ICD

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HCR/201

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History

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Feb 20, 2024

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ICD-10 1. Benign neoplasm of cranial nerves -D33.3 2. Acute respiratory failure with hypoxia -J96.01 3. Crushing injury of the face, initial encounter -S07.0XXA 4. Open bite of the right hand, subsequent encounter -S61.451D 5. Contact with and suspected exposure to arsenic. -Z77.010 6. Puncture wound with foreign body of right forearm, initial encounter. -S51.841A 7. Asymptomatic varicose veins of right lower extremity -I83.91 8. Osteolysis, right upper arm -M.89.521 9. Laceration of popliteal artery, right leg, subsequent encounter -S85.011D 10. Malignant neoplasm of cerebellum -C71.6 11. Displaced fracture of second metatarsal bone, right foot, initial encounter -S92.321A 12. Tobacco abuse counseling -Z71.6 13. Acute kidney failure with medullary necrosis -N17.2 CPT Suture repair of aorta or great vessel with shunt bypass -33321 Urinalysis, automated with microscopy. -81000 Removal, Implantable contraceptive capsules -11976 Simple repair of superficial wound of scalp, neck, axillae, external genitalia, trunk and or extremities (including hands and feet) 7.6cm-12.5 cm. -12004 Hospital discharge management more than 30 minutes -99316 Modifiers Bilateral procedure -50

Unusual anesthesia -23 Professional Component -26 Postoperative Management Only -55 Surgical Team -66 HCPCS Level II Stomach Tube-Levine type -B4083 IV Pole -E0776 Administration of influenza virus vaccine -G0008 Foot insert, removable, molded to patient model, longitudinal/metatarsal support arch Injection, digoxin, up to 0.5mg -L3020, J1160 Leg strap, H style, each -K0039 HCPCS Level II Modifiers F1 -Left hand, second digit RT - Right side (used to identify procedures performed on the right side of the body) QM -Ambulance service provided under arrangement by a provider of services T8 -Right foot, four digit E1 -Upper left eyelid

"Mock" Medical Record Patient: Jane Jones Date of Birth: 8/29/1960 History of Present Illness: This is an established patient who presents with complaints of a chronic cough, shortness of breath and a low- grade fever for two days. She also states that she has had some chest discomfort and chest congestion. She states she has been having a “very bad cold” for the past two weeks. She had a history of asthma and has been using her rescue inhaler more often in recent days. Past Medical History: The patient has a history of asthma for past 40 years which has been controlled by use of medication. Medications: Flovent inhaler 2x per day, Proventil inhaler 2 puffs every four hours as needed. Physical Examination: This is a well-nourished female in moderate respiratory distress. Neck is supple without palpable masses. Trachea is midline. Chest with faint wheezing on expiration throughout. Pulse ox is at 94% on room air. Examination of the heart shows no murmurs, gallops or rubs. Abdomen is soft and non-tender. Plan: Azithromycin 500mg injection administered. Aerosol treatment Xopenex 0.5mg administered. Pulse ox rechecked after aerosol treatment at 97% on room air with relief of symptoms. Plan home nebulizer every 4-6 hours as needed. Prescription provided for 7- day steroid pack. Prescription provided for Z-pack antibiotic. Referral provided for Dr. Smith in pulmonology. Face to face time 25 minutes. Impression: Acute bronchitis, asthma exacerbation.

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Patient Amounts You are reviewing the vision exam benefits for Louann Bergman. She presented for an eye exam, stating she needed new glasses. She had an examination 15 months prior and notes she can have an exam every year. The eye physician is in-network with her plan and total charges equal $650. Her benefits are as follows:  PPO medical care office visits  The annual deductible is $500.  In-network benefit: One vision exam every calendar year covered at 100%; exempt from deductible.  Out-of-network deductible required with coinsurance of 20% The patient has a $1,500 yearly deductible of which they have paid $1,200. There is also a 20% coinsurance that is due. How much would the patient owe if the total services billed equaled $2,290? The patient is a member of an HMO plan. The contract allowable amount for a procedure is $1,500. The physician has charged $2,000. If the patient were to have a $1,000 yearly deductible of which they have paid $600 along with 15% coinsurance, how much would the patient owe If they have received these services through an in-network provider?

ICD

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