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Original Question

Provide an example of when you would use modifier 25; what type of codes does it go on Provide an example of when you would use modifier 59; what type of codes does it go on Provide an example of when you would use modifier 26 Provide an example of when you would use modifier TC If documentation supports billing 2 codes, and CCI edits shows a 0 indicator, how do you bill? Give an example of pathology codes 88304 and 88305 What ICD10 diagnosis code is used for a well child visit w/o abnormal findings (>28 days)? _____________ Adult physical? ___________ A 55 year old female has a lesion on her back. The area excised is 3 cm in diameter. A layered closure is required to close the defect. The pathology report indicates it is malignant melanoma. CPT _________ ___________ _____________ ICD10 DX ___________ A 40 year old male is experiencing seizures. A CT exam of the brain was performed at the hospital. It was interpreted by Dr. Johnson, a local radiologist, as generalized idiopathic epilepsy. Code Dr. Johnson’s services. CPT ____________ ICD10 DX ______________ A patient came to the office today for her allergy injection. You billed a 99213 and the allergy injection. Would you expect the claim to process or deny? Justify. A patient insists on having a bone density test performed before age 50 just to see if her running is helping her bone mass. How could you determine if this service would be covered by her insurance or not? Which pathology code would you use for: Gallbladder _____________ Biopsy of testicle _____________ Colorectal polyp ________________ Case 1 Patient: Brock Jones Brock is a 18M male here for well child visit. He has been seen by me since birth. Medical, surgical, family and social history reviewed and updated today. Interval History: No pertinent changes Parental Concerns: None Physical Exam Findings: GENERAL: alert, active, in no acute distress SKIN: clear, no rash, abnormal pigmentation or lesions HEAD: normocephalic EYES: PERRL, EOMI, light reflex is symmetric and no eye movement on cover/uncover test EARS: external canals clear, TM’s pearly gray NOSE: clear, no discharge or congestion OROPHARYNX: clear, moist mucous membranes, poor dentition with cavities noted.no oral lesions NECK: supple, no masses, no thyromegaly, full ROM LYMPHATIC: no adenopathy LUNGS: clear to auscultation, no rales, rhonchi, wheezing, or retractions CARDIOVASCULAR: regular rate and rhythm, normal S1 & S2, no murmurs, normal pulses ABDOMEN: normal bowel sounds, nontender, nondistended, no hepatosplenomegaly, no masses GU: normal male Tanner staging for age, external genitalia, testes descended bilaterally, no hydrocele, no hernia MUSCULOSKELETAL: full ROM, normal strength, symmetric extremities with no deformities, no scoliosis NEUROLOGICAL: normal tone throughout with normal and symmetric reflexes for age PSYCHIATRIC: normal mental status with normal affect, judgement, memory and mood Assessment: Well Child Plan: Immunizations: Up-to-date on routine immunizations. Additional vaccines requested by parent. HEPATITIS A VACCINE, PED/ADOL, IM 2 dose schedule INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE SPLIT 6-35 MONTHS Briefly discussed going to dentist CPT ICD10 __________________ __________________ __________________ __________________ __________________ __________________ __________________ Case 2 Patient: Margaret Mosh SUBJECTIVE: Margaret is an 87-year-old female patient of mine seen in the clinic today with complaints of “cyst on her tailbone area.” She reports it has been there for about a week and the pain is now radiating down her left leg. It seems to have gotten larger, more red, and extremely painful to sit. She has been applying heat to the area. She feels as if this is definitely getting worse. She has been afebrile. Her medical and surgical history along with medications and allergies were reviewed and are unchanged. OBJECTIVE: A pleasant 87-year-old female in no distress. Pulse is 56. Temperature 98 degrees. Blood pressure 130/70. Examination reveals a fluctuant abscess on the tailbone. There is surrounding erythema. There is swelling. The area was anesthetized with lidocaine and cleansed with Betadine. Incision and drainage was done with great results. It was packed and dressed. ASSESSMENT: Incision and drainage, abscessed pilonidal cyst. PLAN: She will remove the packing tomorrow. In the meantime recommended antibiotic ointment and watching for further infection. Went over all symptoms of an increasing infection with her. I did place her on Keflex 500 mg b.i.d. for seven days. She is certainly going to follow up with any concerns at all or if this not completely resolving. CPT ICD10 __________________ __________________ __________________ Case 3 Patient: Harry Smythe PRE-OP DIAGNOSIS: Chronic diarrhea POST OP DIAGNOSIS: Normal colon. PROCEDURE: Colonoscopy. ANESTHESIA: Conscious sedation with 0.4 mg of atropine, 5 mg of Versed, and 100 mcg of fentanyl and 40 mg of Diprivan. COMPLICATIONS: None. OPERATIVE DESCRIPTION: The patient was prepped with GoLYTELY and describes a good prep. We reviewed the possible risks and complications of colonoscopy and conscious sedation, and she agreed to proceed. The patient is taken to the endoscopy suite and placed in the left side-lying position, given conscious sedation, appropriately monitored, and then an Olympus 170-cm videocolonoscope was passed through the anorectal canal and advanced around the colon. We had some difficulty getting the scope past the mid ascending colon and into the cecum. With a little abdominal manipulation, I was able to do that. The cecum was then well visualized. On withdrawal, the cecum and ileocecal valve are normal. The ascending colon is normal. The transverse colon is normal. The descending colon is normal except for a few scattered diverticula in the sigmoid colon. The scope is reversed on itself, and the rectal ampulla and the internal rectal shelf look normal. There are prominent hemorrhoidal veins. Otherwise the anus was normal to inspection, both inside and out, and digital palpation inside and out. CPT ICD10 __________________ __________________ Case 4 Patient: George Hoppe Physician ordered a CBC with automated differential, Basic Metabolic panel, Lipid panel, and SGOT for hypertension & hyperlipidemia CPT ICD10 __________________ __________________ __________________ __________________ __________________ __________________ CASE 5 Patient: Amber Stone Amber is a 30-year-old female, gravid 4, para 2, now at 40 weeks gestation, admitted for induction of labor, secondary to term pregnancy with positive Group B Strep carrier status complicating the pregnancy. Labor was augmented with Pitocin and artificial rupture of the membranes once penicillin was administered. Antibiotics were administered for 4 hours prior. An epidural was administered for pain. The cervix reached complete dilation at 1010 hours. There was excellent maternal effort with pushing. The head was spontaneously delivered from the OA position over intact perineum at 1020 hours. Mouth and nose were suctioned. The body of the infant was then delivered and placed on the mother’s abdomen. Mouth and nose were resuctioned and cord was clamped and then cut by the father of the baby. No resuscitation was needed. Apgars were 9 and 10. Placenta was spontaneously delivered. There were no posterior perineal lacerations. There was a superficial laceration extending upward on the right labia that was repaired using 3-0 Vicryl. Estimated blood loss was 300 cc. Mother and baby are in stable condition.(She has received her prenatal care and will receive postpartum care by same physician) CPT ICD10 __________________ __________________ __________________ __________________ If this were a normal pregnancy, what diagnosis code would be used? ___________ Case 6 PROCDURE: Steroid injection INDICATIONS: Left shoulder subacromial bursitits PROCEDURE: This procedure was done in the procedure area in the hospital. After obtaining consent, the area of the left shoulder was prepped in the usual fashion with Betadine. 6 cc of 1% lidocaine with 1 cc of Kenalog was injected in the left subacromial bursa without difficulty. The patient tolerated the procedure well without immediate complications. There was moderate relief of pain afterward. The patient was advised to call me if she gets any signs of infection, such as fever, chills, erythema, or swelling. CPT ICD10 __________________ __________________ Case 7 Patient: Dorothy Green Procedure: Bilateral digital diagnostic mammogram with CAD Diagnosis: Patient had breast cancer, treated with lumpectomy in 2012 Findings: Current study was also evaluated with computer aided detection (CAD). No significant masses, calcifications or other findings are seen in either breast. Impression: There is no mammographic evidence of malignancy, A 1 year screening mammogram is recommended. CPT ICD10 __________________ __________________ __________________ __________________

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