HIM 1275 MODULE 03 ASSIGNMENT

docx

School

Rasmussen College, Florida *

*We aren’t endorsed by this school

Course

HIM1257

Subject

Mechanical Engineering

Date

Dec 6, 2023

Type

docx

Pages

Uploaded by DrNeutron10657

HIM 1275 MODULE 03 ASSIGNMENT CODING FROM MEDICAL DOCUMENTATION WORKSHEET 1. Question 1 1/1 Code the following case study. One code is required. Preoperative Diagnosis: Internal derangement left knee Postoperative Diagnosis: Tear of lateral meniscus Procedure: Left knee arthroscopy, partial meniscectomy Procedure Notes: The arthroscope was inserted through the routine superolateral portal as well as an inferomedial portal for insertion of scope and instruments. The knee joint was then examined in routine manner; the medial meniscus was intact. The lateral meniscus was partially detached, and this portion was removed. No other defects were noted. The knee was irrigated well using normal saline. The instruments were removed from the knee. Wound closed with #4-0 nylon and dressed. Estimated blood loss 0. Intravenous fluids 1,000 cc. Specimen: meniscus. CPT code: 29881-LT Correct Acceptable answer for BLANK-1 is 29881-LT Responses must be an exact match 2. Question 2 1/1 Upgrade of a single chamber cardiac pacemaker system to a dual chamber system. Provide the CPT code: 33214 Correct Acceptable answer for BLANK-1 is 33214 Responses must be an exact match 3. Question 3

0/1 Code the following case study. Multiple codes required. Subjective: This 17-year-old girl was struck in the nose by a baseball at school this morning. A 1.6 cm laceration on the right side of her nose is present. There has been only minimal swelling postinjury. She denies any loss of consciousness. She feels that her nasal airway was stuffy before the injury and remains slightly congested. Patient has mild right periorbital ecchymoses. There is deformity of the nasal bones with angulation to the left. x-rays from Radiology Associates across the hallway show a nasal fracture. Objective: Temp 98.4 degrees. Pulse 92, resp 22, weight 126. Examination of the nasal airway reveals dried blood in the superior left airway. There is some narrowing with septal deformity of the superior portion of the right airway. Remainder of the examination of the ears, throat, and neck were normal. Patient’s x-ray films were reviewed and demonstrate a fracture of the nasal bones. They are minimally displaced on the x-ray. However, clinical evaluation reveals a moderate deformity. Assessment and Plan: Displaced fracture of nasal bones, 1.6-cm laceration to skin on side of nose. Procedure Notes: Under topical anesthesia with Pontocaine and Neo-Synephrine, the nasal cavity was decongested. With closed instrument reduction, the fracture of the nasal bones was reduced. There was a definite realignment of the nasal bones with good visible and palpable reduction. The bones are stable postreduction. The 1.6-cm laceration was closed in a single layer with two stitches after infiltration with 2% Lidocaine. The patient was advised to avoid further trauma and given a nose guard to wear while sleeping. Avoid suture line with tape. Return for follow-up in 7 days for suture removal. CPT code(s): Your Answer 30210 ,12011-51 4. Question 4 1/1 Code the following case study. One code is required. Chief Complaint: Lacerations; left face History of Present Illness: Patient is a 26-year-old man who was driving a car with the window down when another car moving in the opposite direction hit his mirror. Glass from the broken mirror flew into his face, and he sustained two small lacerations. There were no other injuries. Past Medical History: Unremarkable Medications: None Allergies: None Physical Examination: Alert male in no acute distress

HEENT: Pupils are equal and reactive to light. Extraocular muscles intact. Nose is clear. Oropharynx negative. Two lacerations are on left cheek region. The uppermost laceration is about 2 cm below the eye laterally and is about 0.75 cm in length. Full-skin thickness. The second laceration is about 1.5 cm below the first and is 1.25 cm in length. Full-skin thickness. No palpable foreign bodies. Procedure Notes: Local injection with a total of 3 cc's 1% lidocaine with epinephrine. Prepped and routine exploration performed. The upper laceration is only about 5 mm deep. No foreign bodies noted. No neurovascular injuries. It was closed with three 6-0 nylon sutures. The lower laceration was approximately 12 to 15 mm deep. I could not palpate any foreign bodies. There are no obvious neurovascular injuries. Closed in single layer with five 6-0 nylon sutures. Polysporin ointment was applied. X-ray to rule out foreign body negative.Diagnosis: Simple facial laceration, 1.25 cm, Simple facial laceration, 0.75 cm CPT code: 12011 Correct Acceptable answer for BLANK-1 is 12011 Responses must be an exact match 5. Question 5 1/1 Removal of an implantable defibrillator pulse generator without replacement. Provide the CPT code: 33241 Correct Acceptable answer for BLANK-1 is 33241 Responses must be an exact match 6. Question 6 1/1 A patient was seen in the physician’s office where a removal of one nasal polyp was performed. Provide the CPT code: 30110 Correct

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Acceptable answer for BLANK-1 is 30110 Responses must be an exact match 7. Question 7 1/1 Blepharoplasty, left upper eyelid. Provide the CPT code: 15822-E1 Correct Acceptable answer for BLANK-1 is 15822-E1 Responses must be an exact match 8. Question 8 0/1 Repair of nail bed, third digit left hand. Provide the CPT code: 11769-F2 Incorrect Acceptable answer for BLANK-1 is 11760-F2 Responses must be an exact match 9. Question 9 1/1 A child was brought to the physician’s office with a Lego stuck up her nose. The physician was able to remove it with forceps. Provide the CPT code: 30300 Correct Acceptable answer for BLANK-1 is 30300 Responses must be an exact match 10. Question 10

1/1 Code the following case study. One code is required. Preoperative Diagnosis: Symptomatic third-degree heart block Postoperative Diagnosis: Symptomatic third-degree heart block Procedure: Placement of permanent pacemaker with transvenous electrode, ventricle Anesthesia: Local infiltration of lidocaine 1%, total volume 13cc Complications: None Indications: This 74-year-old man was admitted with a diagnosis of three-degree heart block complicated by congestive cardiac failure. Patient is schedule for placement of a permanent pacemaker today. Procedure Notes: With the patient supine on the operating table with a shoulder roll placed beneath the thoracic spine, the chest was prepared and draped in a sterile fashion. In the right infraclavicular region, a subcutaneous pocket was created for containing the pulse generator. Using an introducer guide wire, a sheath technique bipolar-targeted lead was introduced into the right subclavian vein. Under fluoroscopy control, this was directed into the right ventricle. Two initial locations were not satisfactory for pacing parameters. Finally, the pacemaker was positioned in satisfactory position with the following parameters: at the threshold 0.4 volts, current 1.5 milliamps, and R wave 15. The pacing system analyzer was then turned to 10 volts output and the diaphragm observed for pulsations, which were not proven. The lead was then secured under the clavicle with a single suture of 2-0 Ethibond. It was then attached to a 5794 Medtronic low-profile VVI pacemaker programmed at 70 beats per minute. The pulse generator was then anchored in the subcutaneous pocket with a single 0 PDS suture. The subcutaneous tissue was then approximated with 2-0 PDS and the skin approximated with 4-0 Maxon. Sterile dressing was applied. A chest x-ray was obtained, which showed no pneumothorax and satisfactory position of the lead. The patient was then returned to the coronary care unit in good condition. CPT code: 33207 Correct Acceptable answer for BLANK-1 is 33207 Responses must be an exact match 11. Question 11 1/1 Modified Fontan procedure. Provide the CPT code: 33617 Correct

Acceptable answer for BLANK-1 is 33617 Responses must be an exact match 12. Question 12 1/1 Collection of blood specimen from an implanted central venous access device. Provide the CPT code: 36591 Correct Acceptable answer for BLANK-1 is 36591 Responses must be an exact match 13. Question 13 0/1 Code the following case study. Multiple codes required. Preoperative Diagnosis: Multiple lacerations to both ears Postoperative Diagnosis: Multiple lacerations to both ears, one laceration to the left ear and a series of four lacerations to the right ear Anesthetic: Local anesthetic was used. 1% Carbocaine Plain Indications: The patient sustained the above-named lacerations when she was involved in a hay wagon accident. Procedure Notes: The patient was treated in the emergency department. The right ear was treated first. There were a total of 4 lacerations on the right ear treated. The two smaller, more superficial lacerations, measuring 1.0 cm each were closed in a single layer after the wounds had been infiltrated with 1% carbocaine and then cleaned copiously with Betadine, saline, and peroxide. They were closed with simple interrupted #6-0 Prolene sutures. The two other lacerations on the right ear, totaling 3 cm in length (one laceration was 1.2 cm in length and the other laceration was 1.8 cm in length) were closed in multiple layers with #5-0 Vicryl suture after they had been infiltrated with 1% carbocaine prepared and draped in the appropriate fashion using Betadine, peroxide, and saline. The superficial layers were closed with interrupted #6-0 Prolene suture. After the right ear was completed the wounds were covered with polysporin. The 2.0 cm laceration on the left ear was then closed in a single layer. It was infiltrated with 1% carbocaine. After the wound was cleaned with Betadine, saline, and peroxide the superficial layers were closed with interrupted #6-0 Prolene suture. The wounds were then covered with polysporin. CPT code(s):

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Your Answer 00120, 12013, 12014 14. Question 14 1/1 Percutaneous needle biopsy of left lung upper lobe. Provide the CPT code 32408-LT Correct Acceptable answer for BLANK-1 is 32408-LT Responses must be an exact match 15. Question 15 1/1 An asymmetrical nevi measuring 3.0 cm with 0.2 cm margins is excised from the patient’s back. The pathologist indicated that this was an intradermal nevi. Provide the CPT code: 11404 Correct Acceptable answer for BLANK-1 is 11404 Responses must be an exact match 16. Question 16 1/1 5 ccs of pus were aspirated from a patient’s left wrist joint. Provide the CPT code: 20605 Correct Acceptable answer for BLANK-1 is 20605 Responses must be an exact match

17. Question 17 1/1 Puncture aspiration of cyst on left breast. Provide the CPT code 19000-LT Correct Acceptable answer for BLANK-1 is 19000-LT Responses must be an exact match 18. Question 18 1/1 A patient presented with a right shoulder dislocation. The dislocation was reduced without the use of anesthesia. Provide the CPT code: 23650-RT Correct Acceptable answer for BLANK-1 is 23650-RT Responses must be an exact match 19. Question 19 1/1 Code the following case study. One code is required. Preoperative Diagnosis : Dermal Cyst of right breast Postoperative Diagnosis: Dermal Cyst of right breast Procedure Performed: Excision of Dermal Cyst of right breast Procedure Notes: Erythematous dermal cystic area of the right breast was marked out with an elliptical incision, anesthetized with local anesthesia, and prepped and draped sterilely. Incision was made elliptically, including the whole cyst down through the fatty tissue. On palpation afterward, no abnormalities were noted. Then the area had hemostasis obtained with electrocautery. The incision was closed with interrupted 3-0 Vicryl sutures. The skin was closed with interrupted 5-0 nylon sutures. Steri-Strips and a sterile dressing were applied over it. The patient tolerated the procedure well and was sent to the recovery room with instructions to be discharged home with follow-up appointment given. CPT code:

19120-RT Correct Acceptable answer for BLANK-1 is 19120-RT Responses must be an exact match 20. Question 20 1/1 Code the following case study. One code is required. Preoperative Diagnosis: Chronic laryngitis with polypoid disease Postoperative Diagnosis: Chronic laryngitis with polypoid disease Procedure: Laryngoscopy with removal of polyps Procedure Notes: After adequate premedication, the 60-year-old female patient was taken to the operating room and placed in supine position. The patient was given a general oral endotracheal anesthetic with a small endotracheal tube. The Jako laryngoscope was then inserted. Large polyps were noted on both vocal cords, essentially obstructing the glottic airway when the tube was in place. The polyps appeared larger on the right cord. Using the straight-cup forceps, the polyps were removed from the left cord first. The polyps were removed from the right cord up to the anterior commissure. Very minimal bleeding was noted. This opened up the airway extremely well. The patient was extubated and sent to recovery in good condition. CPT code: 31540 Correct Acceptable answer for BLANK-1 is 31540 Responses must be an exact match 21. Question 21 1/1 Blalock-Taussig shunt placement. Provide the CPT code: 33750 Correct Acceptable answer for BLANK-1 is 33750

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Responses must be an exact match 22. Question 22 0/1 Code the following case study. Multiple codes required. Preoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Postoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Procedure: Excision of the .8 cm lesion with .5 cm margins on each side, layered primary closure, totaling 4 cm in length Anesthetic: Local Brief Clinical History: The patient had a biopsy-proven squamous cell carcinoma of the left forearm. After explanation of the risks, benefits, and alternatives, she agreed to re- excision and closure. She understood that there would be a scar as a result. Procedure Notes: The patient was taken to the outpatient operating area. An ellipse was taken around the primary lesion with .5-cm margins for excision around the .8 cm lesion. The area was infiltrated with 1/2% Xylocaine with 1:200,000 epinephrines and approximately 5 cc was used. The area was prepared with Betadine paint and draped in a sterile manner. The lesion was elliptically excised. After excision, the elliptical defect was closed in layers with 4-0PDS totally 4 cm in length. The deep subcutaneous layer was closed separately and then a running subcuticular layer was performed. She tolerated the procedure well. She was given instructions for local care and will return in 9 days for a checkup and suture removal. CPT code(s): Your Answer 25065 , 25075 23. Question 23 0/1 Code the following case study. Multiple codes required. Subjective: Patient is a 68-year-old male who presents today for skin tag removal and treatment of multiple actinic keratoses. He has several keratoses around the ears and several skin tags around the neck. He would like to have the lesions examined and removed today. Objective: Temp 97.6, pulse 70, resp 20, blood pressure 148/68. Weight of 198 pounds. Skin: Shows seven flatter skin tags noted along the neckline, but there are two pedunculated skin tag lesions and a similar, larger one on the right upper/inner thigh. He has two actinic keratoses on the chest and back. He also has two more actinic keratoses located above the right ear and one above the left ear. Patient also has some lesions that look like compound nevi on the back near the belt line. There is a

confluence of several darker compound nevi. They have regular borders and are homogenous in color at this time. They do not appear to be any larger than 6 mm in size. No treatment is done for these today. Assessment and Plan: Skin tag removal. Procedure Notes: Skin tag removal. These areas were cleansed with alcohol. Curved iris and pickups were used to snip the skin tags off at the base of the two skin tags around the neck. Triple antibiotic ointment and a bandage was placed over these. For the skin tag in the right upper/inner thigh, 2% Xylocaine without epinephrine was used for anesthesia. It did have a somewhat large base, but a curved iris and pickups were used to cut the skin tag off at the base and handheld electrocautery was used to control bleeding. Triple antibiotic ointment and a bandage was put over this. Multiple actinic keratoses were treated with liquid nitrogen. One keratosis on the chest, one keratosis on the back, one keratosis above the right ear, one keratosis above the left ear. Each were treated with liquid nitrogen. Complex nevi. I advised him that he should have these looked at every six months, and he will return for this. CPT code(s): Your Answer 11200,17000, 17003, 24. Question 24 1/1 Single layer closure of a 2.1 cm laceration on the right lower arm. Provide the CPT code: 12001-RT Incorrect Acceptable answer for BLANK-1 is 12001 Responses must be an exact match 25. Question 25 1/1 Code the following case study. One code is required. Preoperative Diagnosis: Dysphonia Postoperative Diagnosis: Dysphonia Procedure: Direct microlaryngoscopy under general anesthesia Procedure Notes: A 40-year-old patient was taken to the OR where; under general a laryngoscope was inserted with the operating microscope to perform a laryngoscopy. The vocal cords were found to be totally normal on both sides with no evidence of

nodules or granuloma formation. The entire endolarynx was well visualized. Moreover, there was no evidence of subglottic stenosis; and as the patient was awakening, vocal cord mobility appeared to be normal. The procedure was completed, and the patient awakened and was taken to the recovery room in good condition with stable vital signs. CPT code: 31526 Correct Acceptable answer for BLANK-1 is 31526 Responses must be an exact match

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version