2023_MAT_CPMA_PA-WB_Student_Ch2

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 27 Chapter 2 You are conducting an audit of medical records for emergency department physicians. Case 1 Emergency Department Visit Re: Amy L. Jones Date of Service: January 4, 20XX MR #: 200-1 ED Prescriptions Medication Sig by mouth 2 (two) times daily Dispense Auth. Provider Tramadol (UL TRAM) 50 mg tablet Take 1 tablet (50 mg total) by mouth every 6 (six) hours as needed for pain. 20 tablets Christopher Campbell, MD Discharge Instructions received: None Follow-up Information Follow up with Curtis Cooper Details in 3 days Comments Contact Info 106 E Broad Street P.O. Box 2024 Savannah GA 31401·2917 912-527-1000 Memorial University Medical In Center Emergency Department In 2 days 4700 Waters Avenue Savannah Georgia 31403 912·350·8113 Patient Follow-up information Edit Trail: None ED Decision to Admit: None ED Physician Notes History of Present Illness Patient Identification: Amy L. Jones is a 31-year-old female. History/Exam limitations: none. Chief Complaint: Neck skin infection HPI: Onset of symptoms was 1 day ago, with gradually worsening symptoms since that time. Symptoms include erythema and swelling. Patient reports no fever, nausea, or vomiting. There is not a history of trauma to the area. Has taken over the counter medication with minimal relief.

30 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Emergency Department Coding Fee Ticket Patient Name Amy L. Jones Medical Record Number/Account Number 200-1 ED Physician Jeremiah Shullo, MD Insurance Company Health 123 Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/4/20XX AAPC Hospital 23 99284 L02.11 25 1 $350.00 1/4/20XX AAPC Hospital 23 10060 L02.11 1 $120.00 Total $470.00 1. The documentation supports what ED E/M and procedure codes? A. 99283, 21501 B. 99283-25,10061 C. 99283-25, 69000 D. 99284-25, 10060 2. When meeting with this physician post audit, what issue needs to be addressed? A. The audit was documented and billed correctly. B. The emergency department E/M visit should not be reported separately as it is included in the procedure. C. Documentation supports a lower ED E/M level than what the physician reported. D. The diagnosis reported is incorrect. Case 2 Emergency Department Visit Re: Shawn M. Jones Date of Service: January 2, 20XX MR # 200-2 Patient Identification: Shawn M. Jones is a 10-month-old male Chief Complaint: Patient presents with fall and hitting his head History of Present Illness : Mother was sleeping with patient in her bed and woke up when she heard a thud to find patient on the floor. Mother states patient started to cry immediately and rubbing his head. Patient is laughing and acting age appropriate in triage. According to mother, there have been no other issues. She says that the bed was higher than usual and the child fell onto a wood floor; did not notice any bruises on skin or signs of other injury. No vomiting.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 33 Chapter 2 1. The documentation supports what ED E/M level? A. 99282 B. 99283 C. 99284 D. 99285 2. When meeting with this physician post audit, what issues need to be addressed? A. The level of service was documented and billed correctly. B. Level of service on fee ticket is not supported in documentation – under-coded C. The diagnosis is incorrect D. The documentation was not appropriate for a pediatric patient Case 3 Emergency Department Visit Re: Donnie A. Smith Date of Service: January 10, 20XX MR # 200-3 Patient Identification: Donnie A. Smith is a 55-year-old male. Chief Complaint: Chest pain Patient is a 55-year-old male who complains of sharp retrosternal chest pain in the left arm that started one hour ago. He reported the pain as 10/10, but reduced to 5/10 after given Nitroglycerin enroute to hospital. He reports the pain has been rapidly improving since then, but still has complaints of shortness of breath and left arm paresthesia. This patient is at risk for CAD given the following risk factors; advanced age (older than 55 for men, 65 for women), dyslipidemia and hypertension, and cocaine used last night. Past Medical History Diagnosis l Hypertension Past Surgical History Procedure l Hernia repair No current facility-administered medications for this encounter.

36 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Comprehensive Metabolic Panel Component Value Range Glucose 114(*) 74-106 mg/dl Sodium 139 137-145 mmol/L Potassium 3.9 3.5-5.1 mmol/L Chloride 103 98-107 mmol/L CO2 24 21-31 mmol/L Anion Gap 16.2 10.0-20.0 BUN 10.0 9.0-21.0 mg/dl Creatine 1.22 0.52-1.25 mg/dl Age for GFR 55 Gender for GFR 0.000 GFR African American 75 56-130 ml/min/1.73m2 GFR Not African American 62 56-130 ml/min/1.73m2 Calcium 9.9 8.5-10.5 mg/dl TP 7.8 6.0-8.4 gm/dl Albumin 4.2 3.0-5.0gm/dl A/G Ratio 1.1 1.0-2.2gm/dl Globulin 3.6 1.5-3.8gm/L Bilirubin Total 0.2 0.2-1.3 mg/dl AST 45 5-49 IU/L Alkaline Phos 48 38-126 IU/L ALT 32 7-56IU/L Magnesium 1.7 1.7-2.2 mg/dl Phosphorus 4.3 2.5-4.5 mg/dl CK (CPK) 406(*) 55-170 IU/L Creatinine Kinase (CK-MB) 1.5 0.2-5.3 ng/ml Troponin l <0.020 0.000-0.034 ng/ml Lipid Panel Component Value Range Cholesterol 229(*) 112-199 mg/dl HDL Cholesterol 37(*) 60-96 mg/dl Triglyceride 753(*) 36-150 mg/dl LDL Cholesterol- Calculated Not Calculated, Trig > 400 60-100 mg/dl Chol-HDLC Ratio 6.19(*) 0.00-4.96 Component Value Range Prothrombin Time 12.7 11.5-15.2 Sec INR 0.97 0.00-1.49 PTT 28.7 22.1-35.7 sec

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 39 Chapter 2 Neck: Supple Cardiovascular: Regular rate and rhythm Respiratory: Breath sounds equal bilaterally Chest: No chest deformity Head: Mild facial tenderness to palpation with some swelling to the back of the head. Neuro: Normal speech Psychiatric: Alert and Oriented x 3 CT Scan ordered. ED Course/MDM Patient Vitals for the past 24 hrs: BP Temp Temp Src Pulse Resp SpO2 Height Weight 03/04/XX 120/53 mmHg 98.3F Oral 91 20 100% 1.778m 62.1kg Impressions : The patient is well appearing with a benign exam and unremarkable vital signs. I feel comfortable with the patient’s appearance and the way that he’s acting. I have considered serious and emergent etiologies and comorbidities associated with the patient’s current complaint, physical exam, and evaluation; therefore, I have determined them to be unlikely. I have discussed the patient’s occipital bone fracture with a neurosurgeon and agreed to discharge the patient home. The patient has been given careful instructions on symptoms to pay attention to and reasons to return promptly to the emergency department: These include, but are not limited to, a worsening of his current symptoms, the development of new symptoms, or a failure to improve. The patient has also been given careful instructions on how to follow up and the importance of maintaining follow up with a primary care provider. The patient has been advised that his evaluation today was intended to evaluate for emergent conditions and that certain diagnostic possibilities still remain. On the basis of these facts, I have determined that additional testing is not warranted in the emergency department setting at this time and that close outpatient follow-up is an appropriate course of action. The patient verbalized understanding with these instructions and agrees to comply with the treatment plan that we have discussed. Prescription given for Naproxen for pain. Records Reviewed: None. Consultations: Treatment options were discussed and plan of care agreed upon. Reassessment: repeat neurological exam: unchanged Electronically signed by Paul Randolph, MD on 03/04/20XX at 11:33 AM Sign off status: Completed Emergency Department Coding Fee Ticket Patient Name Bill D. Johnson Medical Record Number/Account Number 200-4 ED Physician Paul Randolph, MD Insurance Company Self-Pay Comments

42 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Review of Systems All other systems reviewed and are negative, except any described as pertinent in the HPI. Physical Exam BP 101/63, Pulse 82, Temp 99.8 oF (Oral), Resp 18, Ht 1.626 m, Wt 99.791 kg, BMI 37.74 kg/m2, SpO2 97%, LMP 12/10/20XX Constitutional: Pleasant, NAD. Eyes: Sclera clear, no icterus, conjunctivae and lid normal, EOMI Ear Nose Mouth Throat: Ear, nose and throat exam normal; normal TMs; no lesions Neck: Supple, non-tender Cardiovascular: Regular rate and rhythm, no gallop, no murmurs, distal pulses normal, NL S1/S2, no rub detected Respiratory: Breath sounds equal bilaterally, no rales, rhonchi, or wheezes, normal respiratory effort/excursion Chest: No chest deformity, movement normal, movement symmetrical Gastrointestinal: Normal, nondistended abdomen, abdomen soft, nontender, no masses palpated, no rebound, guarding, rigidity, or pulsatile masses Musculoskeletal: Normal extremities, no deformities. Full ROM all extremities. Skin: Skin turgor normal, mucosal membranes moist, skin color good Neuro: Normal, motor intact in all extremities, normal coordination, cranial nerves grossly intact Psychiatric: No abnormalities of mood or affect Lymphatic: No palpable cervical or axillary adenopathy ED Course/MDM Patient Vitals for the past 24 hrs: BP Temp Temp src Pulse Resp SpO2 Height Weight 01/05/20XX 101/63 99.8 oF Oral 82 18 97 % - - 0157 01/04/20XX mmHg 100.1 oF Oral 104 18 96% - - 2317 139/83 mmHg MDM : Medical Decision Making: Differential diagnoses that have been ruled out based on HPI, ROS, and PE: Encephalitis, Meningitis, Serotonin syndrome, Sickle cell crisis, Thyrotoxicosis Differential Diagnoses: Bacteremia, fever, fever symptoms, infection, pneumonia, pyelonephritis, sepsis, sepsis syndrome, viral syndrome, gastroenteritis Diagnostic Evaluation ordered: Chest X-ray, 12 lead ECG, urinalysis, blood work Amount and complexity of data: The EM Physician performed a face-to-face evaluation in this patient, current EKG reviewed, current labs reviewed, current x-ray reviewed Discussion: Provider to admit and follow Records Reviewed: none

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 45 Chapter 2 Mother reports patient awoke from a nap yesterday and had crust and drainage to eyes. Awoke with both eyes crusted shut this morning. Denies fever. Physical Examination BP 103/80, Pulse 83, Temp 98.4 F (Oral), Resp 18. Ht 1.27 m, Wt26.3 kg, BM116.31 kg/m2, Sp02 100% Nursing note and vitals reviewed. Constitutional: She appears well-developed and well-nourished. She is active. Head: Atraumatic. No signs of injury EENT: Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Nose: Nose normal. No nasal discharge. Mouth/Throat: Mucous membranes are moist. Dentition is normal. No dental caries. No tonsillar exudate. Oropharynx is clear. Pharynx is normal. Eyes: EOM are normal. Pupils are equal, round, and reactive to light. bulbar and palpebral conjunctiva with white discharge. Mild edema and erythema of upper/lower lids. No periorbital edema/erythema/tenderness. Neck: Normal range of motion, neck supple. No adenopathy/lymphadenopathy. Cardiovascular: Normal rate, regular rhythm, S1 normal and S2 normal. Pulmonary/Chest: Effort normal. There is normal air entry. No stridor. No respiratory distress. Air movement is not decreased. She has no wheezes. She has no rhonchi. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension and no mass. There is no hepatosplenomegaly. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. ED Course Procedures Acute conjunctivitis. No history of trauma. No concern for globe injury, corneal abrasion, or retained foreign body. No evidence to suggest perseptal cellulitis or orbital cellulitis. Will treat with drops prescription, Polytrim ® . No indication for systemic antibiotics or blood work. Discussed indications for return with parent. Electronically signed by Nichole Lawrence, MD on 12/20/20XX at 10.47 AM Sign off status: Completed Emergency Department Coding Fee Ticket Patient Name Missy S. Mills Medical Record Number/Account Number 200-6 ED Physician Nichole Lawrence, MD Insurance Company Medicaid Comments

46 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 12/20/20XX AAPC Hospital 23 99282 H10.33 1 $487.00 Total $487.00 1 The documentation supports what ED E/M level? A. 99282 B. 99283 C. 99284 D. 99285 2. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. The E/M level is incorrect. C. The diagnosis is incorrect. D. Both B and C Case 7 Emergency Department Visit Re: Nikki R. Smith Date of Service: January 5, 20XX MR # 200-7 History Chief Complaint: Sickle Cell Pain Crisis Patient is 11-year-old female. The patient presents with a chief complaint of abdominal pain. The onset this am. No relief with Motrin 150 mg. No narcotics given PTA. Child tolerating PO without difficulty. The related history is significant for HbSS. Patient seen 6 days ago for pain crisis; patient improved. Child treated PTA with ibuprofen 150mg. The symptoms have not been associated with fever, nasal congestion or discharge, with dyspnea, dysuria, diarrhea, irritability, petechial rash, respiratory distress, or vomiting. Surgical History Tonsillectomy

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 47 Chapter 2 Medication Sig Start Date End Date Taking? albuterol (PROVENTIL) 2.5 mg 13 mL (0.083 %) nebulizer solution Take 3 mLs (2.5 mg total) by nebulization every 6 (six) hours as needed for Wheezing. 3/16/19 ALBUTEROL INHL Inhale into the Lungs Budesonide (Pulmicort) 0.25 Take 0.25 mg by Nebulization daily mg/2 mL nebulizer solution folic acid (FOL VITE) 1 MG tablet Take 1 MG by Mouth HYDROcodone-acetaminophen Take 7.5 mLs by mouth 2/7/19 (LORTAB ELIXIR) 7.5-500 mg/15 mL Solution every 6 (six) hours as needed for Pain. HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet Take 1 tablet by mouth every 6 (six) hours as needed for Pain. 4/25/19 HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet Take 1 tablet by mouth every 6 (six) hours as needed. ibuprofen (ADVIL, MOTRIN) 200 MG Tablet Take 200 mg by mouth every 6 (six) hours as needed. magnesium citrate solution 3.5 Oz po q 4-6 x 4 doses 217/14 over 24 hr period 2/7/19 polyethylene glycol (GL YCOLAX) 17 gram packet Take 17 g by mouth daily. polyethylene glycol (MIRALAX) 17 gram/dose powder 1 ¾ Capfuls po qd 2/7/19 Physical Exam BP 121 / 65, Pulse 78, Temp 98.6 F (Oral), Resp 18, Ht 1.44 m, Wt 31.2 kg, BMI 15.05 kg/m2, Sp02 99% Physical Exam Constitutional: She appears well-developed and well-nourished. HEENT: Head: Atraumatic. No signs of injury. Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Nose: Nose normal. No nasal discharge. Mouth/Throat: Mucous membranes are moist. Dentition is normal. 1\10 dental caries. No tonsillar exudate. Oropharynx is clear. Pharynx is normal.

48 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Eyes: Conjunctivae normal and EOM are normal. Pupils are equal, round, and reactive to light. Neck: Normal range of motion. Neck supple. No rigidity, adenopathy Cardiovascular: Normal rate, regular rhythm, S1 normal and S2 normal. Pulses are palpable. No murmur heard. Pulmonary/Chest: Effort normal. There is normal air entry. No stridor. No respiratory distress. Air movement is not decreased. She has no wheezes. She has no rhonchi. She has no rales. She exhibits no retraction. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension and no mass. There is no hepatosplenomegaly. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. Neurological: She is alert. No cranial nerve deficit. Coordination normal. Skin: Skin is warm. Capillary refill takes less than 3 seconds. No petechiae, no purpura and no rash noted. ED Courses Clinical lab tests: ordered and reviewed CBC with DIFFERENTIAL Radiology: ordered and reviewed CXR- no focal consolidation, no pneumothorax/pneumomediastinum, no pulmonary edema, pleural effusion Abdominal X-ray- Moderate to large amount of colonic stool, no air fluid levels, no bowel distension, no evidence of obstruction Patient with a history of HbSS and acute onset of pain. No evidence of clinical dehydration, well perfused. No increased work of breathing, hypoxia or current complaints of chest pain. Afebrile. Patient has constipation. Doubt sickle cell vaso occlusive crisis. Abdomen soft and nontender, no rebound or guarding. No concern for surgical abdominal process. Patient treated with neostigmine 0.08 mg IV was administered slowly over 3-4 minutes. No narcotics. No evidence to suggest bacterial infection including pneumonia, bacteremia, osteomyelitis/septic joint. Hemoglobin and hematocrit at baseline. Improvement in pain over ED course. Start Miralax and magnesium citrate. Will discharge with instructions/indications for return. Re-Evaluating Notes Date and Time 01/05/XX 1925 Who Re-Evaluation Comfortable, no c/o pain BH C No orders of the defined types were placed in this encounter.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 49 Chapter 2 Results for orders placed during the hospital encounter of 0105XX CBC with DIFFERENTIAL Component Value Range WBC 13.4 4.5- 13.5 thou/ul RBC 2.3 (*) 3.7- 5.3 Mill/ul HGB 7.0(*) 10.5-14.0 gm/dl HCT 21.4 (*) 34.0- 45.0 % MCV 93.7(*) 75.0- 90.0 fl MCH 30.5 25.0- 33.0 pg MCHC 32.6 30.0- 36.0 gm/dl RDW 23.5 (*) 11.5- 14.6 % Platelet Count 225 150- 450 thou/ul Neutrophil 32 (*) 40-70% Lymphocyte 53 (*) 15-45% Monocyte 13(*) 1-8 % Eosinophil 1 0-6 % Basophil 1 0-2% Anisocytosis Mark Platelet Estimate Normal Moderate Polk & Ovalo Mod Poik Mod Abnormal HGB Mod Target & Sickle Moderate Shape Change Few Teardrop Reticulocytes Component Value Range Retic 11.89 (*) 0.28- 2.28% Retic Absolute 0.27 (*) 0.02- 0.11 mill/ul Immature Retic Fract 0.57 (*) 0.16- 0.36 Discharge—home Condition at discharge stable The primary encounter diagnosis was Constipation, acute. A diagnosis of Sickle cell anemia was also pertinent to this visit. Electronically signed by Nathan Spires, MD on 1/5/20XX at 11:43 AM Sign off status: Completed Emergency Department Coding Fee Ticket Patient Name Nikki R. Smith Medical Record Number/Account Number 200-7 ED Physician Nathan Spires, MD Insurance Company Medicaid Comments

50 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 23 99283 D57.1 1 $334.00 Total $334.00 1. The documentation supports what ED E/M level? A. 99282 B. 99283 C. 99284 D. 99285 2. When meeting with this physician post audit, what issues need to be addressed? A. CPT ® and diagnosis codes are correctly reported. B. Level of service selected is not supported in documentation – over-coded. C. X-rays should have been reported with modifier 26. D. Level of service selected is not supported in documentation – under-coded and the documented primary diagnosis was not billed. Case 8 Emergency Department Visit Re: Bella Smith Date of Service: July 30, 20XX MR # 200-8 Chief Complaint: Rash. HPI: The patient presents with a complaint of rash. It has been occurring for 1 day. The cause of the rash is unknown, although in pool earlier today and began having rash at feet, abdomen and bilateral upper extremities. The rash is papular and located over the trunk and extremities. Intensity is characterized as mild to moderate. The symptoms have no relieving factors. The patient was not treated with anything for the rash prior to arrival. The symptoms have been associated with pruritus. Symptoms that have not been associated are difficulty breathing, difficulty speaking, difficulty swallowing, lip swelling, throat swelling, or tongue swelling. The related history is not significant. Noted redness at this time to upper arms and feet. Noted child scratching areas of redness at this time. Allergies – Reaction to penicillin Physical Exam: Constitutional: She is active. No distress. ENT: TMs normal.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 51 Chapter 2 Eyes: Pupils are equal, round, and reactive to light. Neck: Neck supple. Cardiovascular: Normal rate Pulmonary/Chest: Effort normal and breath sounds normal. Skin: Skin is warm. Rash noted. Diffuse erythema over arms, trunk, and LE with associated excoriation. Assessment: Mild allergic dermatitis. No concern for serious bacterial infection/cellulitis. No concern for erythema multiforme or Stevens Johnson Syndrome. Treated with H1 and H2 blocker, and will continue symptomatic care upon discharge. Prescribed Claritin and Zantac to relieve symptoms. These can be picked up over-the-counter or at the pharmacy. Discussed indications for return to ED with parent. Discharge Instructions Received ED Decision to Admit None Electronically signed by Brian Chen, MD on 7/30/20XX at 2:13 PM Sign off status: Completed Emergency Department Coding Fee Ticket Patient Name Bella Smith Medical Record Number/Account Number 200-8 ED Physician Brian Chen, MD Insurance Company Medicaid Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 7/30/20XX AAPC Hospital 23 99283 R21 1 $334.00 Total $334.00 1. You are conducting an audit of the medical record for the emergency department physicians. The documentation supports what ED E/M level? A. 99281 B. 99282 C. 99283 D. 99284 2. When meeting with this physician post audit, what issues need to be addressed? A. The encounter note was documented and billed correctly. B. The diagnosis code reported is incorrect. C. Level of service selected is not supported in documentation – under-coded. D. Wrong place of service indicated on the fee ticket.

52 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Case 9 Emergency Department Visit Re: Michael Johnson Date of Service: February 5, 20XX MR # 200-9 HPI: The patient presents with a chief complaint of making violent threats. Started last night and it has been occurring for 1 day. Patient was in an argument with his brothers and threatened to stab them. No acute thoughts of harming himself. No history of auditory or visual hallucinations. Patient denies ingestion. The symptoms have not been associated with fever, irritability, petechial rash, respiratory distress, or vomiting. The related history is significant for schizoaffective d/o. The patient was treated prior to arrival with nothing. Review of Systems: A full 10-point review of systems with what is noted in the HPI, were reviewed and are otherwise were negative. Past Medical History: l Tuberous sclerosis l Schizo affective/schizophrenia l Mental/behavioral problem No Known Allergies No Surgical History Social History: Smoking status: former smoker Smokeless tobacco: never used Alcohol use: No Drug Use: Yes, Marijuana Prior to Admission Medications Oxcarbazepine (TRILEPTAL) 300 MG tablet Take 300 MG by mouth 2 times daily Physical Exam: BP 136/83, Pulse 88, Temp 98.7 F (Oral), Resp 18, Sp02 98% Constitutional: He is oriented to person, place, and time. He appears well developed and well nourished. No distress, comfortable. HEENT: Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae normal and EOM are normal. Pupils are equal, round, and reactive to light. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard.

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 53 Chapter 2 Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is no tenderness. There Is no rebound and no guarding. No hepatosplenomegaly Musculoskeletal: Normal range of motion. He exhibits no edema and no tenderness. Normal gait. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. No cranial nerve deficit. He exhibits normal muscle tone. Coordination normal. Skin: Skin is warm and dry. No rash noted. No erythema. No petechiae/purpura/vesicles/pustules ED COURSE Patient alert, and interactive. Benign physical exam/ neurological exam. History of Violent threats to stab brothers. No suicidal ideation. No evidence to suggest psychosis. Not concerned that patient’s behavioral changes are due to organic etiology (increased intracranial pressure, meningitis/encephalitis, metabolic abnormality, thyrotoxicosis, ingestion, or seizures). After discussion with her and the patient’s family it is felt that the patient warrants inpatient stabilization due to potential threat to others. Psychiatry consult requested due to threat of others. Patient will be further assessed by the Psychiatric Assessment. Patient will be transferred to Lakeside for admission. Diagnosis Emergency Department Coding Fee Ticket Patient Name Michael Johnson Medical Record Number/Account Number 200-9 ED Physician Emergency Doctor, MD Insurance Company Medicaid Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 2/6/20XX AAPC Hospital 52 99285 F25.9 1 $334.00 Total $334.00 1. The documentation supports what ED E/M level? A. 99282 B. 99283 C. 99284 D. 99285 2. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. Level of service selected is not supported in documentation – under-coded. C. Level of service selected is not supported in documentation – over-coded D. The audit showed there were multiple billing errors on the claim.

54 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Case 10 Emergency Department Visit Re: Joseph Davis Date of Service: August 30, 20XX MR # 200-10 Chief Complaint: Mouth Injury HPI: Patient presents with noted buccal laceration to inner right side of mouth, which he sustained from being pushed and the tooth cutting his cheek. Injury occurred at approximately 10:30 this morning. Review of Systems: The trauma ROS is positive for bleeding. Physical Exam: Constitutional: Comfortable and well appearing. HEENT: Head: No signs of injury. Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Nose: Nose normal. No nasal discharge. Mouth/Throat: Mucous membranes are moist. Dentition is normal and stable. No dental caries. No tonsillar exudate. Oropharynx is clear. Pharynx is normal. No point tenderness over the mandible. Full ROM at TMJ. 1 cm laceration inner aspect right buccal mucosa. Eyes: Pupils are equal, round, and reactive to light. Skin: Skin is warm. ED Course: Simple, laceration to buccal mucosa. Neurovascularly intact. No associated injuries. Minimal risk of no concern for retained foreign body, underlying facial fracture, dental injury, or vascular injury. No indication for wound closure. Tetanus immunization is up to date. No indication for systemic antibiotics. Discussed wound care, signs and symptoms of wound infection with parent and indications for return. Electronically signed by Naomi Watts, MD on 8/30/20XX at 2:13 PM Sign off status: Completed Emergency Department Coding Fee Ticket Patient Name Joseph S. Davis Medical Record Number/Account Number 200-10 ED Physician Naomi Watts, MD Insurance Company Medicaid Comments

2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 55 Chapter 2 Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 8/30/20XX AAPC Hospital ED 23 99283 S01.522A 1 $334.00 Total $334.00 1. The documentation supports what CPT ® coding? A. 99282 B. 99282-25, 12011 C. 99283 D. 99283-25, 12011 2. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. Level of service reported by the physician is not supported in documentation – under-coded. C. Repair CPT ® code should be reported. D. The level of service is incorrect and the diagnosis is incorrect.