Course BC3030X: Billing and Coding Applications with Simulations (12-17-2012) Section 8
Test Week 2 - Coding Applications Test
• Question 1
Needs Grading LOCATION: Outpatient, Hospital
PATIENT: Kim Fields
PHYSICIAN: Gregory Dawson. MO
ENTRANCE DIAGNOSIS: Dyspnea on ascending hills and stairs. Frequent wheezing and productive cough in a patient with a 0.75-pack-year smoking history; quit 1 year ago. Gave good consistent effort.
I. Baseline spirometry is normal with maybe a hint of concavity towards the volume axis at the terminal portion of the curve. The spirometry does show only a 61%
FEF2S-7S indicating peripheral dysfunction, i.e., mild COPD/emphysema.
II. Baseline FEVI of 3.02. which was 84% of…show more content…
The report notes that a separate procedure was done to take cytologic brush washings which is coded as a separate procedure with 31622 and adding a -59 modifier.
The diagnosis is hemoptysis due to lesion on the lung. This is coded as 239.1 • Question 3
Needs Grading This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.
PHYSICIAN:Gregory Dawson, MDATTENDING
PHYSICIAN:Gregory Dawson, MDPREOPERATIVE
DIAGNOSIS:Acute respiratory failurePOSTOPERATIVE
DIAGNOSIS:Acute respiratory failurePROCEDURE
INDICATIONS FOR SURGERY: The patient is a 62-year-old Caucasian male who has pneumonia. The patient has been on a ventilator for over 2 weeks and appears to require long-term ventilator. The patient is undergoing tracheostomy for this purpose.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual manner. A vertical incision was made along the anterior border of the neck. The patient has a very short neck; therefore, it made the operation much more difficult. Dissection was carried down to the trachea using Bovie cautery. The patient had multiple small vessels in the operative area that had to be either bovied or ligated with interrupted 3-0 silk sutures or stick tied with 3-0 silk sutures. After completion of the