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Medical Coding Scenarios Case Study

Part 1

Review each of the following medical coding scenarios. Assign the ICD-10-CM codes for the diagnoses indicated in each scenario. Also assign the ICD-10-PCS code if any procedures are performed, unless otherwise indicated.

A 61-year-old female patient is seen for a complaint of severe heartburn, lightheadedness, skin reddening, and shortness of breath. The physician renders a diagnosis of GERD, sickle cell anemia, lymphangitis, and diaphragmatic paralysis. What code(s) should be assigned?

ICD-10:____K21.9, D57.1, I89.1, J98.6______________________________________

GERD: A burning sensation, usually centered in the middle of the chest near the breast bone, caused by the reflux of acidic stomach fluids that enter the lower end of the esophagus.

Sickle cell anemia: Chronic, hereditary disease in which red blood cells contain abnormal hemoglobin S and are stiff and misshapen like a crescent, inhibiting blood flow through small blood vessels.

Lymphangitis: Lymphangitis is an inflammation affecting a lymph vessel.

Diaphragmatic paralysis: The diaphragm is the muscular structure that separates the abdominal organs from the organs of the chest. The diaphragm expands and contracts to move air into and out of the lungs.

  1. A 37-year-old patient comes in complaining of swollen joints and headaches. The physician’s diagnosis is SLE. The patient also has rheumatoid arthritis and asthma with status asthmaticus. What code(s) are assigned?

ICD-10:____M32.10, M06.9, J45.902________________________________________

SLE: Systemic lupus erythematosus is an autoimmune disorder that affects numerous parts of the body, including the joints, skin, kidneys, heart and blood vessels, lungs, and brain. It can present with varying symptoms but the most common are extreme fatigue, painful and/or swollen joints (i.e., arthritis), fever, kidney problems, and a skin rash that can give the patient’s face a wolf-like appearance (giving the disease its name). These symptoms appear in episodes known as \”flares\” and then go into remission. There is no cure for lupus, but medication can reduce symptoms and allow the patient to live a normal, healthy life.

Rheumatoid arthritis: Disorders affecting predominantly peripheral (limb) joints.

Asthma with status asthmaticus: Asthma is a condition of diffuse airway inflammation making it very difficult to breathe that may be triggered by a variety of stimuli that include household and environmental allergens, infections, exercising, emotional upset or excitement, inhaled irritants like perfumes, cigarette smoke, and air pollution, and even aspirin. An attack causes the bronchial tubes to spasm and constrict. If the hyper reactive bronchial tubes are severely constricted, carbon dioxide can accumulate in the lungs and cause unconsciousness or death. Airway remodeling involving fibrosis, hypertrophy of pulmonary smooth muscle, and desquamation caused by extensive inflammatory infiltrate also occurs with asthma.

A 52-year-old patient is seen for mouth pain, knee pain, and fluid buildup in the chest. The physician renders a diagnosis of pulp degeneration, old disruption of the posterior cruciate ligament, and pleural effusion. The physician also performed a chest tube insertion (draining the right pleural cavity with a drainage device using a percutaneous approach) prior to diagnosing the patient’s pleural effusion. What diagnosis and procedure code(s) are assigned?

ICD-10: K04.2, M23.50, J90, OW9930Z_____________________________________

Pulp degeneration: Pulp degeneration indicates wasting away of the pulp, which will cause death of the surrounding dentine. In some cases, this wasting away may be accompanied by hardening of the tissue of the pulp, forming stones of calcified material within it.

Old disruption of the posterior cruciate ligament: Chronic instability of knee, unspecified knee.

Pleural effusion: Pleurisy is a condition in which the fluid-filled sacs that separate the lungs from the chest wall become inflamed. The hallmark symptom of this condition is a sharp chest pain while inhaling deeply. Patients with pleurisy tend to take rapid shallow breaths. Other symptoms include chills, coughing, and fever. This code reports pleurisy with effusion when there is seepage of fluid into the chest cavity.

A 30-year-old male is admitted to the hospital with lymphadenitis, acute lymphoid leukemia in relapse, and von Willebrand disease. What code(s) are reported?

ICD-10: I88.9, C91.02, D68.0__________________________

Lymphadenitis: Diseases of veins, lymphatic vessels and lymph nodes.

Acute lymphoid leukemia in relapse: Also known as acute lymphocytic or acute lymphoid leukemia (ALL), this is the most common type of leukemia affecting children, mainly those under 10 years of age. This type of leukemia occurs when immature lymphocytic white blood cells, called lymphoblasts, reproduce abnormally fast in the bone marrow without maturing properly. They crowd out healthy blood cell production and then spread into the bloodstream and other organs. ALL comes on suddenly and develops quickly. It can be fatal in a few months if not treated. Symptoms include fever, fatigue, aching bones and joints, swollen glands, bleeding gums, bruising or petechiae, slow healing cuts, and frequent infections.

Von Willebrand disease: Von Willebrand’s disease is a hereditary defect in which von Willebrand protein, a substance that helps protect the walls of red blood cells, is deficient or defective. This disease is more common that hemophilia, and is usually mild. Most patients will only need treatment following surgery, trauma, or other instances that lead to blood loss.

A 47-year-old male is involved in a motor vehicle accident. He was driving on the highway when his car collided with another vehicle. He was brought to the hospital with a lower arm injury. The physician obtained an x-ray of the arm and, after careful review and interpretation of the x-ray, rendered a diagnosis of lower arm fracture. The physician repaired the arm fracture using open reduction and internal fixation (reposition of the right radius with internal fixation using a percutaneous endoscopic approach). What diagnosis and procedure code(s) are reported?

ICD-10: S52.501A, V49.49, OPSH04Z_______________________________________

Part 2

Review each of the following medical coding scenarios. Assign the CPT code for the services and procedures indicated in each scenario.

A 48-year-old male patient comes to the emergency room with complaints of GERD. The physician performs a laparoscopic fundoplasty with a Collis gastroplasty. What CPT code(s) should be assigned?

CPT: 43280__________________________________________________________

A 40-year-old female patient is diagnosed with cervical cancer. She also complains about difficulty breathing. She is admitted to the hospital, where the physician begins to perform a bronchoscopy after anesthesia administration. However, the procedure is discontinued due to unforeseen complications. Later the same day, a bilateral cervical lymphadenectomy is performed to address the patient’s cervical cancer. What CPT code(s) are assigned?

CPT: 38720-50, 38724________________________________________

A 50-year-old patient is admitted for a repair of a laceration to the diaphragm resulting from an accident involving a bus that ran into a ditch. She also received eight trigger point injections into the transverse abdominus muscle due to pain resulting from the accident. What CPT code(s) are assigned?

CPT: _____39501, 20552____________________________________________

A 23-year-old patient comes to the emergency room after being physically assaulted by her boyfriend. She complains of nasal pain and bleeding from the left nostril. The physician obtains an x-ray of the nasal cavity, and the x-ray confirms a nasal septum fracture. The physician performs an open treatment of the nasal fracture with a concomitant open treatment of the fractured septum. What CPT code(s) should be assigned?

CPT: _____21335____________________________________________

A 33-year-old patient is seen in the emergency room due to complaints of headaches and congestion. The final diagnosis is maxillary sinus infection. The physician performs a nasal endoscopy with a maxillary antrostomy. She also removes some tissue from the maxillary sinus. What CPT code(s) should be assigned?

CPT: ___31231, 31267__________________________________________

Part 3

Review each of the following medical coding scenarios. Assign the HCPCS code(s) required for each coding scenario.

  1. A 49-year-old patient is admitted to the hospital for repair of an ankle fracture. On the day of discharge, the physician prescribes a dynamic ankle extension and flexion device with a soft interface material. The ankle device is adjustable. What HCPCS code(s) are assigned?

HCPCS: ___ E1815___________________________________

  1. A 26-year-old patient was admitted to the hospital with acute exacerbation of allergic asthma. During the course of the hospitalization, the patient received 5 mg of omalizumab administered subcutaneously. What HCPCS code(s) are assigned?

HCPCS: ___ J2357___________________________________

  1. A 58-year-old patient is admitted to the hospital due to severe anemia. He receives six units of fresh frozen plasma on the first day of admission. What HCPCS code(s) should be assigned?

HCPCS: __ P9027, P9023, P9059____________________________________

  1. A 26-year-old patient comes to the emergency room complaining of watery diarrhea for five days. She receives 25 mcg of octreotide acetate administered intravenously. What HCPCS code(s) are assigned?

HCPCS: ___ J2354___________________________________

  1. A patient is brought to the emergency room after ingesting a bottle of Extra-Strength Tylenol (acetaminophen) as a suicide attempt. After treating and stabilizing the patient, the ER physician orders a maintenance does of the antidote, acetylcysteine 600mg mixed in 1000ml D5W in an IV to be infused over the next 24 hours. What HCPCS code(s) should be assigned?

HCPCS: ____ J0132 6 units, J7070 __________________________________

Part 4

Review the following medical coding scenario. Assign all of the ICD-10 and CPT codes for the diagnoses and procedures indicated in the scenario.

After being evaluated by his gastroenterologist, Mr. Jackson was sent to the hospital for a diagnostic esophagogastroduodenoscopy. He is having several symptoms that indicate a potential gastrointestinal condition. As a result, he was admitted in observation. His symptoms include vomiting, weight loss, and dysphagia. The esophagogastroduodenoscopy reveals that the patient has low-grade Barrett’s esophagus, GERD with reflux esophagitis and a non-obstructing hiatal hernia. Patient was also incidentally diagnosed with Crest Syndrome (CRST), which correlates with his complaint of dysphagia. After the procedure, the patient was noted to have several PVC’s on his EKG. These resolved shortly after the patient arrived in the recovery room. Based on the results of the detailed history, detailed, exam, and straight forward medical decision making, it was decided that the patient could be discharged home on the same day with instructions for a follow up office appointment in 2 days. Code this scenario.

ICD-10: _____ K22.710, K21.0, K44.9, M34.1__________________

CPT: _________43235, 93000, 99234___________________________________________



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