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8.4. The following documentation is from the health record of a 66 year old male patient. Outpatient Hospital Department Services History: This is a 66 year old male who had a coronary artery bypass graft in February. He did well. He was discharged home. Sometime after that when he was home, he had two days of black stools. He mentioned it to the nurse, but I’m not sure anything was done about it. He has not had any other evidence of hematemesis, melena, or hematochezia but was feeling rather weak and fatigued. He had blood work done that showed a hemoglobin of 5.7, hematocrit of 20.9, and MCV of 80. Serum iron of 8.2 percent saturation. No indigestion or heartburn. No abdominal pain of any kind. No past history of anemia or GI bleed. Past Medical History: General health has been good Allergies: None known Previous Surgeries: Coronary artery bypass graft Medications: At the time of admission include Glucotrol, Lasix, potassium, and aspirin. Review of Systems: EndocrineL He does have diabetes controlled with medication. Cardiovascular: History of coronary artery disease with coronary artery bypass graft. No recent symptoms of chest pain or shortness of breath. Respiraroty: No chronic cough or sputum production. GU: No arthritic complains or muscle weakness. Neuropsychiatric: No syncope, seizures, weakness, paralysis, depression. Family History: Is positive for cardiovascular disease and diabetes in his mother. No history of cancer. Social History: The patient is married. Never smoked. Doesn’t drink any alcohol. Works in a factory. On physical examination, a well-developed, well-nourished, alert male in no acute distress. Blood pressure: 146/82. Respirations: 18. Heart rate:78. Skin: Good turgor and texture. Eyes: No scleral icterus. Pupils are round, regular, equal, and react to light. Neck: No jugular venous distention. No carotid bruits. Thyroid is not enlarged, Trachea in the midline. Lungs are clear. Heart: No murmor noted. Abdomen is soft. Bowel sounds present. No masses, no tenderness. Liver and spleen are not palpably enlarged. Extremities: Good pulses. Trace edema of the feet. Laboratory values show sever anemia with a hemoglobin of 5.7. Hemoccult is also positive. His iron studies showed low iron and low ferritin, consistent with chronic blood loss anemia. His B12 and folate levels were normal. His SMA-12 was essentially unremarkable. Impression: 1. Anemia. Probably he is anemic after bypass and then had stress gastritis with a little bit of bleeding and has never recovered from that. No evidence of acute or active bleeding at this time. The patient is stable. Possibility of occult malignancy or active peptic ulcer disease does exist. 2. Arterioslerotic heart disease of native vessel, stable. Recommendations: Admit patient as an outpatient for blood transfusion. Patient is being transfused. He should have an esophagogastroduodenoscopy and colonoscopy, possibly biopsy, or polypectomy, which has been explained to the patient along with potential risks and complications including bleeding, transfusion, perforation, and surgery. These tests will be scheduled as soon as possible. Discharge Note Final Diagnoses: 1. Sever blood loss anemia; weakness. 2. Type 2 diabetes mellitus 3. History of coronary artery disease status post coronary artery bypass graft The patient received three units of packed red blood cells, leukoreduced, CMV negative. He felt better with subsidence of his shortness of breath, and his weakness improved. His last hemoglobin was 8.4, with a hematocrit of 27.7. The patient was scheduled for EGD to rule out peptic ulcer disease and colonoscopy to rule our occult malignancy in one week. The patient will be discharged home, and he will have a clear liquid diet. He is to call for any problems. He will continue with his home medications, and he was placed on ferrous sulfate, one tablet twice a day. What ICD-10-Cm, CPT, and/or HCPCS codes are reported for this outpatient encounter? The facility purchases its blood from the blood bank. a. D50.0, E11.9, I25.10, Z95.1, Z82.49, Z79.84, Z83.3, 36430, P9051-BL, Rev code 390 (3 units), P9051-BL Rev code 385 (3 units). b. D64.9, R53.1, 36430, P9051-BL Rev code 390 (3 units), P9051-BL Rev code 385 (3 units) c. D50.0, K92.2, I25.10, Z95.1, Z82.49, 36430 d. D64.9, E11.9, R19.5, I25.10, Z95.1, Z82.49, Z79.84, P9051 (3 units) #8.32. The following documentation is from the health record of a 45 year old female patient. Mental Health Clinic Visit (Facility Services) The 45-year-old patient is seen today for 30 minutes of individual therapy in the Community Mental Health Center. Patient continues to be somewhat elevated in her mood with some evidence of grandiosity but overall is goal directed and seems to be doing reasonably well with her chronic undifferentiated schizophrenia in the structured setting. Patient currently is now off Seroquel and will continue to transition from oral Prolixin to Prolixin Decanoate. She did receive Proloxin Decanoate 12.5 mg IM on XX/XX/XX. When I try to decrease her oral Proloxin dosage, we notice some more increased grandiosity as well as more impulsive behavior and more thought disorganization, so on XX/XX/XX we increased her Prolixin back to 5 mg q. h.s. orally. On seeing her today, she seems to be improving somewhat on that. Her appetite and sleep pattern were fine over the weekend. She had no evidence of aggressive behavior. I decided at this time to maybe increase her Prolixin Decanoate to 25 mg IM every two weeks, and that will start today. Will continue with the oral Prolixin for a period of time and then will be able to eliminate that. There is a meeting with her family this upcoming Wednesday, and we’ll discuss patient’s care and how they feel she is doing and also discuss discharge and aftercare planning if that’s appropriate. Mental Status Exam: Appearance: The patient is a female who looks her stated age. Behavior: Cooperative, fair eye contact. Speech: Normal rate and volume. Mood slightly elevated. Affect less liable. Thought process: More goal directed. Negative for racing thoughts, flight of ideas. Thought content: Has delusional belief system, but it has decreased in intensity. No evidence of auditory, visual or olfactory hallucinations. Denies current suicide or homicide intent. Insight: Judgment remains impaired. Impulse control improving. Impression: Axis I: Schizophrenia, chronic undifferentiated type Axis II: None known Axis III: Combined hyperlipidemia; currently on Lipitor Plan: At this time will continue on the Prolixin Decanoate but increase to 25 mg IM every two weeks. Will continue with the oral Prolixin at 5 mg q. h.s. Which of the following is the correct ICd-10-CM and CPT Code set for reporting this clinical service? a. F20.5, E78.2, 90832 b. F20.2, E78.2, 90832 c. F20.5, 99213, 90833 d. F20.5, E78.2, 90834 #8.66. The following documentation is from the health record of a male patient with a hand injury. Hospital Outpatient Surgery Services Preoperative Diagnosis: Open fracture, shaft of the middle phalanx of the left small finger, on the oblique. Postoperative Diagnosis: Open fracture, shaft of the middle phalanx of the left small finger, on the oblique with disruption of collateral ligament and extensor tendon. Procedure: Irrigation and debridment, open reduction of fracture, repair of extensor tendon and lateral collateral ligament, left small finger. Indications: This 42 year old male sustained this injury at his single-family home while using a powered hedge trimmer which slipped. The medial ligament, soft tissue, and skin are intact. Because of this wound, the patient was brought to the operating room today. Descroption: two grams of Ancef were administered prior to the start of the case. The patient was identified by site of surgery, by direct communication with the patient, and by consent form. Following induction of general anesthesia, the left upper extremity was prepped and draped in the usual manner. A tourniquet was placed. Attention was first directed to the wound, and the margins of the wound were trimmed of devascularized tissue. There was a significant amount of debris in the wound. It was debrided of bone chips using the operating microscope and lavaged with 4 liters of Kantrex solution. Following this, the oblique fracture of the middle phalanx was approximated over a metal pin using fluoroscopic guidance. This provided excellent alignment of the fracture and appropriate positioning of the finger. The extensor tendon was repaired with acceptable extension being achieved. The lateral collateral ligament was repaired and the PIP joint was again stable. The wound was closed using 4-0 nylon suture, opposing his soft tissues. The tourniquet was released. Tourniquet time was 40 minutes. Vascularizzation appeared adequate. Sterile bandage of bacitracin, Adaptic, 2 x 2s, and a tube gauze bandage were applied. Estimated blood loss was minimal during the procedure. Which of the following ICD-10-CM and CPT code sets is appropriate for this service? a. S62.627A, 26756-F4, 13131-F4 b. S62.627A, W29.3XXA, Y92.017, Y93.H2, Y99.8, 26735-F4 c. S62.627B, S63.697A, S66.317A, W29.3XXA, Y92.017, Y93.H2, Y99.8, 26735-F4, 26418-F4, 26540-F4-59 or -XS, 11012. d. S62.627B, W29.3XXA, Y92.017, Y93.H2, Y99.8, 26756-F4, 26418-F4, 26540-F4, 11012

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