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
What is the level of medical decision making - Straightforward level
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 - 99252
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
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 – C32.1
Mitchell Lane, a 48-year-old male, presents with the complaints of
night sweats and weight loss. Dr. Clark completes an examination
noting hemoptysis and takes a chest x-ray, which reveals a mass.
Mitchell is admitted to Weston Hospital where a CT-guided needle
biopsy is then performed. Mitchell is diagnosed with a malignant
primary neoplasm of the posterior mediastinum.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual – Table of Neoplasm
What is the anatomical site -Mediastinum
What is the location – Posterior
Do any of the following apply to the condition -Malignant, primary
Do any of the following apply to the condition – None of these
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 –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 - No
If so does the Excludes2 note apply to the case study – No Excludes2 notation
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 – C38.2
Ben Jameson, a 31-year-old male, was admitted today for the
prophylactic removal of his prostate. Both Ben’s father and brother
have prostate cancer that has spread to the lungs and liver. Ben
, decides to have a laparoscopic radical prostatectomy while he is still
healthy.
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 – Prophylactic
What type – organ removal
What is the anatomical site -Prostate
Do any of the following apply to the condition – None of these
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 –Yes
If so does the Use additional code note apply to the case study – Yes
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 – Z40.09
Second diagnosis:
Where should you begin to look up the code in the coding manual – Index to Diseases and
Injuries
What is the key term – History
What type- Family
What type – malignant neoplasm
Do any of the following apply to the condition – None of these
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 - Yes
If so does the Code also note apply to the case study – No
Is there a Use additional code notation – No
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
What is the level of medical decision making - Straightforward level
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 - 99252
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
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 – C32.1
Mitchell Lane, a 48-year-old male, presents with the complaints of
night sweats and weight loss. Dr. Clark completes an examination
noting hemoptysis and takes a chest x-ray, which reveals a mass.
Mitchell is admitted to Weston Hospital where a CT-guided needle
biopsy is then performed. Mitchell is diagnosed with a malignant
primary neoplasm of the posterior mediastinum.
Explanation
Principal diagnosis:
Where should you begin to look up the code in the coding manual – Table of Neoplasm
What is the anatomical site -Mediastinum
What is the location – Posterior
Do any of the following apply to the condition -Malignant, primary
Do any of the following apply to the condition – None of these
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 –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 - No
If so does the Excludes2 note apply to the case study – No Excludes2 notation
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 – C38.2
Ben Jameson, a 31-year-old male, was admitted today for the
prophylactic removal of his prostate. Both Ben’s father and brother
have prostate cancer that has spread to the lungs and liver. Ben
, decides to have a laparoscopic radical prostatectomy while he is still
healthy.
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 – Prophylactic
What type – organ removal
What is the anatomical site -Prostate
Do any of the following apply to the condition – None of these
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 –Yes
If so does the Use additional code note apply to the case study – Yes
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 – Z40.09
Second diagnosis:
Where should you begin to look up the code in the coding manual – Index to Diseases and
Injuries
What is the key term – History
What type- Family
What type – malignant neoplasm
Do any of the following apply to the condition – None of these
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 - Yes
If so does the Code also note apply to the case study – No
Is there a Use additional code notation – No
