2023_MAT_CPMA_PA-WB_Student_Ch3

Practical Application Workbook Medical Auditing Training: CPMA ® 2023

ii www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations. US Government Rights This product includes CPT ® , which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 330 N. Wabash, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. AMA Disclaimer CPT ® copyright 2022 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT ® , and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT ® is a registered trademark of the American Medical Association. Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially, they are as one would find them in a coding setting. © 2022 AAPC 2233 South Presidents Dr. Suite F, Salt Lake City, UT 84120 800-626-2633, Fax 801-236-2258, www.aapc.com Updated 10262022. All rights reserved. Print ISBN: 978-1-646317-875 CPC ® , CIC ® , COC ® , CPC-P ® , CPMA ® , CPCO ® , and CPPM ® are trademarks of AAPC.

58 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 LUNGS: Clear. No wheezes, rhonchi, or rales. ABDOMEN: Obese, soft, nontender, nondistended, normoactive bowel sounds. No masses, rebounding, or guarding. No hepatosplenomegaly. EXTREMITIES: No pretibial edema or calf tenderness. Patient is too weak to examine gait and station. GENITOURINARY: Genitalia with circumcision normal. No masses, infection, no hernias. No pain felt with examination of the kidney area on both sides and with percussion. No CVA tenderness. LABORATORY DATA: Sodium is 120, potassium 3.9, chloride 89, CO2 20, BUN 28, creatinine is 1.77, and liver function tests remarkable for mildly low protein and albumin. White count 17.8, hemoglobin is 10, platelets are 141, MCV is 91.5. Urinalysis remarkable for 77 white cells, 2 red cells, leukocyte esterase 2+, urine nitrite is negative, and by way of comparison sodium was 131 in October 20XX, and hemoglobin was 12.8 in January 20XX. Other pertinent office labs included hemoglobin A1c of 6.8 on April 23 rd of last year and BMP on June 3 rd showed BUN 25 and creatinine 1.4. Sodium was 131 and PSA was normal at 1.14 on March 20, 20XX. TSH was 0.78, but this was in August 20XX, vitamin B12 level was above normal. Last EKG in the system was January 20XX, showing normal sinus rhythm and inferior Q-waves and old MI. CT abdomen and pelvis without contrast ordered today and shows evidence of enlarged prostate and heavily diseased abdominal aorta without dilations. IMPRESSION AND PLAN: 1. Complicated urinary tract infection with fever. Patient on Cipro. His fever was improving, but he has been seen by Urology while in the ER and was switched to cefepime. It will be important to get the culture result if it is available from the office. Cultures including blood cultures were repeated here and he has been put on normal saline IV. 2. Severe hyponatremia, with previous history of milder hyponatremia and chronic kidney disease, which is probably worse due to dehydration. He is getting hydrated with normal saline and I will consult Nephrology regarding this and repeat a TSH. 3. Hypertension and hypertensives have been ordered. EKG ordered. 4. History of coronary artery disease. We will not pursue this further, unless he might need an operation, which is doubtful. 5. Adult-onset diabetes, well controlled and will hold oral medications. Will put him on a sliding scale insulin. Electronically authenticated at end of document. Dictated by: Bradley Young, MD Authenticated by Bradley Young, MD on 1/5/20XX 07:01:06 AM Inpatient Hospital Coding Fee Ticket Patient Name Richard Johnson Medical Record Number/Account Number 300-1 Physician Bradley Young, MD Insurance Company UPMC for Life Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 23 99222 N39.0 E87.1 I10 E11.9 D64.9 1 $210.00 Total $210.00

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 59 Chapter 3 1. The level of medical decision making documented in the medical record based on the audit result is? A. Straightforward B. Low complexity C. Moderate complexity D. High complexity 2. You are conducting an audit of the medical record for the inpatient hospital admitting physician. What E/M code is supported by the documentation? A. 99221 B. 99222 C. 99223 D. 99284 3. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. CT of the abdomen and pelvis should be reported. C. Chief complaint documentation and diagnosis coding are incorrect. D. Place of service reporting, diagnosis coding, and EM level reported by the physician are incorrect. Case 2 Initial Inpatient Hospital E/M Admission Re: Greg A. Morris Date of Service: January 5, 20XX MR # 300-2 Family Medicine History and Physical Mr. Morris is a 38-year-old patient followed at his group home by Dr. Moore and admitted this afternoon. He has a history of cerebral palsy with seizures related to anoxia during surgery at age 2. He was sent to the Emergency Department by his aide because of concerns about possible seizures. The Emergency Department physician doubted seizure activity based on his conversation with the aide. He was found to have an intestinal fecal impaction, which is a recurrent problem for him. I am familiar with this patient from previous admissions and follow-ups at his group home. History was obtained from his records and I had a discussion with the nurse coordinator at our practice. I read the Emergency Department documentation which indicated episodes of unresponsiveness today. PAST MEDICAL HISTORY: Per the Emergency Department and the patient’s aide, the patient’s history was obtained. The aide denies any history of meningitis.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 61 Chapter 3 ADDENDUM: I attempted fecal disimpaction. I could palpate some firm, but not hard stool high in the rectal vault and this was tan. This was clearly uncomfortable for him. I was not able to remove any significant amount of stool. The patient was cooperative with the exam. Will try the minor disimpaction procedure again under general anesthesia. Electronically authenticated at end of document. Dictated by: Bradley Young, MD Authenticated by Bradley Young, MD on 1/5/20XX 1:45 PM Inpatient Hospital Coding Fee Ticket Patient Name Greg A. Morris Medical Record Number/Account Number 300-2 Physician Bradley Young, MD Insurance Company Medicare Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 21 99222 K56.41 G80.9 1 $210.00 Total $210.00 1. What E/M level of service is supported? A. 99221 B. 99222 C. 99283 D. 99223 2. What education is given regarding the physician's level of service? A. The level coded is incorrect - undercoded B. The level coded is correct C. The level coded is incorrect - overcoded D. The physician cannot bill for an E/M visit 3. What is the level of medical decision making documented in the medical record based on the audit result? A. Straightforward Complexity B. Low Complexity C. Moderate Complexity D. High Complexity

62 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 4. You are conducting an audit of the medical record for the inpatient hospital physician. The documentation supports what procedure code? A. 45915 B. 45999 C. 45915-52 D. No separate identifiable procedure performed 5. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. The level of service is incorrect. C. The diagnosis codes are incorrect. D. Both B and C. Case 3 Inpatient Hospital Re: Julia P. Baker Date of Service: October 5, 20XX MR # 300-3 Gastroenterology – Dr. Woods Patient is alert and cooperative and progressing as expected after removal of fecal impaction under general anesthesia. Cardiologist to round on non-gastroenterology management for the patient’s chronic atrial fibrillation. Cardiology – Dr. Blake History of chronic atrial fibrillation. Second day in the hospital. She reports no significant symptoms for cardiac arrhythmias. The patient denies chest pain, respiratory or neurological complaints. All other symptoms were reviewed and negative. The patient is not smoking. The patient is a woman with a history of chronic atrial fibrillation who is asymptomatic from such. Coumadin Therapy : Patient has her INRs followed as an outpatient. EXAM: She is healthy appearing and obese. Eyes: Conjunctivae and sclerae clear. Neck: Supple with no carotid bruits. Lungs: Clear, normal respiratory effort. Cardiac: S1, S2 within normal limits. Abdomen: No abdominal masses.

64 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 Case 4 Inpatient Hospital E/M Re: Stephanie B. Young Date of Service: January 5, 20XX MR # 300-11 Chief Complaint: Abdominal pain Subjective: Had surgery yesterday by another physician. She was having increasing upper abdominal pain as of this morning. Having sweats and chills. No shortness of breath on oxygen. No chest pain. She has an NG with some sore throat due to this, has not had flatus or bowel movements, is urinating okay. History of sleep apnea, currently on 02. She Is on Lovenox for DVT prophylaxis. She has no personal or family history of DVT or pulmonary embolism. Objective: General: No acute distress ENT: Oral mucosa is moist. External auditory canals clear Respiratory: Lungs are clear to auscultation Cardiovascular: Normal rate, Regular rhythm Gastrointestinal: Deferred to surgery Psychiatric: Appropriate mood & affect Labs/Diagnostics ordered: 1/4 chest X-ray with low lung volumes and left base atelectasis Abdominal X-ray: Impression: Few air distended loops of small bowel with air within the right aspect of the colon, possibly related to postoperative ileus versus partial small bowel obstruction. Working Diagnosis: HTN, Iron deficiency anemia, Diabetes mellitus, type II, acute appendicitis with perforation and peritoneal abscess. Plan: Status post appendectomy. On IV fluids and NG tube. Improved after NG and likely GI. Dictated by: Richard Myers, MD Authenticated by Richard Myers, MD on 1/5/20XX 5:45 PM

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 65 Chapter 3 Inpatient Hospital Coding Fee Ticket Patient Name Stephanie B. Young Medical Record Number/Account Number 300-11 Physician Richard Myers, MD Insurance Company United Healthcare Medicare Advantage Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 21 99232 I10 D64.9 E11.9 K35.21 1 $110.00 Total $110.00 1. The level of medical decision making documented in the medical record based on the audit result is? A. High Complexity B. Straightforward C. Low Complexity D. Moderate Complexity 2. You are conducting an audit of the medical record for the inpatient hospital physicians. The documentation supports what E/M level of service? A. 99253 B. 99221 C. 99232 D. 99231 3. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. The diagnoses reported by the physician are incorrect. C. The place of service of service is incorrect. D. Chest and abdominal X-rays should be reported.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 67 Chapter 3 2. MRA showing a possible right carotid artery aneurysm incidental finding. Will order a carotid duplex ultrasound. On ASA and statin and follow with Dr. Harris in 4 weeks. 3. History of hypertension. Norvasc and lisinopril have been held because of orthostatics. 4. Dyslipidemia, on statin. 5. Deep venous thrombosis prophylaxis with heparin subQ. 6. Exophthalmos - TSH normal. Advised ab o/p eye exam if not done recently. Discharge plans: await Cardiology to round Medications Inpatient Medications Scheduled Medications aspirin EC 325 mg by mouth daily atorvastatin (Lipitor) 40 mg by mouth daily docusate (Colace) 100 mg by mouth at bedtime fludrocortisone (florinef acetate) 0.l mg by mouth daily heparin 5,OOO Unit(s) subQ Q8H metoprolol (metoprolol immediate release) 12.5 mg by mouth BID multivitamin 1 tab by mouth daily PRN Medication tramadol 50mg by mouth Q6H Recently Discontinued Medications amlodipine (Norvasc) 5 mg by mouth daily lisinoprll 10 mg by mouth daily metoprolol (metoprolol immediate release) 12.5 mg by mouth BID Sodium chloride 0.9% 1,000 mL 80mL/hr IV I/O Summary I&O (01/4) 7a-3p 3p-11p 11p-7a Total (01/5) 7a-3p 3p-11p 11p-7a Intake: 0 0 0 0 0 0 0 Output: 0 0 0 0 0 0 0 Balance: 0 0 0 0 0 0 Addendum by Bradley Young, MD on January 5, 20XX 6:11 PM: Case discussed with patient who is concerned with med changes and whether will be OK at assisted living. Prefers consider discharge in AM if stable. Cardio note read and discussed with her. Add lower dose Norvasc. Orthostatics bid. Inpatient Hospital Coding Fee Ticket Patient Name Joy King Medical Record Number/Account Number 300-5 Physician Bradley Young, MD Insurance Company UPMC for Life Comments

68 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 23 99232 R55 I10 1 $110.00 Total $110.00 1. The level of medical decision making documented in the medical record based on the audit result is? A. Straightforward B. Low Complexity C. Moderate Complexity D. High Complexity 2. When meeting with this physician post audit, which issue need to be addressed? A. The audit was documented and billed correctly. B. The encounter was overcoded. C. The encounter was undercoded. D. The accuracy of the coding fee ticket should be reviewed with the provider. Case 6 Initial Inpatient Hospital E/M Admission Re: Nancy L. Anderson Date of Service: October 5, 20XX MR # 300-6 CHIEF COMPLAINT: Right lower back pain. HISTORY OF PRESENT ILLNESS: This is a 94-year-old Caucasian female with significant past medical history of L1 compression fracture, status post L1 kyphoplasty on May 11 th with Dr. Smith. The patient eventually was discharged home in stable condition, but had recurrent pain and presented again with increasing back pain at this time reported in the mid spine in admitting her this morning. At that time the patient was treated with epidural steroid injection and placed in binder. She did have repeat CT scans of the thoracic and lumbar spine for further evaluation as well as a bone scan, which revealed no change or new compression fracture. The patient does have a permanent pacemaker and is unable to have an MRI. The patient now presents with increasing back pain, though this time she states that it is in the right lower back. Pain has been worsening for the past three days. She describes it as a sharp stabbing pain. The pain is at 10 plus. The patient is really unable to ambulate or sit forward without increase in pain. She was previously using a walker for ambulation though now has difficulty even sitting forward in bed. Given the patient’s intractable pain she is quite tearful on examination and unable to finish her thoughts without having episodes of sharp pain. The patient was ordered a CT myelogram by Neurosurgery overnight though it is noted that patient is on Xarelto with last dose on January 5 th . Subsequently, this is on hold. She is ordered a repeat bone scan. Her pain is not currently controlled on the regimen.

70 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 PERRLA. Oropharynx is clear with slightly dry mucous membranes. NECK: Supple, nontender. No lymphadenopathy. No thyromegaly. HEART: Regular rate and rhythm with audible S1, S2, plus II/VI systolic ejection murmur. No gallops or rubs. LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi. ABDOMEN: Positive bowel sounds throughout. Soft, nontender and nondistended. EXTREMITIES: No edema or cyanosis. No clubbing. At this time, she is moving her lower extremities spontaneously. Her spine and lower extremity strength are not tested as she has excruciating pain with even slight movement. SKIN: Warm and dry. No rashes. No lesions. A few areas of ecchymosis. NEUROLOGIC: Alert and oriented x 3. No focal deficits. Her sensation is intact. We will defer this to Neurosurgery. ANCILLARY DATA: Labs ordered: CBC with differential reveals white count of 7.3, hemoglobin 11.6, hematocrit 35.3, MCV 94.7, platelets 171. Comprehensive metabolic panel is overall unremarkable. Albumin 3.2. LFTs within normal limits. Urinalysis reveals 1 WBC, 6 RBCs, otherwise unremarkable. CT scan of abdomen and pelvis without IV contrast completed in the Emergency Department revealed marked constipation, advanced L1 central canal stenosis due to retropulsion of the L1 vertebral body. She has no pericolonic inflammatory stranding, pneumatosis or pneumoperitoneum. No small-bowel obstruction. She has extrahepatic biliary ductal dilatation, status post cholecystectomy. Last echocardiogram on December 5, 20XX revealing ejection fraction of 45-50%, which could be due to RV pacing, but also could be prior MI. She has mild-to-moderate aortic regurgitation, mild-to- moderate tricuspid and mild pulmonary arterial dilatation with moderate pulmonary hypertens1on. There is diastolic dysfunction grade I. ASSESSMENT AND PLAN: This is a 94-year-old Caucasian female who is being admitted with intractable back pain status post recent kyphoplasty and epidural steroid injection. 1. Intractable back pain located in the right lower lumbar paraspinal muscles with no focal pain over the spine itself. Case was discussed with Neurosurgery who recommended completing a bone scan to rule out any additional fracture. CT myelogram at this point is not possible given her Xarelto. Per discussion with Radiology, this needs to be held 5 days prior to CT myelogram. This was discussed with the family. I will consult Dr. Lee of Pain Management for further recommendations regarding pain control. At this time, will increase dose of Dilaudid IV as she is quite tearful. We will monitor closely for any respiratory depression and titrate carefully. 2. Isolated fever with normal urinalysis and no leukocytosis. The patient is overall doing well this morning. She is afebrile. If she has any recurrent fever, we recommend blood cultures for further evaluation and consider Infectious Disease consultation. She has no evidence of UTI or pyelonephritis contributing to her right lower back pain. CT scan as above. 3. History of atrial fibrillation with permanent pacemaker, on Xarelto. This is now on hold given the above pending further recommendations from Neurosurgery. Recent echocardiogram noted. This was thought secondary to her right ventricular pacing (regarding her left ventricular function). 4. Constipation based upon CT. The patient states that she had 2 bowel movements this morning. We will continue Colace as well as MiraLax daily. Follow clinically. 5. Case was discussed in detail with the daughter at bedside. We will await further recommendations from Neurosurgery pending bone scan. Dictated by: Tina Laffalit, MD Authenticated by Tina Laffalit, MD on 10/5/20XX 1:45 PM

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 71 Chapter 3 Inpatient Hospital Coding Fee Ticket Patient Name Nancy L. Anderson Medical Record Number/Account Number 300-6 Physician Tina Laffalit, MD Insurance Company UPMC for Life Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 10/5/20XX AAPC Hospital 21 99222 M54.9 I48.9 K59.00 1 $210.00 Total $210.00 1. What level of MDM is supported? A. Straightforward complexity B. Low complexity C. Moderate complexity D. High complexity 2. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. The place of service and E/M code are not correct. C. CT scan of the abdomen and pelvis should be reported. D. The diagnoses and E/M codes are not correct.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 73 Chapter 3 metoprolol (metoprolol immediate release) 25 mg by mouth BID pantoprazole EC 40 mg by mouth AC Brkfst senna 2 tab(s) by mouth with lunch warfarin (Coumadin) 5 mg by mouth QPM PRN Medications acetaminophen 650 mg By Mouth Q4H albuterol ipratropium (DuoNeb 3 mg-0.5 mg/3 ml inhalation soln) 3mL Aerosol Q4H bisacodyl 10mg per rectum daily magnesium hydroxide (Milk of Magnesia) 30mL by mouth daily ondansetron (Zofran) 4 mg by mouth Q4H oxycodone (oxycodone immediate release 5 mg by mouth Q4H oxycodone (oxycodone immediate release) 10 mg by mouth Q4H polyethylene glycol 3350 (Miralax) 17 gm by mouth daily Recently Discontinued Medications enoxaparin (Lovenox) 70 mg subQ Q12H Inpatient Hospital Coding Fee Ticket Patient Name Jim James Medical Record Number/Account Number 300-7 Physician Inpatient Doctor, MD Insurance Company Medicaid Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 21 99253 I26.99 S72.002A S12.400A 1 $110.00 Total $110.00 1. Based on the documentation, what level of MDM is supported? A. Straightforward complexity B. Low complexity C. Moderate complexity D. High complexity

74 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 2. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. Wrong place of service and diagnosis coding is incorrect. C. The E/M service is incorrect and signature missing. D. The E/M service is incorrect and diagnosis coding incorrect. Case 8 Inpatient Hospital E/M Re: Sarah Smith Date of Service: March 21, 20XX MR # 300-8 CC: Pulmonary embolus Subjective Follow-up on patient for pulmonary embolus. No chest pain. Objective Vital Signs: Most Recent (Vitals In past 36 hrs; Dosing Wt and BMI this visit) Temp C 37.6 (37.2-39.3) SSP 160 (156-160) OBP 62 (61-69) Pulse 86 (82-86) RR 18 (18-20) Sa02 93 (92-95) Fi02-02(L/m) 2L /m (2I./m·2I./ml./m) Dosing Wt 72.3 kg BMI 0 [1] General : Initially sleeping and in no apparent distress when aroused and oriented to name and not to date or place just saying “here”. HEENT : Tongue somewhat dry. Respiratory : Lungs are dear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion. Cardiovascular : Normal rate, Regular rhythm, No gallop, No edema, 2/6 systolic ejection murmur. Mild diffuse edema of both lower legs above the ankle. Gastrointestinal : Soft, Non-tender, Non-distended. Bowel sounds normal. No enlargement of spleen and liver. Psychiatric : As above.