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AAPC CPC CHAPTER 19
Emergency Department Services - Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He's evaluated by the ED provider. This is the first time he has been to this hospital. What subsection is used to report the ED visit? 32 - What modifier is used to report an evaluation and management service mandated by a court order? Established patient office visit - A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B? Location, quality and duration - Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days. Quality - If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)? 99475 - A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter? 99382 - After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and
provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported? 99367 - A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported? I20.1 - What ICD-10-CM code is reported for angina pectoris with a documented spasm? 99393, 99213-25 - A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI. What CPT® code(s) is/are reported for this visit? 99242 - A 32 year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported? 99213, 99354 - Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit? The acute tonsillitis is reported first; the chronic tonsillitis is reported second. -
An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded? 99231 - The physician was called to the hospital floor for the medical management of a 56 year-old patient admitted one day ago with aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported? 99213, S39.012A, W01.0XXA, Y92.030 - An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped in water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service? 92950, 99291-25, 36556, 31500 - A 5 year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported? 99213 - An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the provider reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and follow up X- ray. What CPT® code is reported?
99214, K37, R12 -
A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter? 20610-50 - An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit? 99288, 99291, 92950 - Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. Defibrillation is performed with 250 joules to a NSR. What are the appropriate procedure codes for this encounter? 99232 - Dr. Jones documents Mrs. Smith's condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and a low medical decision making. What CPT® code should be reported? E/M services are further categorized based on the setting in which the service is provided. What are they?? - Examples of settings include: Office or other outpatient setting Inpatient Hospital Emergency department (ED) Nursing facility (NF) Outpatient Hospital
Severity: - The physician should get some idea about the severity of the discomfort or sensation or pain. The patient may describe the severity of the pain by employing a crude self-assessment scale to measure subjective levels (e.g. 1-10) with one being no pain and 10 the worst pain experience. The pain may also be estimated through nonverbal signals of discomfort, such as the patient lying perfectly still or continuously pacing the floor. Duration: - The physician should determine how long the patient has had the problem. (24 hours, 1 day, 2 weeks, 3 months?) Timing: - Establishing the onset for each symptom or problem and a rough chronology of the development of the problem are also important. Is the pain continuous or nocturnal? Context: - The physician may obtain a description of where the patient is and what the patient does when signs or symptoms begin. Does the symptom occur with activity? Is the symptom aggravated or relieved? Modifying Factors: - What has the patient attempted to do for relief? Have over-the-counter medications been attempted? What were the results? Associated Signs/Symptoms: - A physician's impressions formulated during the interview lead to questioning about additional sensations or feelings. Generalized symptoms, such as chills and fever, headaches, weakness, exhaustion are often relevant. TIP: Chronic Conditions - Elements of HPI are easily defined when the patient presents with a new or acute problem. Here are some tips for documenting an extended HPI for a chronic condition: Chief Complaint HPI (History of Present Illness)
ROS (Review of Systems) PFSH (Past Medical, Family & Social History) History Component GIVE STATUS (Quality) Is the condition improving/worsening/stable? Have they experienced an exacerbation of the condition since you last saw the patient? When were they diagnosed or how long has the patient had the condition? (Duration) How is the condition being managed? Medications? Diet? Exercise? Has the patient undergone surgery to help manage or correct the condition?(Modifying Factors) Give some idea of the severity—is the patient homebound or disabled, does it affect activities of daily living? Pain 1-10? If condition can be measured with lab (ex cholesterol)- give those results. Brief HPI : - 1 to 3 elements Extended HPI: - 4 or more elements (or status of 3+ chronic conditions) CASE 1 Mark is a 45 years-old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None.
My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, perform - 11300 D49. Z85. CASE 3 IDENTIFICATION: The patient is a 37 year-old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37 year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT:
- Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, bu - 99212 M79. I27. CASE 4
AGE: 33 year-old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.) HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode o - 99395 Z00. Z01. E03.
- Depression/anxiety. REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every o - 99213- 20612-F 77080 J M06. M06. M71. M80.08XD CASE 7 XYZ Nursing Home Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious. Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts eve -
S20.211A
M25.
R03.
F03.
I25.
I50.
I48.
E11.
Z79.
CASE 8
Hospital Admission Chief complaint: Nausea and vomiting, weakness HPI: The patient is a 78 year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: MO - 99222
K80.
N30.
H10.
E87.
E87.
E11.
I
CASE 10
Discharge summary Hospital course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that. Discharge Diagnoses:
- Cholelithiasis
- Cystitis
- Conjunctivitis
- Hyponatremia
- Diabetes mellitus type 2
- Hypertension Discharge Medications:
- Levaquin 500 mg p.o. daily x2 days
- Ciloxan ointment, apply b.i.d.to left eye x 4 days/
- Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #
- Benadryl 25 - 99238 K80. N30. H10. E87. E11. Z79. I A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive check-up and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam? - Preventive medicine, established patient Response Feedback: Rationale: The mother "takes her 2-year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc. HISTORY OF PRESENT ILLNESS A 73-year-old man who is a veterinarian is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the
LUNGS: The lungs are diminished breath sounds, though no crackles are noted. CARDIAC: Cardiac exam is tachycardic, no distinct murmurs appreciated. Extremities show no significant edema. ABDOMEN: Abdominal exam is soft. No masses or tenderness. No hepatosplenomegaly. EXTREMITIES: No clubbing or cyanosis. Bilateral lower. No misalignment or tenderness. Based on the 1995 documentation guidelines, what is the level of exam? - Detailed Response Feedback: Rationale: Organ Systems: Constitutional, Skin, Respiratory, Cardiovascular, Gastrointestinal, and Musculoskeletal. There are six organ systems examined with detailed documentation. The level of exam is Detailed. Subsequent Hospital Visit LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12. IMPRESSION:
- Severe exacerbation of CHF
- Poorly controlled HTN
- Worsening ARF due to cardio-renal syndrome PLAN:
- Increase BUMEX to 2 mg IV Q6.
- Give 500 mg IV DIURIL times one.
- Re-check usual labs in a.m. Total time: 20minutes. What is the level of medical decision making? - High Response Feedback: Rationale: Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.
ED Visit: Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the chest x-ray, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD which is stable and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ED, to go directly to the unit. What is the level of medical decision making? - High Response Feedback: Rationale: New problem to examiner, additional workup - dialysis (four points); Labs, EKG, and X-ray reviewed (three points); risk is High (chronic illness posing a threat to life). The medical decision making is High. Mrs. Standerfer's family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction at the nursing home. She has not experienced any chest pain, Dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physician takes her BP both supine and standing, and notes her pulse and temperature. A detailed exam of the eyes, ears, nose, and throat is performed along with a detailed neurological exam. The physician orders blood work to determine if her electrolytes are out of balance again. What is the appropriate E/M code for this visit? - 99309 Response Feedback: Rationale: For subsequent nursing facility care codes, 2 of three key components must be met. History - (Extended), ROS (Extended), PFSH (1-Pertinent) = Detailed
