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CLINICAL CODING WORKOUT 2012 EIGHT QUESTION. ICD -9-CM AND CPT CODES ON SOME OF THE QUESTION 5.96. While running, a 10-year-old boy began choking on a small latex balloon and was rushed from the amusement park to the emergency department. The balloon is lodged in the trachea just past the larynx and threatening to obstruct his breathing. The piece of latex balloon is carefully removed from the trachea by use of biopsy forceps through flexible fiberoptic laryngoscope following administration of topical anesthesia. Which codes are reported for this service in addition to the ED visit code? Which codes reported for this service in addition to the ED visit in addition to the ED visit code? ICD-9-Code(s): a. 930.0,912,E000.8,e849.4,31577 b. 934.0,E912,E849.4,31511 c. 784.99,E912,E00.8,E849.4,31530 d. 933.1,31577 5.97. This 23-year-old female is brought to the emergency department after being found by her college roommate. Sometime within the last hour and a half after the roommate left, the patient ingested her entire bottle of verapamil (estimated at over 20 [pills) as a suicide attempt, evidenced by a note. The physician ordered a high-dose glucagon HCl administration as an antidote, consisting of 10mg/100 ml of D5W in an IV over 2 minutes, followed by a 5 mg/100ml of DtW per hour for two more hours. A gastric lavage and aspiration were also performed. The patient’s vital signs stabilized and lab work returned to normal over the next several hours. The patient was transferred to an inpatient psychiatric facility for follow-up treatment on her suicide attempt. Assign the correct codes for this encounter. ICD-9-CM,CPT and HCPCS Level II Codes:___________________________ 5.98. This 32-year-old female was burned by hot grease in her kitchen 1 week ago. She is seen in the hospital-based wound clinic for large dressing changes on both upper extremities following second-degree burns to both arms. This is accomplished without requiring anesthesia. What codes are assigned for this service? ICD-9-CM AND CPT CODES___________________ 5.99. A physician performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced lung cancer with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same physician performed a repeat thoracentesis. Report diagnosis and procedure codes. Do not report observation codes. ICD-9-CM AND CPT CODES _____________________________________ 5.100 A 12-year-old boy presents with his father to the ER due to open wounds to his arm, hand, and upper leg. The injury occurred when the boy fell on a barbed-wire fence at the farm while running. Diagnosis: Multiple open wounds to the right forearm, right hand, and left thigh. Procedure: Suture repair of the following: single-layer closure,4.0 cm, forearm; layered closure,3.0 cm, hand; 6.0 simple repair, thigh. ICD-9-CM Reason for Visit code__________________ ICD-9-CM and CPT Codes_____________________ 5.101. From the health record of a patient seen in the emergency room/observation area for an allergic reaction: Discharge Summary Date of discharge: 01/08/XX Chief Compliant: Allergic reaction to Bactrim, resulting in angioedema and mild respiratory distress. Hospital Course: fifty-six-year-old male admitted for angioedema after taking Bactrim for an ear infection. The patient had mild respiratory distress and marked swelling of his hands, face and his oropharynx. The patient was given IV steroids in the Emergency Room and was admitted overnight for observation. The patient’s swelling rapidly improved and by the morning after his admission he was back to baseline. He had no complaints of shortness of breath and desired to go home. Condition on discharge: Good. Activity: As tolerated. Diet: As tolerated. Medications: Home medications only including: 1. Celebrex 200 mg one b.i.d 2. Isosorbide 30 mg once a day. 3. Atenolol 25 mg per day. 4. Lipitor 10 mg per day. Follow – up: Will be as needed with primary care physician if ear problem returns and/ or if he has any evidence of recurrent swelling and /or respiratory distress. Emergency Assessment Chief Compliant: Swelling, itching, and change in voice. Present Illness: This is a 56-year-old white male with a history of allergic reaction to and antibiotic in the past, who presents today after taking his second dose of Bactrim this morning at home. He then had acute onset of swelling, redness, itching, and change in voice; also states that he was slightly short of breath but no wheezing. He denies any nausea, vomiting, fevers chills. Past Medical History: Coronary artery disease, MI 2 years ago, is currently taking Celebrex, Isosorbide, Atenolol, Lipitor, and Bactrim that he just started on this morning. Physical Examination: Appears very red, swollen diffusely with erythematous rash, macular type rash. Bloo


        CLINICAL CODING WORKOUT 2012 EIGHT QUESTION. ICD -9-CM AND CPT CODES ON SOME OF THE QUESTION


 


 5.96.  While running, a 10-year-old boy began choking on a small latex balloon and was rushed from the amusement park to the emergency department. The balloon is lodged in the trachea just past the larynx and threatening to obstruct his breathing. The piece of latex balloon is carefully removed from the trachea by use of biopsy forceps through flexible fiberoptic laryngoscope following administration of topical anesthesia. Which codes are reported for this service in addition to the ED visit code?


Which codes reported for this service in addition to the ED visit in addition to the ED visit code?


ICD-9-Code(s):



  1. 930.0,912,E000.8,e849.4,31577

  2. 934.0,E912,E849.4,31511

  3. 784.99,E912,E00.8,E849.4,31530

  4. 933.1,31577


5.97. This 23-year-old female is brought to the emergency department after being found by her college roommate. Sometime within the last hour and a half after the roommate left, the patient ingested her entire bottle of verapamil (estimated at over 20 [pills) as a suicide attempt, evidenced by a note. The physician ordered a high-dose glucagon HCl administration as an antidote, consisting of 10mg/100 ml of D5W in an IV over 2 minutes, followed by a 5 mg/100ml of DtW per hour for two more hours. A gastric lavage and aspiration were also performed. The patient’s vital signs stabilized and lab work returned to normal over the next several hours. The patient was transferred to an inpatient psychiatric facility for follow-up treatment on her suicide attempt.


Assign the correct codes for this encounter.


ICD-9-CM,CPT and HCPCS Level II Codes:___________________________           


5.98. This 32-year-old female was burned by hot grease in her kitchen 1 week ago.


She is seen in the hospital-based wound clinic for large dressing changes on both upper extremities following second-degree burns to both arms. This is accomplished without requiring anesthesia.


What codes are assigned for this service?


ICD-9-CM AND CPT CODES___________________


5.99. A physician performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced lung cancer with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same physician performed a repeat thoracentesis.


               Report diagnosis and procedure codes. Do not report observation codes.


                ICD-9-CM AND CPT CODES _____________________________________


                5.100 A 12-year-old boy presents with his father to the ER due to open wounds to his arm, hand, and upper leg. The injury occurred when the boy fell on a barbed-wire fence at the farm while running. Diagnosis: Multiple open wounds to the right forearm, right hand, and left thigh. Procedure: Suture repair of the following: single-layer closure,4.0 cm, forearm; layered closure,3.0 cm, hand; 6.0 simple repair, thigh.


ICD-9-CM Reason for Visit code__________________


ICD-9-CM and CPT Codes_____________________


5.101. From the health record of a patient seen in the emergency room/observation area for an allergic reaction:


Discharge Summary


Date of discharge: 01/08/XX


Chief Compliant:  Allergic reaction to Bactrim, resulting in angioedema and mild respiratory distress.


Hospital Course: fifty-six-year-old male admitted for angioedema after taking Bactrim for an ear infection. The patient had mild respiratory distress and marked swelling of his hands, face and his oropharynx. The patient was given IV steroids in the Emergency Room and was admitted overnight for observation. The patient’s swelling rapidly improved and by the morning after his admission he was back to baseline. He had no complaints of shortness of breath and desired to go home.


Condition on discharge: Good. Activity: As tolerated. Diet:  As tolerated.


Medications: Home medications only including:



  1. Celebrex 200 mg one b.i.d

  2. Isosorbide 30 mg once a day.

  3. Atenolol 25 mg per day.

  4. Lipitor 10 mg per day.


 


 Follow – up: Will be as needed with primary care physician if ear problem returns and/ or if he has any evidence of recurrent swelling and /or respiratory distress.


Emergency Assessment


Chief Compliant: Swelling, itching, and change in voice.


Present Illness:  This is a 56-year-old white male with a history of allergic reaction to and antibiotic in the past, who presents today after taking his second dose of Bactrim this morning at home. He then had acute onset of swelling, redness, itching, and change in voice; also states that he was slightly short of breath but no wheezing. He denies any nausea, vomiting, fevers chills.


Past Medical History: Coronary artery disease, MI 2 years ago, is currently taking Celebrex, Isosorbide,


Atenolol,  Lipitor, and Bactrim that he just started on this morning.           


Physical Examination: Appears very red, swollen diffusely with erythematous rash, macular type rash.


Blood pressure is 146/77, heart rate of 120, respiration rate 18 and 02; saturation is 96%. On room air. HEENT; He does have swollen eyelids, both upper and lower eyelids. With also some facial swelling and some uvular swelling as well as some lateral pharyngeal and uvular swelling, which appears to be allergic in nature. His tongue appears also slight swollen, does not have any neck swelling, also has and erythematous rash. Lungs: Clear to auscultation with no wheezing noted. Abdomen: Soft, nontender.


ED Course: Received Benadryl 25 mg IV, Pepcid 20 mg IV. Solu-Medrol 125 mg IV.  AT This point, his voice was still changing, and decision was made to admit the patient to the hospital for observation and then to observe and given a second dose of Solu-Medrol and Benadryl. Consultation between patient’s private physician.


Select the correct codes for this observation patient.


ICD-9-CM Codes



  1. 961.0,786.09,995.1,693.0,E857,E849.0

  2. 995.20,E931.0,E849.0

  3. 995.1,786.09,E931.0,E849.0

  4.  995.1,786.09,693.0,E930.9,E849.0


 


5.102. Operative Report


Preoperative Diagnosis: Circular saw injury with complex laceration of left index finger with laceration of extensor tendon and joint capsule; laceration collateral ligament, radial side displaced fracture at base of the middle phalanx, articular involvement.


Postoperative Diagnosis:  Circular saw injury with complex laceration of left index finger with laceration of extensor tendon and joint capsule; laceration collateral ligament, radial side: compound fracture, base of the middle phalanx, articular involvement.


 


 


Operation Performed


Debridement and repair extensor tendon and joint capsule. Repair radial collateral ligament and wound closure.


Anesthesia: Digital block


This is a 42-year-old white male who accidentally injured his left index finger on circular saw while working on broken shutters at home in his garage. The Patient sustained a jagged laceration over the dorsal radial aspect of the index finger at the proximal interphalangeal


Joint. The wound was deep, involving the joint capsule. Extensor tendon and collateral ligament.


The bone was also involved, especially at the base of the middle phalanx into the apical surface. The sensation to the tip of the finger was intact, especially all the of radial side.  The wound measured about 3 cm in length


Procedure: 0.5 percent Marcaine was used as local anesthetic digital block. After anesthesia had been obtained, the hand was prepped and draped in the usual manner. Tourniquet then was placed at the base of the fingers. The wound was then debrided. The minute loose bone and articular surface had to be removed. Some skin debrided also was removed. After satisfactory debridement, the joint capsule and extensor tendon then were repaired with 5-0 PDS suture material. The radial collateral ligament also was repaired with the same suture material. The skin then was carefully approximated with 5-0 nylon. After completion, a dressing was applied.


The tourniquet was released and there was good perfusion throughout the fingers. An aluminum splint was placed.


The patient received 1 g of Ancef in the emergency room. He will continue to take Keftab 500 mg twice daily for 4 days and Vicodin 1 tablet q.4h. p.r.n for pain. The postoperative instructions were given. Also the patient was informed about his injury patient will be followed up in my office.


Assign the correct codes and modifier for this encounter.


ICD-9-CM AND CPT CODES____________________________


 


 


 


 


 


 


                

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