2023_MAT_CPMA_PA-WB_Student_Ch2

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Practical Application Workbook Medical Auditing Training: CPMA ® 2023
ii www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations. US Government Rights This product includes CPT ® , which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 330 N. Wabash, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. AMA Disclaimer CPT ® copyright 2022 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT ® , and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT ® is a registered trademark of the American Medical Association. Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially, they are as one would find them in a coding setting. © 2022 AAPC 2233 South Presidents Dr. Suite F, Salt Lake City, UT 84120 800-626-2633, Fax 801-236-2258, www.aapc.com Updated 10262022. All rights reserved. Print ISBN: 978-1-646317-875 CPC ® , CIC ® , COC ® , CPC-P ® , CPMA ® , CPCO ® , and CPPM ® are trademarks of AAPC.
2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 27 Chapter 2 You are conducting an audit of medical records for emergency department physicians. Case 1 Emergency Department Visit Re: Amy L. Jones Date of Service: January 4, 20XX MR #: 200-1 ED Prescriptions Medication Sig by mouth 2 (two) times daily Dispense Auth. Provider Tramadol (UL TRAM) 50 mg tablet Take 1 tablet (50 mg total) by mouth every 6 (six) hours as needed for pain. 20 tablets Christopher Campbell, MD Discharge Instructions received: None Follow-up Information Follow up with Curtis Cooper Details in 3 days Comments Contact Info 106 E Broad Street P.O. Box 2024 Savannah GA 31401·2917 912-527-1000 Memorial University Medical In Center Emergency Department In 2 days 4700 Waters Avenue Savannah Georgia 31403 912·350·8113 Patient Follow-up information Edit Trail: None ED Decision to Admit: None ED Physician Notes History of Present Illness Patient Identification: Amy L. Jones is a 31-year-old female. History/Exam limitations: none. Chief Complaint: Neck skin infection HPI: Onset of symptoms was 1 day ago, with gradually worsening symptoms since that time. Symptoms include erythema and swelling. Patient reports no fever, nausea, or vomiting. There is not a history of trauma to the area. Has taken over the counter medication with minimal relief.
28 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Past Medical History Diagnoses l Heart murmur of newborn l Anxiety attack Family History Mother deceased. Father had colon cancer. No current facility-administered medications for this encounter. Current Outpatient Prescriptions Medication Sig Dispense Refill Albuterol (PROVENTIL HFA; VENTOLIN HFA) 90 mcg/actuation inhaler Inhale 2 puffs into the lungs every 4 (four) hours as needed for Wheezing. 1 Inhaler 0 Azithromycin (ZITHROMAX) 250 MG tablet Take 1 tablet (250 mg total) by mouth daily. Take first tablets together, then 1 every day until finished. 6 tablets 0 Brompheniramine-pseudoephedrine-DM 230-10 mg/5 mL Syrup Take 10 mls by mouth every 4 (four) hours. 1 Bottle 0 Dimenhydrinate (DRAMAMINE) 50 MG tablet Take 50 mg by mouth nightly as needed. DIPHENHYDRAMINE HCL. (BENADRYL ORAL) Take by mouth DM/P- EPHED/ ACETAMINOPH/ DOXYLAM (VICKS NYQUIL ORAL) Take by mouth Naproxen sodium (ALEVE) 220 MG tablet Take 220 mg by mouth 2 (two) times daily with meals. Naproxen sodium (ANAPROX DS) 550 MG Tablet Take 1 tablet (550 mg total) by mouth 2 (two) times dally with meals. 14 tablets 0 Allergies: NKDA Allergen Reactions Flagyl (Metronidazole) “It gives me shakes really bad” Paxil (Paroxetine Hel) “shake really bad and jerk. “ Penicillins Hives Social History Marital Status: Married Spouse name: N/A Number of Children: N/A Years of Education: N/A Occupational History: Not on file Social History Main Topics
2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 29 Chapter 2 Smoking Status: Current Every Day Smoker- 1.0 Packs/day Types: Cigarettes Smokeless tobacco: Not on file Alcohol Use: No Drug Use: No Sexually Active: Not on file Review of Systems constitutional: otherwise negative ENT: otherwise negative musculoskeletal: otherwise negative neurovascular: otherwise negative skin: otherwise negative Physical Exam BP 143/78, Pulse 98, Temp 97.1 (Oral), Resp. 20, Ht 1.702 m, Wt 80.6 kg, BMI 27.82 kg/m2, Sp02 99%, LMP 01/04/20XX 11 Constitutional: Oriented, Alert, in NAD, well developed, good hydration. Eyes: Conjunctivae and lid normal. Neck: Negative for ecchymosis, hematoma, neck stiffness and tracheal deviation. Cardiovascular: Normal cardiovascular function, no JVD; distal pulses normal. Respiratory: Normal respiratory function, normal respiratory effort/excursion, normal retraction; No rales, rhonchi, or wheezes. Chest: Movement symmetrical, expansion normal. Musculoskeletal: Normal exam, joints without deformity. Normal gait. Skin: Normal, mucosal membranes moist. A soft mobile subQ mass, a subcutaneous mass consistent with a cutaneous abscess, fluctuance, tenderness. All of this located in the skin of the neck just inferior to the right ear. Neuro: DTRs normal, normal motor and sensory function. Psychiatric: No abnormalities of mood or affect, alert and oriented person, place, and time, memory intact. ED Course This patient has an abscess on the neck that requires incision and drainage. Incision and drainage was performed. The patient will be discharged with antibiotic Amoxicillin as well as follow-up care. Strict return precautions have been discussed. At this time there are no signs or symptoms of systemic infection. I do not think the patient requires IV antibiotics. There are no signs of SJS, TEN, purpura, petechiae and I do not suspect a sepsis syndrome, based on the patient’s presentation today. Procedure: I&D abscess Informed Consent: Red rules followed and time out occurred. Patient has acknowledged the risks and benefits and has consented to procedure. Procedure: Complicated incision and drainage of pus. Blunt dissection to break up loculations. A drain was sutured into place and the wound covered with gauze. Anesthesia: Local infiltration of Lidocaine 1% with epinephrine, Dressing: Sterile Electronically signed by Jeremiah Shullo, MD on 01/04/20XX at 12:38 PM Sign off status: Completed
30 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 2 Emergency Department Coding Fee Ticket Patient Name Amy L. Jones Medical Record Number/Account Number 200-1 ED Physician Jeremiah Shullo, MD Insurance Company Health 123 Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/4/20XX AAPC Hospital 23 99284 L02.11 25 1 $350.00 1/4/20XX AAPC Hospital 23 10060 L02.11 1 $120.00 Total $470.00 1. The documentation supports what ED E/M and procedure codes? A. 99283, 21501 B. 99283-25,10061 C. 99283-25, 69000 D. 99284-25, 10060 2. When meeting with this physician post audit, what issue needs to be addressed? A. The audit was documented and billed correctly. B. The emergency department E/M visit should not be reported separately as it is included in the procedure. C. Documentation supports a lower ED E/M level than what the physician reported. D. The diagnosis reported is incorrect. Case 2 Emergency Department Visit Re: Shawn M. Jones Date of Service: January 2, 20XX MR # 200-2 Patient Identification: Shawn M. Jones is a 10-month-old male Chief Complaint: Patient presents with fall and hitting his head History of Present Illness : Mother was sleeping with patient in her bed and woke up when she heard a thud to find patient on the floor. Mother states patient started to cry immediately and rubbing his head. Patient is laughing and acting age appropriate in triage. According to mother, there have been no other issues. She says that the bed was higher than usual and the child fell onto a wood floor; did not notice any bruises on skin or signs of other injury. No vomiting.
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