\/p>\n
B. The patient was in my office for two hours receiving hydration and counseling regarding<\/p>\n
food poisoning side effects<\/p>\n
C. 25 minutes was spent in face to face time with the patient. 50% or more was spent in<\/p>\n
counseling and coordination of care concerning dosage of new medications and possible<\/p>\n
side effects.<\/p>\n
D. I spent 25 minutes with the patient and 20 minutes were in counseling.<\/p>\n
7 | Page<\/p>\n
Coding Quiz Operative Report 1:<\/p>\n
DATE OF PROCEDURE: 07\/01\/2017<\/p>\n
PREOPERATIVE DIAGNOSIS: Lumbar stenosis L4-5.<\/p>\n
POSTOPERATIVE DIAGNOSIS: Same.<\/p>\n
PROCEDURE: Lumbar laminectomy, bilateral L4-5.<\/p>\n
SURGEON: Ima Neurosurgeon, MD.<\/p>\n
HelpANT: Hesmy Helpant, PA-C.<\/p>\n
ANESTHESIA: General.<\/p>\n
INDICATIONS: The patient is a pleasant 85-year-old woman with symptoms of<\/p>\n
neurogenic claudication. Her symptoms were refractory to conservative<\/p>\n
care. Her imaging studies revealed severe stenosis at L4-L5, relatively<\/p>\n
modest stenosis at ____ level. Given these findings, after a careful<\/p>\n
explanation of risks, benefits, likely outcome, the patient and family<\/p>\n
agreed to proceed with surgery.<\/p>\n
NARRATIVE: The patient was brought to the operating room. After suitable<\/p>\n
induction of general anesthetic, the patient was carefully positioned<\/p>\n
prone 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-<\/p>\n
arm, the incision was planned. The patient was prepped and draped in the<\/p>\n
usual sterile fashion. After infiltration of local anesthetic, incision<\/p>\n
was made with a #10 blade. Hemostasis was obtained with Bovie<\/p>\n
cauterization. The incision was carried down to the level of the lumbar<\/p>\n
dorsal fascia. Ligamentous muscular attachments were elevated at the L4-5<\/p>\n
region. X-ray once again confirmed our position.<\/p>\n
Leksell rongeur was then used to remove the spinous processes and portion<\/p>\n
of the lamina.<\/p>\n
The operative microscope was brought into the field. High speed drill was<\/p>\n
then used to thin the lamina. A curet was used to then separate the<\/p>\n
lamina from the ligamentum flavum. With that complete, the remainder of<\/p>\n
the bone was removed.<\/p>\n
With careful dissection, I was able to then dissect the ligamentum flavum<\/p>\n
from the dura. There is perhaps a small fenestration was made in the<\/p>\n
dura. This was closed with interrupted 4-0 Nurolon. The facet joints were<\/p>\n
undercut laterally on both sides. The remainder of the ligament was also<\/p>\n
removed.<\/p>\n
Once I was satisfied that the decompression was adequate, the seal was<\/p>\n
placed over the area where the suture had been placed. The Duragen was<\/p>\n
also placed prior to placement of the Tisseel sealant.<\/p>\n
The wound was closed with multiple layers of Vicryl followed by a running<\/p>\n
locking Prolene.<\/p>\n
The patient tolerated the procedure well.<\/p>\n
Sponge and instrument counts were correct at the end of the case.<\/p>\n
Of note, at the end of the case, the neural monitoring unit had placed<\/p>\n
its leads. There were no untoward findings with the neuromonitoring.<\/p>\n
8 | Page<\/p>\n
The patient tolerated the procedure well, was turned over to anesthesia<\/p>\n
for awakening.<\/p>\n
DICTATED BY: Ima Neurosurgeon, MD<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Comments:<\/p>\n
9 | Page<\/p>\n
Coding Quiz Operative Report 2:<\/p>\n
DATE OF PROCEDURE: 07\/07\/2017<\/p>\n
PREOPERATIVE DIAGNOSIS: Left subtrochanteric femur fracture.<\/p>\n
POSTOPERATIVE DIAGNOSIS: Same.<\/p>\n
PROCEDURE: Intramedullary nailing of left subtrochanteric femur fracture.<\/p>\n
SURGEON: Shesa Doctor, MD.<\/p>\n
HelpANT: Hesher Helper, MD. Please note, Mr. Helper was medically<\/p>\n
necessary for this patient to help position the patient, to help hold<\/p>\n
retractors during the procedure, to help reduce the fracture and to<\/p>\n
Help with wound closure.<\/p>\n
ANESTHESIA: General endotracheal anesthesia.<\/p>\n
ESTIMATED BLOOD LOSS: 250 mL.<\/p>\n
COMPLICATIONS: None.<\/p>\n
DISPOSITION: The patient was successfully awakened and extubated in the<\/p>\n
operating room and returned to the postanesthesia care unit in stable<\/p>\n
condition.<\/p>\n
BRIEF PREOPERATIVE NOTE: The patient is a 63-year-old gentleman who was<\/p>\n
riding his bicycle when he had a terrible accident, landing directly onto<\/p>\n
his left hip. He sustained a comminuted complex proximal femur fracture<\/p>\n
which was also complicated by the fact that he was on anticoagulants and<\/p>\n
his INR was 3.38. Upon presentation to the hospital. Overnight, he was<\/p>\n
given vitamin K and prior to surgery given FFP to get him to a more<\/p>\n
normalized INR. The risks and benefits of this procedure were explained<\/p>\n
to the patient. The patient asked appropriate questions. After all<\/p>\n
appropriate questions were answered, informed consent was obtained and<\/p>\n
placed on the chart. At this time, the patient did agree to proceed to<\/p>\n
the operating room for the above listed operative procedure.<\/p>\n
BRIEF OPERATIVE NOTE: The patient was brought to the operating room,<\/p>\n
first in his hospital bed general anesthesia was administered. Next, the<\/p>\n
patient was transferred to the fracture table where the endotracheal tube<\/p>\n
was in placed under the general anesthetic at that time. The left lower<\/p>\n
extremity was placed into a well padded longitudinal traction and the<\/p>\n
right lower extremity was placed into a well padded, well leg holder.<\/p>\n
Next, image intensifier was brought into the field to ensure that we<\/p>\n
could get adequate closed reduction. After significant traction,<\/p>\n
adduction and internal rotation of the leg, we were able to get an<\/p>\n
adequate reduction. Next, the left lower extremity was prepped and draped<\/p>\n
in the usual orthopedic sterile fashion. Next, a 3.2 mm guidewire for the<\/p>\n
trochanteric fixation nail was then passed in an intramedullary position.<\/p>\n
Next, the opening awl was passed without complication. Next, a ball<\/p>\n
tipped guidewire was passed into the canal and measured to the distal<\/p>\n
femur 460, but we placed a 420 mm trochanteric fixation nail with a 130<\/p>\n
degree helical blade setting. Next, the nail was passed without<\/p>\n
complication. Next, the outrigger was placed for placement of the helical<\/p>\n
blade. Guide pin was passed for the helical blade in a center-center<\/p>\n
position into the femoral neck and head measured a 105 mm. The outer<\/p>\n
lateral cortex was drilled without complication, then the triple reamer<\/p>\n
10 | Page<\/p>\n
was passed. Next, the 105 mm helical blade was passed without<\/p>\n
complication and locked into position. Next, the outrigger was removed.<\/p>\n
Orthogonal x-rays showed near anatomic alignment of the proximal femur.<\/p>\n
Next, attention was then paid distally to the distal femur for perfect<\/p>\n
circles and one 5.0, 52 mm locking bolt was then placed without<\/p>\n
complication. Again, orthogonal x-rays showed near anatomic alignment of<\/p>\n
the proximal femur, no evidence of hardware failure. At this time, all<\/p>\n
wounds were thoroughly irrigated with bacitracin-laden normal saline.<\/p>\n
Next, the deep layer was closed with a #1 Vicryl in an interrupted<\/p>\n
fashion. The wound was infiltrated with 30 mL of 0.5% Marcaine without<\/p>\n
epinephrine. The deep subcuticular layer was closed with an 0 Vicryl,<\/p>\n
skin reapproximated with 2-0 Vicryl and then skin staples. Next, sterile<\/p>\n
dressings were applied.<\/p>\n
Next, the patient was taken out of traction and returned to the hospital<\/p>\n
bed. General endotracheal anesthesia was terminated. The patient<\/p>\n
tolerated the procedure without complication, was successfully awakened<\/p>\n
and extubated in the operating room, returned to the postanesthesia care<\/p>\n
unit in stable condition.<\/p>\n
DICTATED BY: Shesa Doctor, MD<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Comments:<\/p>\n
Coding Quiz Operative Report 3:<\/p>\n
11 | Page<\/p>\n
DATE OF PROCEDURE: 07\/14\/2017<\/p>\n
SURGEON: Fixer Upper, MD.<\/p>\n
FIRST HelpANT: None.<\/p>\n
PREOPERATIVE DIAGNOSES:<\/p>\n
1. Symptomatic asymmetrical mammary hypertrophy.<\/p>\n
2. Cervicalgia.<\/p>\n
3. Thoracic pain.<\/p>\n
POSTOPERATIVE DIAGNOSIS: Same.<\/p>\n
OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.<\/p>\n
INDICATIONS FOR SURGERY: The patient is a 66-year-old female who requests<\/p>\n
reduction mammoplasty for symptoms related to large and heavy breasts.<\/p>\n
The patient has nod only severe tilt of the shoulder with the right<\/p>\n
breast larger and lower, but has bra strap grooves. The size is<\/p>\n
consistent with a 38 G to H size. She has rounded forward anterior<\/p>\n
displaced shoulders, large pendulous ptotic asymmetrical breasts, bra<\/p>\n
strap grooves and nonfocal, tightness and tenderness in the trapezius,<\/p>\n
interscapular and paraspinal musculature. The patient requests reduction<\/p>\n
mammoplasty in an attempt to improve symptoms from large and heavy<\/p>\n
breasts.<\/p>\n
PROCEDURE: Markings made preoperatively for a medial pedicle vertical<\/p>\n
type reduction mammoplasty accounting for the dyssymmetry. The patient<\/p>\n
taken to the operating room, placed on the operating table in the supine<\/p>\n
position. All bony prominences were well padded. PAS stockings were in<\/p>\n
place and functioning. General anesthesia was induced bilateral upper<\/p>\n
extremities were abducted to under 80 degrees on arm boards. Prepping and<\/p>\n
draping was performed in a sterile fashion.<\/p>\n
Of note, the patient has severe compromised skin envelope with striate<\/p>\n
and severe ptosis. Stab incision was made in the area of intended<\/p>\n
vertical excision and using a blunt infiltration cannula on each side 500<\/p>\n
mL of 0.03% lidocaine with adrenalin 1:1 million was infiltrated on each<\/p>\n
side. The operation was performed similarly on each side. First,<\/p>\n
attention was directed to the right side after adequate epinephrine<\/p>\n
effect, a 45 mm areola was incised. De-epithelization of the medial<\/p>\n
pedicle was performed. Incision was made in the upper keyhole in vertical<\/p>\n
area, keeping the lower extent of excision 4 cm up from the inframammary<\/p>\n
fold. Composite resection was performed after isolating the pedicle by<\/p>\n
sharp 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<\/p>\n
right side 716 grams. Meticulous hemostasis obtained with<\/p>\n
electrocauterization. Irrigation was performed with saline. The vertical<\/p>\n
pillars repaired with #1 Vicryl sutures. The vertical closure for 8 cm<\/p>\n
was performed using gathering 4-0 Monocryl deep dermal sutures, running<\/p>\n
12 | Page<\/p>\n
subcuticular 3-0 V-Loc suture. The nipple areolar complex was sutured to<\/p>\n
surrounding flaps using interrupted simple 4-0 Monocryl for the deep<\/p>\n
dermis, running subcuticular 4-0 Monocryl for the skin. Because of severe<\/p>\n
skin envelope laxity, the patient’s body habitus, was necessary to<\/p>\n
perform dog ear excision of skin and subcutaneous tissue in the neo-<\/p>\n
inframammary fold for contouring purposes. Closure in this area, after<\/p>\n
hemostasis obtained with electrocauterization was accomplished using<\/p>\n
interrupted 3-0 Vicryl to deep dermis, running subcuticular 3-0 V-Loc<\/p>\n
Monocryl for the skin. Next, attention was directed to the left side<\/p>\n
where resection of 757 grams was performed, hemostasis obtained with<\/p>\n
electrocauterization, closure and dog ear excision was performed in a<\/p>\n
similar fashion. The patient’s areola to neo-inframammary fold was 8 cm<\/p>\n
on each side with symmetrical mounds created. Specimen was sent to<\/p>\n
pathology. After completion of bilateral reductions, the wounds were<\/p>\n
dressed with Dermabond and Tegaderm. General anesthesia was then<\/p>\n
terminated. The patient went to the recovery room in stable condition.<\/p>\n
There were no complications. Sponge and instrument counts correct.<\/p>\n
Estimated blood loss was minimal. The patient was discharged with<\/p>\n
instructions to resume usual diet and medications with the exception of<\/p>\n
holding aspirin and Advil\/ibuprofen. The patient will ambulate q.i.d. She<\/p>\n
will drink plenty of fluids. She will avoid pressure on her chest. She<\/p>\n
will be seen tomorrow in follow up. She will begin Lovenox at 0800 on<\/p>\n
07\/15\/2014. The patient will call for problems, questions or concerns.<\/p>\n
Final pathology is pending at the time of dictation.<\/p>\n
DICTATED BY: Fixer Upper, MD<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n
CPT Code(s): _____________________________________________________<\/p>\n
Case Study 1:<\/p>\n
Please select the level of History (HX) documented in the following statement:<\/p>\n
\u2022 HPI: The patient is an 87-year-old white female who lives in a skilled nursing facility. She tells<\/p>\n
me that her phone was ringing and she tried to reach over to get the phone but fell out of bed and<\/p>\n
ended up on the floor. She reports yelling for help. She was brought to the emergency room with<\/p>\n
a facial fracture. She was also found to have a small right frontal intracerebral hemorrhage. She<\/p>\n
is being admitted for observation and treatment. She also has a Colles fracture.<\/p>\n
\u2022 ROS: Constitutional: Denies fevers. Neurologic: She denies a headache. Eyes: She denies any<\/p>\n
vision problems. Thinks she has had some cataract surgery. Notes no vision problems right now.<\/p>\n
ENT: Denies recent cyanosis or respiratory infection or chronic headache problems.<\/p>\n
13 | Page<\/p>\n
Cardiovascular: Denies heart problems or chest pains. Respiratory: Denies shortness of breath or<\/p>\n
breathing problems. Gastrointestinal: Denies nausea or diarrhea. Musculoskeletal: Has chronic<\/p>\n
back pain mentioned above. Skin: Denies any rashes. Psychiatric: Acknowledges a history of<\/p>\n
low-grade depression but has not been problematic recently.<\/p>\n
\u2022 Patient has a past medical history positive for parkinsons, frequent UTIs and chronic low back<\/p>\n
pain. She does not smoke and rarely drinks alcohol. Both parents are dead.<\/p>\n
List the HPI elements:<\/p>\n
List the ROS:<\/p>\n
List the level of history this documentation supports:<\/p>\n
For an inpatient admission, would this documentation support a 99221, 99222, or 99223? Please<\/p>\n
explain your reasoning.<\/p>\n
ICD-10 Code(s): ____________________________________________________<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"
This is an \u201copen book\u201d test with regard to CPT and ICD-10 coding books. 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 to maintain with […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10601,10596,10882,479,537,172,478,10597,10599,10595],"tags":[10524,10522,10890,10561,10883,10889,10515,10521,10696,10518,10888,10887,10886,10885,10884,10525],"class_list":["post-129014","post","type-post","status-publish","format-standard","hentry","category-assignment-help-by-uks-no-1-writing-service","category-assignment-writers-canada-university-cost","category-free-ai-english-assignment-writers-china","category-nursing-course-hero","category-nursing-essay-pro","category-nursing-study-bay","category-nursing-study-pool","category-professional-assignment-writers-usa","category-uae-1-cheap-assignment-writing-service","category-write-a-word-essay","tag-apa-citation-format-assignment","tag-assignment-writers-australia-college-student","tag-best-nursing-case-study-writing-services","tag-buy-essay-usa","tag-case-study-nursing-writing-services-for-care-plans","tag-free-nursing-case-study-writing-services","tag-help-write-a-page-assignment","tag-i-need-someone-to-do-my-assignment-within-hours","tag-need-assistance-completing-the-assignment","tag-need-to-write-an-essay","tag-nursing-case-studies-with-answers","tag-nursing-case-study-paper-example","tag-nursing-case-study-template-examples-of-case-studies-nursing","tag-pharmacology-case-study","tag-soap-note-case-study","tag-write-pages"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/129014","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/comments?post=129014"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/129014\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/media?parent=129014"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/categories?post=129014"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/tags?post=129014"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}