age 1 of 66
Medical coding and billing ACTUAL EXAM 2025/2026
QUESTIONS AND CORRECT DETAILED ANSWERS ||
ALREADY GRADED A+ <RECENT VERSION>
Progress Note TIME IN: 1000 TIME OUT: 1020 CHIEF
COMPLAINT today is follow up for severe chronic paranoid
schizophrenia. HISTORY OF PRESENT ILLNESS: This patient is a
pleasant 50-year-old white male, established patient. He has a
history of severe paranoid-type schizophrenia. He does follow
closely with his mental healthcare provider and receives routine
Prolixin shots every 2 weeks. He has no specific complaint today,
but does describe and display a bit of anxiety over his current
living condition at _____[PLACE]. He is upset over the rules he
must follow there while "paying a large amount money every
month." He offers no further complaints today. On EXAM today,
his blood pressure is 135/96, pulse 66, respirations 18,
,age 2 of 66
temperature 97.3 degrees. GENERALLY the patient is quite
excitable and somewhat tangential. This is unchanged. LUNGS
are clear. HEART is regular without murmurs, rubs, or gallops.
ABDOMEN is soft and n .......Answer.........F20.0, I10, 99213,
90833
Code for the technical component. Radiology Report EXAM:
Ultrasound of uterus. INDICATIONS: This is a 34-year-old
female with no fetal heart motion noted on office scan.
FINDINGS: By dates the patient is 8 weeks 2 days. There is a
gestational sac within the endometrial cavity measuring 2.1 cm
consistent with 6 weeks 4 days. There is a fetal pole measuring
7 mm, consistent with 6 weeks 4 days. There was no fetal heart
motion on Doppler or on color Doppler. There is no fluid within
the endometrial cavity. IMPRESSION: Gestational sac with a
fetal pole but no fetal heart motion with fetal demise at 6
,age 3 of 66
weeks 4 days. By dates the patient is 8 weeks 2 days. A
preliminary report was called by the ultrasound technologist to
the referring physician. .......Answer.........O02.1, 76815-TC
Progress Note REASON FOR VISIT: IHSS. The patient is a 51-
year-old gentleman, established patient, recently diagnosed
with IHSS and placed on verapamil SA 120 mg a day since past
____[DATE]. He has been doing quite well on this but says he
started having upper respiratory tract symptoms last week and
says he has become more short of breath. He had some
greenish-yellow phlegm expectoration. No fevers or chills. He
denies any chest pain. Denies syncope or palpitations. Denies
PND or orthopnea. Denies bleeding, lower extremity edema, or
cramps. He continues to smoke. His cholesterol status has been
unknown for the last year and a half. The last one was in
____[DATE] with total cholesterol of 198, triglycerides 124, HDL
, age 4 of 66
59, LDL 113. He is currently taking verapamil SA 120 mg p.o.
q.d., albuterol, Paxil, multivitamins, and Flovent inhaler. Vital
signs: Blood pressure 124/79, pulse 88. HEENT: PERRL. EOMI.
No JVD. No caroti .......Answer.........I42.1, J44.1, F32.9, F17.210,
93000
During Mrs. Smith's visit to Dr. Johnson she provides a description
of a concerning health condition.. Mrs. Smith believes that Dr.
Johnson will use this information to evaluate and manage her
condition and for no other purpose. Mrs. Smith's belief is an
expectation of ____. .......Answer.........confidentiality
The documentation type that contains various types of analyses
or examinations of body substances collected from the patient.
.......Answer.........Lab Report
Medical coding and billing ACTUAL EXAM 2025/2026
QUESTIONS AND CORRECT DETAILED ANSWERS ||
ALREADY GRADED A+ <RECENT VERSION>
Progress Note TIME IN: 1000 TIME OUT: 1020 CHIEF
COMPLAINT today is follow up for severe chronic paranoid
schizophrenia. HISTORY OF PRESENT ILLNESS: This patient is a
pleasant 50-year-old white male, established patient. He has a
history of severe paranoid-type schizophrenia. He does follow
closely with his mental healthcare provider and receives routine
Prolixin shots every 2 weeks. He has no specific complaint today,
but does describe and display a bit of anxiety over his current
living condition at _____[PLACE]. He is upset over the rules he
must follow there while "paying a large amount money every
month." He offers no further complaints today. On EXAM today,
his blood pressure is 135/96, pulse 66, respirations 18,
,age 2 of 66
temperature 97.3 degrees. GENERALLY the patient is quite
excitable and somewhat tangential. This is unchanged. LUNGS
are clear. HEART is regular without murmurs, rubs, or gallops.
ABDOMEN is soft and n .......Answer.........F20.0, I10, 99213,
90833
Code for the technical component. Radiology Report EXAM:
Ultrasound of uterus. INDICATIONS: This is a 34-year-old
female with no fetal heart motion noted on office scan.
FINDINGS: By dates the patient is 8 weeks 2 days. There is a
gestational sac within the endometrial cavity measuring 2.1 cm
consistent with 6 weeks 4 days. There is a fetal pole measuring
7 mm, consistent with 6 weeks 4 days. There was no fetal heart
motion on Doppler or on color Doppler. There is no fluid within
the endometrial cavity. IMPRESSION: Gestational sac with a
fetal pole but no fetal heart motion with fetal demise at 6
,age 3 of 66
weeks 4 days. By dates the patient is 8 weeks 2 days. A
preliminary report was called by the ultrasound technologist to
the referring physician. .......Answer.........O02.1, 76815-TC
Progress Note REASON FOR VISIT: IHSS. The patient is a 51-
year-old gentleman, established patient, recently diagnosed
with IHSS and placed on verapamil SA 120 mg a day since past
____[DATE]. He has been doing quite well on this but says he
started having upper respiratory tract symptoms last week and
says he has become more short of breath. He had some
greenish-yellow phlegm expectoration. No fevers or chills. He
denies any chest pain. Denies syncope or palpitations. Denies
PND or orthopnea. Denies bleeding, lower extremity edema, or
cramps. He continues to smoke. His cholesterol status has been
unknown for the last year and a half. The last one was in
____[DATE] with total cholesterol of 198, triglycerides 124, HDL
, age 4 of 66
59, LDL 113. He is currently taking verapamil SA 120 mg p.o.
q.d., albuterol, Paxil, multivitamins, and Flovent inhaler. Vital
signs: Blood pressure 124/79, pulse 88. HEENT: PERRL. EOMI.
No JVD. No caroti .......Answer.........I42.1, J44.1, F32.9, F17.210,
93000
During Mrs. Smith's visit to Dr. Johnson she provides a description
of a concerning health condition.. Mrs. Smith believes that Dr.
Johnson will use this information to evaluate and manage her
condition and for no other purpose. Mrs. Smith's belief is an
expectation of ____. .......Answer.........confidentiality
The documentation type that contains various types of analyses
or examinations of body substances collected from the patient.
.......Answer.........Lab Report
