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Date
Dec 6, 2023
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UNIT 7 QUIZ HELP - practice
Cpt Coding (Rochester Community and Technical College)
Studocu is not sponsored or endorsed by any college or university
UNIT 7 QUIZ HELP - practice
Cpt Coding (Rochester Community and Technical College)
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Dr. Modesta spent 2½ hours evaluating Carolina Tanner upon her admission into the
ICU.
Overall Feedback:
99291: Index>evaluation and management>critical care>first 30-74 minutes
99292x3: Index>evaluation and management>critical care>each additional 30 minutes
2.5 hours = 150 minutes – 74 minutes = 76 minutes / 30 minutes = 2.53 or 3
Raymond Johnston, a 3-year-old male, showed no sign of improvement after 5 days of
antibiotic therapy, so Dr. Servina admits Raymond into the hospital with a diagnosis of
bacterial pneumonia. At Raymond’s admittance, his vitals showed a temperature of
38.3°C (101°F), with a mild rash on his torso. The following day, Dr. Servina performed
a problem-focused history and examination with MDM of low complexity. Code Dr.
Servina’s visit on the second day.
Overall Feedback:
99231: Index>evaluation and management>Hospital>subsequent hospital care
Problem-focused history
Problem-focused examination
MDM of straightforward or low complexity
Royce Onoton’s legs have finally healed to the point that he can be discharged from the
nursing facility, where he has been for the last 6 weeks. Before he can go home, Dr.
Zandi comes in for the final examination and to provide continuing care instructions to
Royce’s wife, who will be caring for Royce at home. Dr. Zandi prepares the discharge
records and writes a prescription for Royce for pain. This whole process takes Dr. Zani
about 45 minutes to complete.
Overall Feedback:
99316: Index>evaluation and management>nursing facility>discharge day management; more than
30 minutes
Before beginning a series of treatments, Anna Hogan came to the Diagnostic Imaging
Center for a metabolic evaluation PET scan of her brain.
78608: Index>positron emission tomography>brain>metabolic evaluation
Howard Shires, a 78-year-old male, was diagnosed with advanced Alzheimer’s disease
about 1 year ago and has been in this facility for approximately 10 months. He was
seen today by the nursing facility’s physician, Dr. Bowyer, over concern of the
development of urinary and fecal incontinence, as well as a number of other medical
problems that have appeared to increase in severity. In addition to the detailed interval
history, the physician spoke with family members and the nursing staff. Then, Dr.
Bowyer reviewed the patient’s record to create an extended history necessary for an
extended review of systems (ROS). Dr. Bowyer performed a comprehensive physical
exam to assess all body systems. Afterward, he wrote all new orders due to the
dramatic change in the patient’s physical and mental condition. A new complex
treatment plan was created.
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Overall Feedback:
99310: Index>evaluation and management>nursing facility>subsequent care
Comprehensive interval history
Comprehensive examination
MDM of high complexity
Dennis Lederrick, a 39-year-old male, had surgery on his left foot. To enable him to take
a shower safely, Dr. Willrodt gave him a tub stool to sit on.
Overall Feedback:
E0245: Index>bathtub>stool
Shirley Loveichelle, an 82-year-old female, was having trouble eating for such a long
period of time that she was exhibiting signs of malnutrition. Therefore, Dr. Milliner
ordered enteral formula (Ensure) to be administered through a feeding tube at 500
calories per day. Code for the nutritional supplement only.
Overall Feedback:
B4150 x 5: Index>enteral>formulae>5 (100 x 5 = 500 calories)
Edith Shapin, a 24-year-old female, is pregnant for the first time and is at approximately
11 weeks gestation. She is brought into the diagnostic center for a fetal biophysical
profile with nonstress testing.
Overall Feedback:
76818: Index>fetal nonstress test>ultrasound
Dr. Sloan provided a complete set of dentures, maxillary and mandibular, for Cheryl
Delaney.
Overall Feedback:
D5110: Index>dentures>maxillary
D5120: Index>dentures>mandibular
Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of
medical problems. She was diagnosed 5 years ago with insulin-dependent diabetes
mellitus with complicating eye and renal problems. In addition, she suffers from
hypertensive heart disease with episodes of congestive heart failure. Her peripheral
vascular disease has worsened, and she can walk only a block before being crippled
with extreme leg pain. The patient reports that a new problem has surfaced: throbbing
headaches with radiating neck pain. Dr. Lunden and Zena thoroughly discuss her health
concerns and issues. In order to manage and investigate the multiplicity of problems,
Dr. Lunden takes a complete PFSH. A complete review of systems (ROS) is performed
and comprehensive physical exam is completed. Dr. Lunden has to take a multitude of
factors into consideration, as the patient’s problems are highly complex.
Overall Feedback:
99205: Index>evaluation and management>office or other outpatient services>new patient
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Comprehensive history
Comprehensive examination
MDM of high complexity
Maxine Zeigleman, newly diagnosed with metastatic lumbar spinal tumors, has been
referred to Dr. Appleton for the creation of a simple radiation therapy plan.
Overall Feedback:
77261: Index>radiation therapy>planning>simple
Premier Life & Health Insurance Company required David Harrison, a 39-year-old male,
to get Dr. Dijohn, his regular physician, to complete a certificate confirming that David’s
current disability prevents him from working at his regular job and makes him eligible for
disability insurance.
Overall Feedback:
99455-32: Index>evaluation and management>work-related and/or medical disability
Evaluation ~ append modifier -32 because it is a mandated encounter.
Muddy Hambaugh, a 27-year-old female with a history of bipolar disorder, was given an
injection IM of Thorazine, 45 mg. Code for the drug.
Overall Feedback:
J3230: Index>drug table>Thorazine>up to 50 mg
Petula Carter, a 4-day-old female, currently weighs 2,000 grams and requires intensive
cardiac and respiratory monitoring. This is her third day in the NICU, and Dr. Wadhwa
comes in to do his E/M of her condition.
Overall Feedback:
99479: Index>evaluation and management>low birth weight infant>subsequent intensive care, per
day, for the evaluation and management of the recovering low birth weight infant, 1,500-2,500 grams
Keith Pawley, a 34-year-old male, came to see Dr. Praylow, his dentist, for an implant-
supported porcelain crown on his back tooth.
Overall Feedback:
D6065: Index>dental>implants
Dr. Anderson works in a very small town in Ohio and travels up to 200 miles to see his
patients in the surrounding rural areas. His patient Brenda Viard gave birth at her home
the previous day to a 6-lb 3-oz baby girl, Alice Rose. Dr. Anderson sees Alice Rose for
the first time today, does a complete history and exam, and prepares her medical chart.
Alice Rose is a healthy newborn.
Overall Feedback:
99461: Index>evaluation and management>newborn care>initial care, per day, for evaluation and
management of normal newborn infant seen in other than a hospital or birthing center
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Daniel Hair, a 56-year-old male with end-stage renal disease (ESRD), was fitted for a
reciprocating peritoneal dialysis system. Code the supply of the equipment.
Overall Feedback:
E1630: Index>reciprocating>peritoneal dialysis system
Sandra Lewis, a 55-year-old female, has been experiencing pain in her lower left back
that wraps around to her inner thigh. Dr. Janson does a renal ultrasound, limited, real
time with image documentation.
Overall Feedback:
76775: Index>ultrasound>retroperitoneal
Martha Lightfood, an 82-year-old female, was brought into Dr. Morrison’s office by her
daughter because Martha was complaining of a sharp pain in her chest. After a negative
EKG, Dr. Morrison had a quantitative differential pulmonary perfusion and ventilation
study performed, which confirmed a pulmonary embolism. Martha was taken
immediately by ambulance to the hospital. Code the quantitative differential pulmonary
perfusion and ventilation study only.
Overall Feedback:
78598: Index>perfusion>imaging>pulmonary>quantitative differential pulmonary perfusion and
ventilation including imaging when performed
Jamie Farmer, a 32-year-old male, goes to his family physician, Dr. Mitchell, for a
tetanus shot after stepping on a rusty nail at the beach. While there, he asks Dr. Mitchell
to look at a cut on his left hand. Dr. Mitchell examines the wound and tells him to keep
the wound clean and bandaged. Dr. Mitchell documents a brief HPI and performs a
limited exam of the left hand, MDM straightforward. Code only the E/M.
Overall Feedback:
99212-25: Index>evaluation and management>office or other outpatient services>established
patient ~ append modifier -25 because patient came in for the tetanus shot and physician also
evaluated a cut on hand.
Problem-focused history
Problem-focused examination
MDM of straightforward complexity
Tom Seihill, a 23-year-old male, was admitted into the hospital 2 days ago for bronchitis.
While in the hospital, Tom requested that his family physician, Dr. Selbiger, perform a
circumcision, so Dr. Selbiger called in Dr. Wacker, a urologist, for a consultation. Dr.
Wacker discussed the request with Tom and took a brief history and performed a limited
genitalia examination. Afterward, Dr. Wacker made a straightforward decision and
recommended that Raymond have the surgical procedure done at a later date as an
outpatient procedure. Code for Dr. Wacker’s services.
Overall Feedback:
99251: Index>evaluation and management>consultation>inpatient consultation>new or established.
Problem-focused history
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Problem-focused examination
MDM of straightforward complexity
William Browne, a 15-year-old male, is brought into Dr. Jenkins’s office with severe right
leg pain. Dr. Jenkins takes x-rays of his right femur, AP and PA, to determine whether or
not Bill’s leg is fractured.
Overall Feedback:
73552-RT: Index>x-ray>femur>2 views
Dr. Harrington provided care plan oversight services for Verniece Dantini, one of her
patients at the Bracker Assisted Living Center. It took her 20 minutes.
Overall Feedback:
99339: Index>evaluation and management>care plan oversight services>15-29 minutes
Roberta Henthorne, a 52-year-old female, was recuperating from surgery to repair a
complex fracture of her tibia and a compound fracture of her ankle. To help her be more
comfortable, Dr. Locklear ordered a fixedheight hospital bed, without side rails and with
a mattress, for her to use at home. Code for the DME only.
Overall Feedback:
E0290: Index>hospital>bed
Owen Unger, a 19-month-old male, is admitted to the hospital by his pediatrician, Dr.
Curtis, after a chest x-ray confirmed the child has pneumonia. Dr. Curtis and Mrs.
Unger, Owen’s mother, discuss the child’s fever, cough, and diarrhea. Mrs. Unger
provides a pertinent PFSH. An extended problem-focused ROS is completed and an
extended examination of the cardiovascular and respiratory systems is performed. The
course of treatment planned by Dr. Curtis is straightforward as the child’s condition is of
low severity.
Overall Feedback:
99221: Index>evaluation and management>hospital>initial hospital care>new or established patient
Detailed history
Detailed examination
MDM straightforward or low complexity
Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated
around her trunk. She was also suffering with spastic muscle weakness. Dr. Maxwell
ordered a radioisotope bone scan of Jonelle’s lumbar spinal area. The scan identified a
metastatic invasion of L1–L3.
Overall Feedback:
78300: Index>nuclear medicine>diagnostic>bone and joint>imaging>limited area
Carl Gadsden, a 66-year-old male, was diagnosed with intrinsic laryngeal cancer,
supraglottic T1 tumor. With the tumor confined to one subsite in the supraglottis, Dr.
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