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Worth 4 points total 15. Scenario 1 HISTORY The patient is a 32-year-old male who presented with a red-colored, 2 cm conical-shaped nodule on the back of his neck. He claims it grew in size within the past 24 hours. He had a boil in the same spot 6 months ago and it required removal. Fluctuant was felt with palpation. Severe pain was noted with slight pressure. He denies a history of diabetes mellitus or use of immunosuppressive drugs. Due to the excessive pain and reoccurrence of this furuncle, incision and drainage was recommended. PROCEDURE The patient signed the consent form and was taken to the procedure room. Using sterile technique, the posterior neck was prepped, draped and anesthetized with 1% lidocaine. The lesion was lanced resulting in rapid resolution and reduction of pain. Pressure was held on the site with minimal bleeding noted. Betadine ointment was applied, and it was then covered with gauze and secured with tape. A sample of the fluid was sent to the laboratory. The patient will return in 3-5 days for a wound check. ICD-10-CM: CPT: Worth 4 points total 16. Scenario 2 HISTORY The patient is a 5-year-old female who was practicing for a ballet recital. As she was completing a pirouette, she twisted her knee and fell to the ground. To ensure that permanent damage had not occurred, the orthopedist felt a diagnostic arthroscopy of her knee should be done. PROCEDURE After full explanation of the procedure, the parents signed the consent form. The patient was escorted into the procedure room by her parents where she was sedated. The incision site was prepped and draped. Injection of a saline solution distended the joint. The arthroscope was advanced into the joint through a small skin incision. The exploration revealed a complex lateral meniscus tear of the right knee. A meniscal repair was then scheduled. The arthroscope was removed. Minimal bleeding was noted and the site was covered with sterile dressing. The patient tolerated the procedure well and was taken to the operating room for further care. Note: External cause code(s) apply, but external cause status is not necessary. ICD-10-CM: ICD-10-CM: CPT: Worth 6 points total 17. Scenario 3 HISTORY This very pleasant 69-year-old male suffered an embolic stroke 11 months ago. He has been in an assisted-care facility for the past 10 months. Redness was noted in his right thigh extending to the toes. He complains of tenderness around the area and a dull, aching pain in his leg when walking that is not relieved with rest. There is also pain when raising his leg and flexing his foot. PROCEDURE Consent forms were signed, and a complete venous occlusion plethysmography of both legs was performed. Deep vein thrombosis of the lower right extremity was noted. Further review of his chart will determine treatment. A physical therapy consult will be ordered. ICD-10-CM: CPT: Worth 4 points total 18. Scenario 4 HISTORY The patient is a 12-year-old female who was at softball practice when she was hit in the nose with the softball while in the outfield. After 20 minutes, the team nurse was unable to control the bleeding. Her father then took his daughter to the emergency department. PROCEDURE After being admitted and consent forms signed, the physician determined her nose is negative for a fracture. The patient was diagnosed with epistaxis. Anterior, simple packing with gauze was inserted into the right nostril to apply constant pressure. The patient was advised to avoid touching or blowing her nose. The packing can be taken out slowly and gently within the next 6-8 hours. If bleeding persists, she should return to the emergency department or contact her physician. ICD-10-CM: CPT: Worth 4 points total 19. Scenario 5 PREOPERATIVE DIAGNOSIS Subdural hematoma. POSTOPERATIVE DIAGNOSIS Subdural hematoma. PRIMARY PROCEDURE BURR HOLE FOR EVACUATION AND DRAINAGE OF SUBDURAL HEMATOMA. BRIEF HISTORY The patient is a 16-year-old student. During cheerleading practice at her high school, she was standing on the top of a “human pyramid,” lost her balance and fell on her head hitting the right side. She immediately felt drowsy and confused. By the time the paramedics arrived, she complained of a unilateral headache on the right side. Pupillary dilation was ipsilateral to the injured side. At the hospital, the location of the hematoma was located by angiography followed by x-ray and a CT scan. PROCEDURE The consent form was signed by the parents, and the patient was taken to the operating room. She was anesthetized, and the right frontotemporal region was prepped and draped. A burr hole, using a rounded tip, was made into the skull. Immediate evacuation and decompression resulted. The patient’s vitals were stable, and she was discharged to the neurosurgeon for evaluation of a craniotomy. Note: External cause code(s) apply. ICD-10-CM: ICD-10-CM: ICD-10-CM: ICD-10-CM: CPT: Worth 10 points total 20. Scenario 6 PREOPERATIVE DIAGNOSIS Rectal prolapse. POSTOPERATIVE DIAGNOSIS Rectal prolapse. PRIMARY PROCEDURE ABDOMINAL PROCTOPEXY. PROCEDURE The patient was taken to the operating room and placed on the table in the supine position. After the induction of anesthesia by the general endotracheal technique, bilateral lower extremity pneumatic compression stockings were placed. A Foley catheter was placed, and a rectal tube was placed for subsequent irrigation and testing of the proctopexy procedure. After standard prep and drape, a midline celiotomy incision was created entering into the peritoneal cavity and subsequent exploration was without discovery of any pathology with exception of extreme laxity of the mesentery of the entire colon and a tremendous amount of redundant colon. Attention was then directed to the rectosigmoid region where peritoneal reflections were taken down bilaterally with specific identification and protection of both ureters. The peritoneal reflection was then divided in the caudad direction, and the rectosigmoid and rectum were mobilized from the sacral hollow utilizing a combination of sharp and blunt dissection. Once the rectum has been freed to the level of the tip of the coccyx, it was brought up under modest tension into the operative field and reflected to the patient’s left. An inverted T-shaped piece of Gore-Tex soft tissue patch was then fashioned and was subsequently secured to the sacral hollow up to the point of the sacral promontory utilizing a series of interrupted 0 Gore-Tex sutures. Subsequently the rectum was placed in mild tension within the span of 2 limbs of Gore-Tex soft tissue patch and subsequently encircled by those limbs. These were each then packed at multiple points to the rectum utilizing a series of interrupted 2-0 Prolene sutures placed in seromuscular fashion. Once the tacking procedure was done, the pelvis and retroperitoneum were irrigated with saline and evacuated. The rectum was then irrigated with saline placed via the rectal tube and was noted to expand easily within the confines of the noncircumferential Gore-Tex sling. The rectum was then evacuated. The midline fascia was then closed utilizing #1 Prolene suture in continuous running fashion. The subcutaneous tissue was irrigated, and the skin was closed with stainless steel clips. A sterile dressing was applied. Patient was aroused from his anesthetic, extubated in the operating room and transported to the PAR in stable condition. ICD-10-CM: CPT: Worth 4 points total 21. Scenario 7 PREOPERATIVE DIAGNOSIS Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage. POSTOPERATIVE DIAGNOSIS Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage. PRIMARY PROCEDURE 1. CONE BIOPSY. 2. ENDOCERVICAL CURETTAGE. 3. ENDOMETRIAL CURETTAGE WITH BIOPSY. FINDINGS AND PROCEDURE After the induction of adequate general endotracheal anesthesia, the patient was placed in the dorsal lithotomy position. Examination under anesthesia demonstrated a small cervix and uterus without any adnexal masses. The cervix was firm to palpation. The speculum demonstrated a cervix that was smooth and without lesions. Colposcopy was performed and was noted to be unsatisfactory. No lesions were seen. Cone biopsy was then performed with a sound in the cervix. This was difficult to accomplish due to the cervix being flush with the uterus. The cone biopsy was tagged at 12 o’clock. No cone tip was cut. Endocervical curettage was performed. Endometrial curettage was then performed. The uterus sounded to 4 cm, and scant tissue was obtained. Hemostasis was then assured. The Bovie was used to control any bleeding. Patient tolerated the procedure satisfactorily; however intraoperatively the patient did have an increased blood pressure that was controlled quickly with nadolol. The patient’s blood pressure then was stable at 120/60. Anesthesia: General endotracheal. Estimated blood loss: 10 mL. Intravenous fluids: 1600 mL. Lines: IV and arterial line. Urinary output during the procedure: 700 mL. Drains: None. Count: Correct. The specimens that were sent to pathology: (1) Cone biopsy, (2) endocervical curettage, (3) endometrial curettage. Urine was sent for cytology. ICD-10-CM: CPT: CPT: Worth 6 points total Use your ICD-10-CM and CPT to determine accurate diagnoses (no external cause codes apply) and E/M codes. 22. Scenario 8 Bobby was playing softball when he misjudged the ball, and it hit him in the nose. He was taken to the emergency department at the hospital. Dr. Jones performed a detailed history and an expanded problem focused exam, with a moderate complexity medical decision making. Bobby was diagnosed with a nasal contusion and released. ICD-10-CM: E/M: Worth 4 points total 23. Scenario 9 Chester has an appointment for a follow up on his asthma. He is wheezy and having labored breathing. His established physician performs an expanded problem focused history and exam. No further treatment is recommended. Chester is to return in 3 months to follow up on his asthma. ICD-10-CM: E/M: Worth 4 points total 24. Scenario 10 Kathy, a 33-year-old established patient, sees Dr. Owens in her office for what she thinks is a sinus infection. Her history is documented as problem focused, while the exam is expanded problem focused with a decision making of moderate complexity. Her diagnosis is acute maxillary sinusitis. ICD-10-CM: E/M: Worth 4 points total 25. Scenario 11 Franco, a new patient to the office, went to see Dr. White complaining of pain in his upper arm. He had been experiencing some muscle weakness and had difficulty getting out of the bathtub. Franco also has a rash and fever. Dr. White documents a detailed history and exam because of Franco’s past medical history of rheumatoid arthritis. The medical decision making was of moderate complexity. Dr. White diagnosed Franco with infective myositis in the upper arm. ICD-10-CM: E/M: Worth 4 points total 26. Scenario 12 Jerry called his doctor when he had a sudden onset of nausea, abdominal cramping and bloody diarrhea with mucus. Dr. Smart had Jerry come to the office right away, and Dr. Smart documented an expanded problem focused history and performed a detailed examination. The medical decision making was moderate complexity. Dr. Smart determined Jerry had noxious food poisoning. Jerry was sent home to rest. Dr. Smart told Jerry that the symptoms should subside within 5-7 days. Jerry was told to watch for dehydration and to call immediately if he felt he was not getting any better. ICD-10-CM:

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