MBC120 Labs 1-8-1
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Fortis College *
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120
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Medicine
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Feb 20, 2024
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Name: ____________________________________ Date: _______________ Score:___________
MBC120 WEEK 1 LABs
Lab 1: Documentation for Procedures
This lab will go through an example of a model note for coding a procedure and one that is missing documentation to discuss the differences.
Read Note A
and begin highlighting how Note A provides complete documentation necessary to identify the diagnoses and procedures for coding. Discuss what would potentially be coded.
Go over Note B
and highlight the information that is missing on this second note that was
in the original.
Discuss the importance of querying the physician when there is incomplete or inaccurate documentation provided.
Medicine Associates
100 Zipper Street, Suite B100, Deltaville, MI 01234 (517)456-7890
NPI: 9186375829 EIN: 62-7149335
CLAIM FORMS W/SECONDARY PAYER 2
____________________________________________________________________________
Erica Doe
Admitted: 7-26
Discharged: 8-05
7-26 Admit by Dr. Fortune.
S:
Ms. Doe was brought to the Hooten Hospital by ambulance. Apparently, she was driving home from the grocery store when her car suddenly
made a sharp turn off the road and struck a tree according to witnesses at the
scene of the accident. Dr. Fortune admitted Ms. Doe.
O:
Ms. Doe has been unconscious since arrival to Hooten Hospital. The patient is wearing a medical alert bracelet with engraving that she is a Coumadin patient and allergic to penicillin. Multiple contusions to the head, on the left temple there is a 2cm gash that will need closure. See Procedure Note for simple closure; heart rate has been elevated. A:
Possible heart-attack. 2cm laceration to left temple. Multiple contusions to the
face. P:
Patient is being admitted to the ICU.
Medicine Associates
100 Zipper Street, Suite B100, Deltaville, MI 01234
(517)456-7890
NPI: 9186375829 EIN: 62-7149335
REJECTED CLAIM
_______________________________________________________________________________
Erica Doe
Admitted: 7-26
Discharged: 8-05
7-26 Admit by Dr. Fortune.
S:
Ms. Doe was brought to the Hooten Hospital by ambulance. Apparently, she was driving home from the grocery store when her car suddenly made a sharp turn off the road and struck a tree according to witnesses at the scene of the accident. Dr. Fortune admitted Ms. Doe.
O:
Ms. Doe has been unconscious since arrival at Hooten Hospital. The patient is wearing a medical alert bracelet with engraving that she is a Coumadin patient and allergic to penicillin. Multiple contusions to the head, on the left temple there is a gash that will need closure. See Procedure Note for closure; heart rate has been elevated. A:
Possible heart-attack. Laceration to left temple. Multiple contusions to the face. P:
Patient is being admitted to the ICU.
Lab 2: Digestive System Coding
You will participate in an instructor led activity using Chapter 19 Step-by-
Step Medical Coding
hard copy of an assignment to code a case. We will discuss anatomy & physiology as it applies to the digestive system and assign codes. Digestive System Worksheet
CPT code
CPT description
_
91110 ___________ GI tract imaging, capsule endoscopy
_
91010 ___________ Esophagus motility study
_91122___________ Anorectal manometry
_
91035 ___________ Gastroesophageal reflux test w/ electrode
Diagnosis Codes
Gastroesophageal Reflux Disease (GERD)
– GERD is a common digestive disorder that arises when the stomach acid backs up or refluxes into the esophagus (the tube connecting your mouth and stomach). Also called acid regurgitation, this condition can cause a burning sensation (known as heartburn) in the chest.
____________ Gastro-esophageal reflux disease
K21.00 ___________ Gastro-esophageal reflux disease with esophagitis
K21.9____________ Gastro-esophageal reflux disease without esophagitis
Gallstones
– Gallstones are hardened deposits of digestive fluid that can form in your gallbladder. K80 – Cholelithiasis
K80.00 ___________ Calculus of gallbladder with acute cholecystitis
K80. 19 ____________ Calculus of gallbladder with other cholecystitis
K80.20____________ Calculus of gallbladder without cholecystitis
K81. 0____________ Cholecystitis
Crohn’s Disease
– Crohn’s disease involves inflammation in the lining of the digestive tract. The condition can occur
at any age, but it will more often develop at a younger age. It is more common among people in the age group of 50- 60 years. K50 – Crohn’s disease [regional enteritis]
K50.00___________ Crohn’s disease of small intestine
K50.10 ____________ Crohn’s disease of large intestine
K50. 80____________ Crohn’s disease of both small and large intestine
K50.90 ____________ Crohn’s disease, unspecified
Irritable Bowel Syndrome (IBS)
– Irritable Bowel Syndrome (also known as irritable bowel disease) is a chronic gastro-intestinal disorder that primarily affects the digestive system, particularly the large intestine. It causes inflammation in the digestive tract, resulting in severe complications. K58 – Irritable bowel syndrome
K58.0____________ Irritable bowel syndrome with diarrhea
K58.1____________ Irritable bowel syndrome with constipation
K58.9 ____________ Irritable bowel syndrome without diarrhea
Diverticular disease
– Regarded as a chronic condition, diverticular disease occurs when small pockets or out-
pouching’s (called diverticula) occur in the bowel. Diverticula can become inflamed when undigested food gets trapped within them, causing pain and constipation, and in some extreme cases fever, nausea, or cramping. This is called diverticulitis. Diverticular disease most commonly affects people above 60 years. K57 – Diverticular disease of intestine
K57. 00____________ Diverticulitis of small intestine with perforation and abscess
K57. 10____________ Diverticular disease of small intestine without perforation or abscess
K57.90____________ Diverticular disease of intestine, part unspecified, without perforation or abscess
Lab 3: Coding Operative Reports for the Digestive System
You will apply the Surgical Guidelines when assigning CPT codes and discuss how modifiers impact NCCI Bundling Edits. Review the
Step-by-Step Medical Coding Workbook
, to code reports ? and ? for the this lab.
Lab 4: Coding Practice for Gastroenterology Procedures
You will apply CPT, ICD-10-CM, and NCCI edits and reimbursement classifications to the
2023 Coding Exam Review: The Physician and Facility Certification Step.
20.19
20.20
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Lab 5: Surgical Coding for the Digestive System with Application of NCCI Edits
Step-by-Step Ch 19 Test Preparation Worksheet
True/False
Indicate whether the statement is true or false.
_F___1.When a colectomy is performed, a segment of the stomach is resected, and an anastomosis is performed between the remaining ends.
__T__2.With the exception of incisional and ventral hernias, the use of mesh or other prosthesis is not separately reported when performing hernia repairs.
__F__3.When coding 44701 it is necessary to add a modifier -51.
__F__4.Code 45999 is the correct code to report an unlisted laparoscopic procedure of the anus.
__T__5.If totally unrelated to the condition requiring critical care, code 43752 can be coded with the critical care codes.
Completion
Complete each statement.
1.
Plastic repair of the cleft lip/nasal deformity primary bilateral, one of two stages.
CPT Code: __
40702__________________
2.
I&D of a peritonsillar abscess.
CPT Code: __42700__________________
3.
A physician is placing a nasogastric tube using fluoroscopic guidance.
CPT Code: __43752__________________
4.
The destruction by electrosurgery of fourteen papilloma lesions in the anal area.
CPT Code: __46924__________________
5.
Surgical repair of reducible inguinal hernia of a 4-month-old male, initial repair.
CPT Code: _40495__________________