AHIMA CCA: Case Studies
CASE INSTRUCTIONS:
To view this fitness document:
Click at the tabs above.
Scroll to the bottom of every record.
For your referance, the Coding Guidelines tab consists of records out of your codebooks.
To answer the questions in this example:
Enter an appropriate codes inside the packing containers on the right.
Enter a DX code in each field.
Any essential decimal factor ought to be gift and effectively placed.
Do no longer encompass areas with your answer.
----------
CODING GUIDELINES
*Candidates will want to click on each tab to study the reviews. Candidates might be told on
exactly what number of codes are required. The key can be displayed as to which codes are
required, which means Diagnosis or Procedure and what number of. In this sample question,
the case calls for 1 Diagnosis code and 1 Procedure code. If the candidate gets each codes
accurate they will receive (2) points. If they get one (1) accurate and one (1) incorrect they will
receive 1 poi - ANSCase Studies
PDX 337.22 Reflex sympathetic dystrophy of the lower limb
PP1 64520-LT Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
PR2 77003 Fluoroscopic steering and localization of needle or catheter tip for backbone or
paraspinous diagnostic or healing injection techniques (epidural or subarachnoid)
Notes for Practice Outpatient Case—Patient 3
337.22 The diagnostic code is needed to set up the clinical necessity for the system and a pain
control code isn't appropriate because the underlying condition is being dealt with (Brown 2012,
163).64520-LT When coding paravertebral spinal nerves and branches, it's far appropriate to
use the modifiers to note the laterality (CPT Assistant July 1998, 10; April 2005, thirteen).
77003 Fluoroscopic steerage isn't always blanketed within the 64520 code; subsequently, it is
consequently appropriate to code a second code (CPT Assistant March 2007, 7; July 2008, 9;
February 2010, 12).
(Garvin 2013, 55, 251.)
AMBULATORY RECORD
, DATE: eight/12/20XX
SURGERY RECORD:
PATIENT HISTORY: This affected person is seen today to insert an intrathecal pump for pain
management because of ductal carcinoma of the left higher breast metastatic to the backbone.
She formerly underwent modified radical mastectomy with fashionable anesthesia and had no
damaging consequences. No other surgical records is given. No recognized hypersensitive
reactions, no modern-day medications. Review of systems is normal ASA = 2.
Following preoperative evaluation and discussion with the patient, local anesthesia changed into
used to implant an intrathecal programmable pump surgically placed and attached to a
previously located catheter. The affected person tolerated the process well. There have been no
damaging consequences of anesthesia.
-----------
Enter 3 prognosis codes and one process code.
PDX
DX2
DX3
PP1 - ANSCase Studies
PDX 338.3 Neoplasm-associated pain (acute) (continual)
DX2 174.Eight Malignant neoplasm of female breast, different particular web sites
DX3 198.5 Secondary malignant neoplasm of bone and bone marrow
PP1 62362 Implantation or replacement of device for intrathecal or epidural drug infusion;
programmable pump, consisting of instruction of pump, without or with programming
Notes for Practice Outpatient Case—Patient 2
338.Three The patient is admitted for pain control due to metastatic most cancers. If the
admission is for pain manipulate associated with, associated with, or because of, a malignancy,
code 338.3 (Brown 2012, 163; Coding Clinic 2nd Quarter 2007, 13-14).
174.8, 198.5 The number one web page and metastatic (secondary) web sites must be coded
(Brown 2012, 378-382).
62362 The reservoir is surgically located and connected to a previously located catheter (CPT
Assistant March 1997, 11).
(Garvin 2013, 54, 250.)
EMERGENCY DEPARTMENT RECORD
CASE INSTRUCTIONS:
To view this fitness document:
Click at the tabs above.
Scroll to the bottom of every record.
For your referance, the Coding Guidelines tab consists of records out of your codebooks.
To answer the questions in this example:
Enter an appropriate codes inside the packing containers on the right.
Enter a DX code in each field.
Any essential decimal factor ought to be gift and effectively placed.
Do no longer encompass areas with your answer.
----------
CODING GUIDELINES
*Candidates will want to click on each tab to study the reviews. Candidates might be told on
exactly what number of codes are required. The key can be displayed as to which codes are
required, which means Diagnosis or Procedure and what number of. In this sample question,
the case calls for 1 Diagnosis code and 1 Procedure code. If the candidate gets each codes
accurate they will receive (2) points. If they get one (1) accurate and one (1) incorrect they will
receive 1 poi - ANSCase Studies
PDX 337.22 Reflex sympathetic dystrophy of the lower limb
PP1 64520-LT Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
PR2 77003 Fluoroscopic steering and localization of needle or catheter tip for backbone or
paraspinous diagnostic or healing injection techniques (epidural or subarachnoid)
Notes for Practice Outpatient Case—Patient 3
337.22 The diagnostic code is needed to set up the clinical necessity for the system and a pain
control code isn't appropriate because the underlying condition is being dealt with (Brown 2012,
163).64520-LT When coding paravertebral spinal nerves and branches, it's far appropriate to
use the modifiers to note the laterality (CPT Assistant July 1998, 10; April 2005, thirteen).
77003 Fluoroscopic steerage isn't always blanketed within the 64520 code; subsequently, it is
consequently appropriate to code a second code (CPT Assistant March 2007, 7; July 2008, 9;
February 2010, 12).
(Garvin 2013, 55, 251.)
AMBULATORY RECORD
, DATE: eight/12/20XX
SURGERY RECORD:
PATIENT HISTORY: This affected person is seen today to insert an intrathecal pump for pain
management because of ductal carcinoma of the left higher breast metastatic to the backbone.
She formerly underwent modified radical mastectomy with fashionable anesthesia and had no
damaging consequences. No other surgical records is given. No recognized hypersensitive
reactions, no modern-day medications. Review of systems is normal ASA = 2.
Following preoperative evaluation and discussion with the patient, local anesthesia changed into
used to implant an intrathecal programmable pump surgically placed and attached to a
previously located catheter. The affected person tolerated the process well. There have been no
damaging consequences of anesthesia.
-----------
Enter 3 prognosis codes and one process code.
PDX
DX2
DX3
PP1 - ANSCase Studies
PDX 338.3 Neoplasm-associated pain (acute) (continual)
DX2 174.Eight Malignant neoplasm of female breast, different particular web sites
DX3 198.5 Secondary malignant neoplasm of bone and bone marrow
PP1 62362 Implantation or replacement of device for intrathecal or epidural drug infusion;
programmable pump, consisting of instruction of pump, without or with programming
Notes for Practice Outpatient Case—Patient 2
338.Three The patient is admitted for pain control due to metastatic most cancers. If the
admission is for pain manipulate associated with, associated with, or because of, a malignancy,
code 338.3 (Brown 2012, 163; Coding Clinic 2nd Quarter 2007, 13-14).
174.8, 198.5 The number one web page and metastatic (secondary) web sites must be coded
(Brown 2012, 378-382).
62362 The reservoir is surgically located and connected to a previously located catheter (CPT
Assistant March 1997, 11).
(Garvin 2013, 54, 250.)
EMERGENCY DEPARTMENT RECORD
