Week 4 Case scenarios

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Bryant & Stratton College *

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146

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Mechanical Engineering

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Feb 20, 2024

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MCCG146 – CPT and HCPCS Level II Coding Week 4 Coding Scenarios This Assessment is part of the Coding Scenarios category, which is worth 15% of your grade. Deadline Due by the end of Week 4 at 11:59 pm, ET. Completing this Assessment will help you to meet the following: Course Outcomes  Utilize CPT guidelines, including abbreviations, punctuation, and symbols, to assign codes and achieve standards.  Identify and apply information from CPT and HCPCS II classification systems and nomenclatures to medical coding in various outpatient settings as well as physician professional services. Directions For this Assessment, you will be presented with three scenarios. Please read each scenario below and then assign the appropriate codes and applicable modifiers. Scenario 1 C hief Complaint: Eosinophilic esophagitis History of Present Illness: Wally is a 4-year-old accompanied by his parents who presents today in the office after being referred to our office by his primary care doctor to discuss treatment options to evaluate the progression of his eosinophilic esophagitis. Wally intermittently has c/o abdominal pain as well as pain in multiple body parts. Wally’s parents are unsure if the pain complaints are accurate as Wally is inconsistent in his description and answers when asked. Wally is being seen by ancillary medical professionals in a “feeding clinic” as he refuses to eat anything that is not wet or soggy preferring instead to eat mostly soup. His mother states that she does blend food into a soup consistency and he has been tested for food allergies which are all negative. Review of Systems: Constitutional: Negative HEENT: Negative Eyes: Negative Respiratory: h/o asthma- currently on inhaler Cardiovascular: Negative Gastrointestinal: See history of present illness.

MCCG146 – Coding Scenarios 2 Genitourinary: Negative Reproductive/Endocrine: Negative Musculoskeletal: Negative Hematology/Lymphatic: Negative Immune/Allergy/Rheumatologic: Negative Skin: Negative Central Nervous: Negative Psychiatric: No concerns reported Family History: Family history is pertinent for brother with Gastroesophageal reflex. Family anesthetic problems (Malignant Hyperthermia): No Bleeding disorders (hemophilia / Von Willebrands): No Personal or family history of connective tissue disorder: No Vitals: Pulse 117 Beats/min| Temp 37.2 Celsius| Resp 22 breaths/min | Ht 122 cm | Wt 26.5 kg | SpO2 95% General: Healthy, alert, well-nourished appearing child. HEENT demonstrates normal extraocular movements. There is no icterus. Nose has no discharge. Mouth is clear with no lesions. Neck is supple with no adenopathy. Cardiac examination reveals regular rate and rhythm with no murmurs, heaves, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, non- tender, with no masses. Extremities demonstrate no rash. There is no edema present. Neurologic examination is grossly normal. Assessment and Plan: Will proceed with EGD with biopsies-discussed risks, benefits, alternatives, indications, methods of above procedure. Because of Wally’s age, he will need to have general anesthesia. The risks and what to expect afterward were explained to Wally’s parents and all questions answered. Obtained informed consent. He will present to surgery with his parents tomorrow. Spent 30 minutes face to face with patient and parents. After reviewing note 1, answer the following questions: Provide the ICD-10-CM Diagnosis Code (s) K20.0 Provide the CPT Evaluation and Management (E/M) Code 99203 Scenario 2 The patient is well known by me and our office. She is a 34-year-old female who presents with several days of malaise, generalized abdominal pain, and

MCCG146 – Coding Scenarios 3 nausea. She states that for about three days now she has had an achy feeling associated with a headache and some chills. In addition, she has had transient intermittent abdominal pain in multiple areas, with no one area being identified. She has had some loose bowel movements and vomited once. Objective: On examination, she is noted to have normal vital signs with the exception of a low-grade fever of 100.6. She is noted to have clear lung fields bilaterally. Examination of the abdomen reveals hyperactive bowel sounds but no tenderness and there is no organomegaly. There is no costovertebral angle tenderness. HEENT: The throat is non-erythematous. Mouth shows normal mucosa with adequate saliva. The neck is supple. Extremities are unremarkable. Assessment: Viral gastroenteritis. Plan: Rest, Fluid, clear liquid diet with increased amounts of clear liquids frequently. Tylenol or aspirin as needed for malaise or fever. Gave prescription to patient for Darvocet-N 100 small prescription of 10 tablets is written to take as needed for abdominal pain. Recheck if not improving after the next three or so days. Spent 15 minutes face to face with patient. After reviewing note 2, answer the following questions: Provide the ICD-10-CM Diagnosis Code (s) A08.4 Provide the CPT Evaluation and Management (E/M) Code 99212 Scenario 3 Stan Shields patient presented to the emergency department complaining of vomiting coffee-ground material several times within the past 2 hours. He

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MCCG146 – Coding Scenarios 4 has excruciating abdominal pain and has been unable to eat for the past 24 hours. He is dizzy and light-headed. His Two stools today have been black and tarry. While in the emergency department, he vomited bright-red blood and some coffee-ground material. A nasogastric tube was inserted and attached to suction with fluoroscopy. An abdominal exam showed a fluid wave consistent with ascites. An IV of lactated ringers was started, and CBC and clotting studies were drawn. A high-complexity medical decision making was documented. A GI consultant was called and the patient was taken to Endoscopy for further evaluation of upper GI bleeding. Diagnosis: hematemesis, rule out esophageal varices; blood loss anemia (CBC review) acute; ascites. Code the services of the ED physician After reviewing note 3, answer the following questions: Provide the ICD-10-CM Diagnosis Code (s) 1. K92.0 - Hematemesis (vomiting blood) 2. I85.00 - Esophageal varices without bleeding (as the diagnosis is to rule out esophageal varices) 3. D62 - Acute posthemorrhagic anemia (blood loss anemia) 4. R18.8 - Other ascites Provide the Evaluation and Management Code (E/M) and applicable modifier (s) This case's E/M code is 99285, which signifies an emergency department visit for a patient's evaluation and care. This visit calls for the completion of three essential steps: a thorough history; a thorough examination; and highly sophisticated medical decision- making. In this instance, the E/M code has no appropriate modifiers. Provide the CPT Code of the Procedure Performed The diagnostic procedure of endoscopy for additional assessment of upper gastrointestinal bleeding would be coded with CPT 43235, which denotes esophagogastroduodenoscopy with or without specimen collection through brushing or washing (separate procedure).

MCCG146 – Coding Scenarios 5