Dr. Anderson works in a very small town in Ohio and travels up to 200 miles
to see his patients in the surrounding rural areas. His patient Brenda Viard
gave birth at her home the previous day to a 6-lb 3-oz baby girl, Alice Rose.
Dr. Anderson sees Alice Rose for the first time today, does a complete history
and exam, and prepares her medical chart. Alice Rose is a healthy newborn.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Evaluation and management
What is the type of service - Newborn care
What else do we know about it - Initial care
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there additional notation(s) - No
If so does the notation(s) apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 99461
Overall Feedback:
99461: Index>evaluation and management>newborn care>initial care, per
day, for evaluation and management of normal newborn infant seen in other
than a hospital or birthing center
Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for
bronchitis. While in the hospital, Tom requested that his family physician, Dr.
Selbiger, perform a circumcision, so Dr. Selbiger called in Dr. Wacker, a
urologist, for a consultation. Dr. Wacker discussed the request with Tom and
took a brief history and performed a limited genitalia examination. Afterward,
Dr. Wacker made a straightforward decision and recommended that
Raymond have the surgical procedure done at a later date as an outpatient
procedure. Code for Dr. Wacker’s services.
Explanation
Principal Procedure:
,Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Evaluation and management
What is the type of service - Inpatient consultations
Do you need to meet 3 of the 3 key components - Yes, 3 of the 3 key
components must meet or exceed stated requirements
What is the level of history - Problem focused
What is the level of the examination - Problem focused
What is the level of medical decision making - Straightforward complexity
What else do we know about it - Patient was admitted for bronchitis
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - Yes
If so what does the symbol mean - Telemedicine
Is there additional notation(s) - No
If so does the notation(s) apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 99251
Overall Feedback:
99251: Index>evaluation and management>consultation>inpatient
consultation>new or established.
Problem-focused history
Problem-focused examination
MDM of straightforward complexity
James Buckholtz, a 3-year-old male, is brought in by his parents.
Jimmy has lost his appetite and is losing weight. Mrs. Buckholtz tells
,Dr. Ferguson that Jimmy's gums bleed and he seems short of breath.
Dr. Ferguson notes splenomegaly and admits Jimmy to Weston
Hospital. After reviewing the blood tests, MRI scan, and bone
marrow aspiration results, Jimmy is diagnosed with acute
lymphoblastic leukemia.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual - Index to
Diseases and
Injuries
What is the key term - Leukemia
What type - acute lymphoblastic
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - No
If so does the Includes note help to clarify - No Includes notation
Is there a Code first notation - No
If so does the Code first note apply to the case study - No Code First notation
Is there a Code also notation - No
If so does the Code also note apply to the case study - No Code Also notation
Is there a Use additional code notation -No
If so does the Use additional code note apply to the case study - No Use
additional code notation
Is there an Excludes1 notation - Yes
If so does the Excludes1 note apply to the case study - No
Is there an Excludes2 notation - Yes
If so does the Excludes2 note apply to the case study - No
Is there a symbol indicating additional characters are required - Yes
Do you need to use the placeholder "X" - No
Did you code to the highest level of specificity - Yes
, What is the correct diagnosis code - C91.00
George Donmoyer, a 58-year-old male, presents today with a sore
throat, persistent cough, and earache. Dr. Selph completes an
examination and appropriate tests. The blood-clotting parameters,
the thyroid function studies, as well as the tissue biopsy confirm a
diagnosis of malignant neoplasm of the extrinsic larynx.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual - Table of
Neoplasms
What is the key term - Larynx
What type - extrinsic
Do any of the following apply to the condition - Malignant, primary
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - Yes
If so does the Includes note help to clarify - Yes
Is there a Code first notation - No
If so does the Code first note apply to the case study - No Code First notation
Is there a Code also notation - No
If so does the Code also note apply to the case study - No Code Also notation
Is there a Use additional code notation -Yes
If so does the Use additional code note apply to the case study - No
Is there an Excludes1 notation - Yes
If so does the Excludes1 note apply to the case study – No
Is there an Excludes2 notation - Yes
If so does the Excludes2 note apply to the case study - No
Is there a symbol indicating additional characters are required - Yes
to see his patients in the surrounding rural areas. His patient Brenda Viard
gave birth at her home the previous day to a 6-lb 3-oz baby girl, Alice Rose.
Dr. Anderson sees Alice Rose for the first time today, does a complete history
and exam, and prepares her medical chart. Alice Rose is a healthy newborn.
Explanation
Principal Procedure:
Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Evaluation and management
What is the type of service - Newborn care
What else do we know about it - Initial care
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - No
If so what does the symbol mean - Does not apply
Is there additional notation(s) - No
If so does the notation(s) apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 99461
Overall Feedback:
99461: Index>evaluation and management>newborn care>initial care, per
day, for evaluation and management of normal newborn infant seen in other
than a hospital or birthing center
Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for
bronchitis. While in the hospital, Tom requested that his family physician, Dr.
Selbiger, perform a circumcision, so Dr. Selbiger called in Dr. Wacker, a
urologist, for a consultation. Dr. Wacker discussed the request with Tom and
took a brief history and performed a limited genitalia examination. Afterward,
Dr. Wacker made a straightforward decision and recommended that
Raymond have the surgical procedure done at a later date as an outpatient
procedure. Code for Dr. Wacker’s services.
Explanation
Principal Procedure:
,Where should you begin to look up the code in the coding manual - CPT
Alphabetic Index
What is the key term - Evaluation and management
What is the type of service - Inpatient consultations
Do you need to meet 3 of the 3 key components - Yes, 3 of the 3 key
components must meet or exceed stated requirements
What is the level of history - Problem focused
What is the level of the examination - Problem focused
What is the level of medical decision making - Straightforward complexity
What else do we know about it - Patient was admitted for bronchitis
Begin to code the encounter
Did you verify the code in the numerical listing - Yes
Is there a symbol for this code - Yes
If so what does the symbol mean - Telemedicine
Is there additional notation(s) - No
If so does the notation(s) apply - Does not apply
Do you need to add a modifier - No
If so what is the modifier - Does not apply
Did you check the guidelines - Yes
Did you code to the highest level of specificity - Yes
What is the correct procedure code - 99251
Overall Feedback:
99251: Index>evaluation and management>consultation>inpatient
consultation>new or established.
Problem-focused history
Problem-focused examination
MDM of straightforward complexity
James Buckholtz, a 3-year-old male, is brought in by his parents.
Jimmy has lost his appetite and is losing weight. Mrs. Buckholtz tells
,Dr. Ferguson that Jimmy's gums bleed and he seems short of breath.
Dr. Ferguson notes splenomegaly and admits Jimmy to Weston
Hospital. After reviewing the blood tests, MRI scan, and bone
marrow aspiration results, Jimmy is diagnosed with acute
lymphoblastic leukemia.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual - Index to
Diseases and
Injuries
What is the key term - Leukemia
What type - acute lymphoblastic
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - No
If so does the Includes note help to clarify - No Includes notation
Is there a Code first notation - No
If so does the Code first note apply to the case study - No Code First notation
Is there a Code also notation - No
If so does the Code also note apply to the case study - No Code Also notation
Is there a Use additional code notation -No
If so does the Use additional code note apply to the case study - No Use
additional code notation
Is there an Excludes1 notation - Yes
If so does the Excludes1 note apply to the case study - No
Is there an Excludes2 notation - Yes
If so does the Excludes2 note apply to the case study - No
Is there a symbol indicating additional characters are required - Yes
Do you need to use the placeholder "X" - No
Did you code to the highest level of specificity - Yes
, What is the correct diagnosis code - C91.00
George Donmoyer, a 58-year-old male, presents today with a sore
throat, persistent cough, and earache. Dr. Selph completes an
examination and appropriate tests. The blood-clotting parameters,
the thyroid function studies, as well as the tissue biopsy confirm a
diagnosis of malignant neoplasm of the extrinsic larynx.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual - Table of
Neoplasms
What is the key term - Larynx
What type - extrinsic
Do any of the following apply to the condition - Malignant, primary
Begin to code the encounter
Did you verify the code in the Tabular List of Diseases and Injuries - Yes
Is there an Includes notation - Yes
If so does the Includes note help to clarify - Yes
Is there a Code first notation - No
If so does the Code first note apply to the case study - No Code First notation
Is there a Code also notation - No
If so does the Code also note apply to the case study - No Code Also notation
Is there a Use additional code notation -Yes
If so does the Use additional code note apply to the case study - No
Is there an Excludes1 notation - Yes
If so does the Excludes1 note apply to the case study – No
Is there an Excludes2 notation - Yes
If so does the Excludes2 note apply to the case study - No
Is there a symbol indicating additional characters are required - Yes
