CHIEF COMPLAINT: CHF

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65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted.Primary care physician is checking for any improvements or if the condition is worsening.

CHIEF COMPLAINT: CHF

INTERVAL HISTORY: CHF symptoms worsened since yesterday.

Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.

REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for

flank pain, obstructive symptoms or documented exposure to nephrotoxins.

PHYSICAL EXAMINATION:

GENERAL: Mild respiratory distress at rest

VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.

LUNGS: Worsening bibasilar crackles

CARDIOVASCULAR: RRR, no MRGs.

EXTREMITIES: Show worsening lower extremity edema.

LABS: BU - CORRECT ANSWER:

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A 1 year post-thyroidectomy patient who had thyroid cancer is coming in for area imaging of the neck and chest to evaluate for metastases. What CPT® code(s) is/are reported for the nuclear medicine exam?

• 78013
• 78015, 78020
• 78014

d. 78015 - CORRECT ANSWER:

A 16 year-old female was hit by a car while crossing a two-lane highway. She was taken to the hospital by ambulance. She was found to have an open wound of the left lower thigh, just above the knee and a displaced fracture of the left femoral neck. She was taken to the operating room within four hours of her injury. She was given general endotracheal anesthesia and was prepped and draped in sterile fashion. Debridement including excision of devitalized skin and muscle was performed on the lateral thigh.The area was approximately 15 sq cm. After debridement and thorough copious irrigation, the wound was closed with layer sutures and a dressing was applied and then covered with adhesive plastic. The patient was then prepped and draped for the fracture and turned on her right side. We all rescrubbed. An 8 inch incision was made over the left hip and the head of the femur was exposed. Multiple fragments from the neck an -

CORRECT ANSWER:

A 27 year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C.What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?

• 32850, 32855, 32851
• 32850, 32856, 32851 x 2
• 32850, 32856, 32853
• 32850, 32855 x 2, 32850-50 - CORRECT ANSWER: 2 / 4

A 32 year-old ETOH dependent female is in a partial hospitalization program and has been seeing an addictive disease specialist (psychotherapist) in a chemical dependency program. Her employer is aware of her problem. She was referred to the group through their Employee Assistance Program. As long as she is in compliance they will support her efforts. Recently, she has arrived late at the meetings. The provider met with the patient and discussed the importance of her treatment, compliance with the program and avoidance of situations in which she may use alcohol. She denies contact with her previous associates and assures the provider she has had no alcohol intake since beginning the substance abuse treatment program. They will continue to reinforce her progress and successful sobriety. Time of the session was 45 minutes. What CPT® and ICD-10-CM codes are reported?

• 90832, F10.220
• 90832, F10.20

c. 90834, F10.20 - CORRECT ANSWER:

A 32 year-old male was seen in the ASC for removal of two lipomas. One was located on his back and the other was located on the right forearm. Both involved subcutaneous tissue. What ICD-10-CM code(s) is/are reported?

• D17.1, D17.23
• D17.21, D17.1
• D17.30

d. D17.39 - CORRECT ANSWER: b. D17.21, D17.1

A 40 year-old presents with vaginal bleeding for several weeks unrelated to her menstrual cycle. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter?

• N92.1
• N92.4
• N92.6 3 / 4

d. N93.9 - CORRECT ANSWER:

A 42 year-old patient was undergoing anesthesia in an ASC and began having complications prior to the administration of anesthesia. The surgeon immediately discontinued the planned surgery. If the insurance company requires a reported modifier, what modifier best describes the extenuating circumstances?

• 53
• 23
• 73

d. 74 - CORRECT ANSWER:

A 43 year-old female presents to the provider for a diabetic ulcer of the right ankle. What ICD-10-CM codes are reported?

• L97.319
• L97.319, E11.9
• L97.319, E11.622

d. E11.622, L97.319 - CORRECT ANSWER: d. E11.622, L97.319

A 43 year-old patient with a severe systemic disease is having surgery to remove an integumentary mass from his neck. What CPT® code and modifier are reported for the anesthesia service?

• 00300-P2
• 00300-P3
• 00322-P3

d. 00350-P3 - CORRECT ANSWER:

A 45 year-old presents with acute pericarditis. The surgeon makes a small incision between two ribs and enters the thoracic cavity. An endoscope is introduced and the

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