Patient Delaney Brooke Question & Answer Guide (With Explanation)

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Original Question

Patient: Delaney Brooke Date of Birth: 09/14/19xx Date of Service: 07/12/20xx This well-groomed, established patient presents to renew her BP medication and have blood work done. The patient has bilateral knee pain, tender and swollen. The patient was doing yard work and states she was on her knees too long. Patient denies shortness of breath or chest pain. Height is 5’2″, weight 125 lbs.; BP is 140/70; heart rate is 72. Head and neck are within normal limits. Chest is clear. CVS is normal. Knee pain bilaterally, which appears swollen. Assessment and Plan: HTN, benign, bilateral knee pain. Hydrochlorothiazide, 50mg, once a day, #100; and Calan SR 240 mg, once a day, sample was given. The patient will return for EKG next week. Also, Voltaren, 75mg once bid, sample given. The patient is noncompliant. She is not exercising and not diet- ing. Advised patient to continue low-fat diet and return in 1 month. Martin Smythe, MD Compliance Medical Group Charge Ticket Patient Name Medical Record Number/Account Number Physician Practice Name Insurance Company Date of Birth Delaney Brooke 174389 Martin Smythe, MD Compliance Medical Group Medicare Part B 09/14/19xx Date of Service Place of Service CPT Code Diagnosis Code(s) Modifier Quantity Fee 07/12/20xx 11 99213 M25.561 M25.562 1 95.00 1) Choose a MDM Level (straightforward, low, moderate, or high) 2) Choose an E/M code as applicable. 3) List any other applicable billable services (CPT code(s)) 4) List any and all Diagnosis code(s) 5) Make a decision – Is the charge ticket accurate per your audit? Why? Why not?

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