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Inpatient Coding And Outpatient Scenarios Exam 1. List the

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Inpatient Coding And Outpatient Scenarios Exam
1. List the three goals of Physician Payment Reform.
2. Mr. Jones is admitted to the hospital by the orthopedic surgeon for severe hip pain. The ortho surgeon provides an initial hospital visit during which it’s determined that Mr.
Jones has a fractured hip that will require surgical intervention. Mr. Jones is taken later that day to the OR, where the doctor performs the surgical procedure to repair Mr. Jones’
hip. Which modifier would you use for the hospital visit?
3. List and define the three components of the relative value unit.
4. List the three types of persons eligible for Medicare.
5. Name the six basic location methods to locate main terms in the index of CPT.
6. An initial inpatient consultation with a detailed history, detailed exam, and MDM of low
complexity would be coded to what E/M code?
7. What are the four elements of history?
8. The complexity of medical decision making is based on what three elements?
9. Provide the CPT code(s) for the following scenario.
A 7-year-old female established patient presents to the pediatrician complaining of
ear pain for the last three days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is
99° F. She has had some chills and cough as well as some difficulty breathing. No
nausea or vomiting. No prior history of otitis. Her brother was sick earlier this
week. The physician performed a detailed exam of the ENT as well as a limited
exam of GI, lungs, and heart. Vital signs were taken in the office. The physician
diagnosed the patient with otitis media and an upper respiratory infection and
prescribed an antibiotic. The MDM is stated to be moderate.
CPT Code: ____________________
10. What are the three key components that are present in every patient case except
counseling encounters or time-based codes, and enable the coder to choose the
appropriate level of service?
11. Provide the CPT code(s) for the following clinic note.
Clinic Note
CC: Patient presents for routine examination.
SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine
physical examination.
OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix:
Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal
1. Normal BP.
2. Normal pelvic exam.
PLAN: Return in 1 year or as needed.
CPT Code: ____________________
12. Provide the CPT code(s) for the following scenario. Donald Mayors is a homebound
patient who is experiencing some new problems with managing his diabetes. Dr.
Martin, who has never seen this patient before, drives to Donald’s residence and
spends 20 minutes examining the patient and explaining the adjustments that are to
be made in the insulin dosage. The medical decision making is straightforward.
CPT Code: ____________________
13. What are the four levels of history type?
14. Provide the CPT and ICD-9 diagnosis codes for the following Emergency Room
SUBJECTIVE: This is a 38-year-old female who presents to the emergency room
with a history of currently being under treatment for a right corneal abrasion that
occurred on Sunday. She states she was seen by the “eye doctor earlier today” and
now has a bandage over her eye. Apparently her eye is opened underneath the
bandage, and she is unable to close her eyelid. She feels her eyelid is stuck to the
OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and
there was a folded piece of Telfa that had slipped down and her upper eyelid was
unable to close over the top of this. The Telfa was removed and a wet patch was
placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as
described above.
PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her
she needs to keep that appointment. She is to return here sooner if she is having
increasing problems.
CPT Code: ____________________
ICD-9-CM Code: ____________________

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