Using Coding Techniques Question & Answer Guide (With Explanation)
This question tests key academic concepts commonly covered in coursework.
What This Question Is About
This question relates to using coding techniques and requires a structured academic response.
How to Approach This Question
Start by identifying the main issue, then apply relevant academic frameworks.
Key Explanation
This topic involves using coding techniques. A strong answer should include explanation, application, and examples.
Original Question
Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate procedure code(s) along with any modifier(s), if appropriate. DERMATOLOGY ASSOCIATES OF CAULDWELL 469 EPIDURAL LANE • SUBQUE, FL 32711 • 407-555-7539 PATIENT: BEGAMMO, SHENIKA ACCOUNT/EHR #: BEGASH001 HISTORY OF PRESENT ILLNESS: This 64-year-old Middle Eastern female presents to the emergency room with a 10-year history of a progressively enlarging ulcer on the right arm. The lesion has never been biopsied or treated. She has not seen a physician for any complaint for 20 years. The patient has hidden the lesion from her family until it was noticed 2 days prior to her presentation by her son, who brought her to the hospital. She denies pain or decreased range of motion of the right arm. She denies systemic symptoms. PAST MEDICAL HISTORY: Patient denied any medical conditions. MEDICATIONS: None PHYSICAL EXAMINATION: A large ulcer is present on the right arm, ulcerated to muscle, with rolled, infiltrated borders. There is a palpable 2-cm right axillary lymphadenopathy. A 2.5 × 1 cm slightly brown, telangiectatic, irregularly shaped plaque is present on the right back. LABORATORY DATA: CBC: WBC: 6.0 (3.8-9.8); Hgb: 2.9 (12.1-15.1); Hct: 10.6 (36.1-44.3); Plt: 445K (140- 440K); MCV 52.7 (74-115) CMP: Sodium: 137 (135-145); Potassium: 3.9 (3.3-4.9); Chloride: 106 (97-110); Bicarbonate: 21 (20-28); Creatinine: 0.8 (0.6-1.4); BUN: 10 (8-25); Glucose: 124 (65-199); Calcium, total 9.2 (8.5-10.2 mg/dl) Plasma protein: 7.8 (6.5-8.5); Albumin: 3.1 (3.6-5.0); Bili: 0.4 (0.3-1.1); Alk Phos: 82 (38-126); AST: 13 (11-47); ALT: 25 (7-53); PT/INR: 1.31 (0.8-1.2): PTT: 32.8 (23-35) RADIOGRAPHY: Chest, single view, and right humerus, 2 views, radiographs revealed multiple poorly defined nodules over the right lung field, slightly enlarged right hilar shadow, with normal left lung field and cardiac silhouette and no effusion. A large soft tissue defect was present over the proximal humerus. DX: Basal cell carcinomas, metastatic PROCEDURE: Surgery to remove carcinoma on humerus to be followed by chemotherapy [Cis-platinum] Suzanna A. Maconi, MD Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2.
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