POFM 2310 Capstone Intermediate Billing And
Coding
1. Harrison Parker, a 69-year-old right-handed male, Explanation
was referred to me for a neurologic evaluation by his
internist, Dr. Brady, for a tremor that has been present Principal
Procedure:Where
for approximately 20 years. should you begin to
look up the code in the
Patient states that the tremor began coding man- ual -
insidiously and Alphabetic IndexWhat
has progressed gradually. It now involves both hands is the procedure
- Evalua-
and affects his handwriting, drinking coffee and other tion and
ManagementWhat
liquids with a cup, and general work that type - ConsultationWhat
requires manual dexterity. Other people is the location - Oflce or
occasionally notice a tremor in his head. other outpatientBegin to
code the encounterDid
you verify the
He is otherwise healthy, although he feels his balance code in the
numerical list-
is not quite as good as it used to be. A glass ing - YesIs there a
of beer or wine markedly decreases the symbol for this code -
tremor severity. His mother and daughter YesIs there an additional
also have tremor. Patient de- nies smoking. notation - NoDo you
On examination, he has a rather regular need to add a modifier -
tremor of
NoDid you check the
guide-
approximately lines - YesDid you
code to the 8 cycles per second (Hz) with his hands
extended
maneuver.and also on finger-nose-finger highest level of specificity
Mild - YesWhat is the
regular "waviness" is seen when writing or draw-
, POFM 2310 Capstone Intermediate Billing And
Coding
correct proce-
ing spirals. His tone is normal, although dure code - 99242
when per-
forming voluntary movements with one hand there is Second
Procedure:Where
a "ratchety" quality felt in the tone of the contralateral should you
begin to look up
arm. Occasional tremor is also noted in the head and the code in the
coding man-
voice. ual - Alphabetic
IndexWhat type of
Diagnosis: Probable essential tremor (ET)
procedure - Magnet- ic
Resonance
Next diagnostic step: MRI of brain and
cervical spine ImagingWhat type -
+ Labs (CBC + TSH) done in our facility today. DiagnosticWhat is the
anatomic site -
BrainBegin to code the
encounterDid you
, POFM 2310 Capstone Intermediate Billing And
Coding
Nurse Montana drew blood specimens. verify the code in the nu-
merical listing - YesIs
Next step in therapy: Primidone or
there a symbol for this
propranolol
code - NoIs there an
additional no- tation -
NoDo you need to add
a modifier - NoDid you
check the guidelines -
YesDid you code to the
highest lev- el of
specificity - YesWhat is
the correct procedure
code - 70551
Third Procedure:Where
should you begin to look
up the code in the
coding man- ual -
Alphabetic IndexWhat
type of procedure -
Magnet- ic Resonance
ImagingWhat type -
DiagnosticWhat is the
anatomic site -
SpineWhat location -
CervicalBegin to code
the encounterDid you
verify the code in the nu-
merical listing - YesIs
there
a symbol for this code -
NoIs there an additional
, POFM 2310 Capstone Intermediate Billing And
Coding
no- tation - NoDo you need to add a modifier - NoDid you
check the guidelines - Yes- Did you code to the highest level
of specificity - YesWhat
is the correct procedure code
Coding
1. Harrison Parker, a 69-year-old right-handed male, Explanation
was referred to me for a neurologic evaluation by his
internist, Dr. Brady, for a tremor that has been present Principal
Procedure:Where
for approximately 20 years. should you begin to
look up the code in the
Patient states that the tremor began coding man- ual -
insidiously and Alphabetic IndexWhat
has progressed gradually. It now involves both hands is the procedure
- Evalua-
and affects his handwriting, drinking coffee and other tion and
ManagementWhat
liquids with a cup, and general work that type - ConsultationWhat
requires manual dexterity. Other people is the location - Oflce or
occasionally notice a tremor in his head. other outpatientBegin to
code the encounterDid
you verify the
He is otherwise healthy, although he feels his balance code in the
numerical list-
is not quite as good as it used to be. A glass ing - YesIs there a
of beer or wine markedly decreases the symbol for this code -
tremor severity. His mother and daughter YesIs there an additional
also have tremor. Patient de- nies smoking. notation - NoDo you
On examination, he has a rather regular need to add a modifier -
tremor of
NoDid you check the
guide-
approximately lines - YesDid you
code to the 8 cycles per second (Hz) with his hands
extended
maneuver.and also on finger-nose-finger highest level of specificity
Mild - YesWhat is the
regular "waviness" is seen when writing or draw-
, POFM 2310 Capstone Intermediate Billing And
Coding
correct proce-
ing spirals. His tone is normal, although dure code - 99242
when per-
forming voluntary movements with one hand there is Second
Procedure:Where
a "ratchety" quality felt in the tone of the contralateral should you
begin to look up
arm. Occasional tremor is also noted in the head and the code in the
coding man-
voice. ual - Alphabetic
IndexWhat type of
Diagnosis: Probable essential tremor (ET)
procedure - Magnet- ic
Resonance
Next diagnostic step: MRI of brain and
cervical spine ImagingWhat type -
+ Labs (CBC + TSH) done in our facility today. DiagnosticWhat is the
anatomic site -
BrainBegin to code the
encounterDid you
, POFM 2310 Capstone Intermediate Billing And
Coding
Nurse Montana drew blood specimens. verify the code in the nu-
merical listing - YesIs
Next step in therapy: Primidone or
there a symbol for this
propranolol
code - NoIs there an
additional no- tation -
NoDo you need to add
a modifier - NoDid you
check the guidelines -
YesDid you code to the
highest lev- el of
specificity - YesWhat is
the correct procedure
code - 70551
Third Procedure:Where
should you begin to look
up the code in the
coding man- ual -
Alphabetic IndexWhat
type of procedure -
Magnet- ic Resonance
ImagingWhat type -
DiagnosticWhat is the
anatomic site -
SpineWhat location -
CervicalBegin to code
the encounterDid you
verify the code in the nu-
merical listing - YesIs
there
a symbol for this code -
NoIs there an additional
, POFM 2310 Capstone Intermediate Billing And
Coding
no- tation - NoDo you need to add a modifier - NoDid you
check the guidelines - Yes- Did you code to the highest level
of specificity - YesWhat
is the correct procedure code
