Bilateral hydrocele.
Case #1
Lincoln Wilson was born with a bilateral hydrocele. He also has a reducible inguinal hernia on both sides. The condition has become troublesome, and the parents and pediatrician have decided that a surgical correction is warranted for this three-year old.
The patient is admitted to the hospital on 09/01/22 for this same day surgery. The patient is discharged on 09/01/22. Dr. Reid performs a bilateral hernia repair with a hydrocelectomy.
Flag question: Question 1Question 11 pts
What is the primary or first listed ICD-10-CM code assigned for the patient’s documented congenital hydrocele?
Flag question: Question 2Question 21 pts
What is the 2nd ICD-10-CM code assigned for this case?
Flag question: Question 3Question 31 pts
What is the CPT surgical code assigned?
Flag question: Question 4Question 41 pts
What modifier should be placed on the CPT code?
Flag question: Question 5Question 50.5 pts
Per the Encoder, what is the APC for the CPT surgical code assigned for this case?
Flag question: Question 6Question 60.5 pts
What is the estimated total reimbursement for this case, per the Encoder?
Group of answer choices
$3604.89
$268.48
$999.99
$2930.81
Flag question: Spacer
Case 2
Patient Name: Mia Washington
Patient Age: 37
Gender: Female
Admission and Discharge Date: 09/15/22
Emergency Services:
Chief Compliant: Cardiac Arrest
HPI: This is 37-year-old female that was found on the floor of her bathroom by her husband. She was in full arrest and he started CPR immediately. She could have been down as long as 20 minutes prior to him finding her. The EMTs took over CPR when they arrived some 20 minutes later and applied AED. They intubated her with a 7.5 ET, the cords were visualized. Good breath sounds bilaterally after intubation. The EMTs administered 1 mg EPI and 1 mg Atropine, no response and ECG was still in asystole.
Physical Exam upon Arrival; The patient was unconscious and apneic and pulseless. Skin: Purple from just above the clavicle and skin was cool and dry. HEENT: Pupils fixed and dilated. Neck: No JVD or trachea deviation. Chest: clear and equal bilateral sounds with intubation. Abdomen: Distended and tight. Extremities: Flaccid and cool.
Emergency Physician’s Note: This 37 y/o while female arrived by ambulance in full arrest. Epi and bicarb were given on the way to the hospital. Two leads showed agonal asystole rhythm. A high dose of epi 5 mg was given IV and shock with 360 joules x 2; no response. A total of 4 amp of bicarb and 4 high dose epi given with intervening defib at 360 joules. No response. Her pupils were fixed and dilated on arrival; has full neck and chest venous stasis. The endo tube was aerating both lungs. Blood gases revealed: Ph 6.909, PO2 57, HCO3 9.9, Base 22.4, O2 sat 64%, PCO2 49
The patient arrived at 11:10 pm and the code was called at 11:45 pm. Patient never had any pulse or spontaneous electrical activity.
Flag question: Question 7Question 71 pts
What is the ICD-10-CM diagnosis code assigned for this patient, Mia Washington?
Flag question: Question 8Question 81 pts
What are the CPT codes assigned?
Group of answer choices
99291 only
99285
99291, 92950
99285, 92950
Flag question: Question 9Question 90.5 pts
What are the APCs assigned for this case?
Group of answer choices
05722 and 05041
05040
No APCs are assigned
05756
Flag question: Question 10Question 100.5 pts
True or False: The estimated total reimbursement for this case is less than $500.
Group of answer choices
True
False
Flag question: Spacer
Case #3
Patient name: John Robinson
Age: 39
Gender: Male
Admission & Discharge Date: 09/20/22
Procedure Report
Procedure: Upper GI Endoscopy
Indications: Heartburn
Complications: No immediate complications
Procedure Details: After obtaining informed consent, the endoscope was passed under direct vision. Throughout the procedure, the patient’s blood pressure, pulse, and oxygen saturations were monitored continuously. The Olympus GIF-Q160 gastroscope was introduced through the mouth, and advanced to the third part of the duodenum. The upper GI endoscopy was accomplished without difficulty.
Findings: Biopsy of the esophageal mucosa with a cold forceps was performed for histology, evaluation for microscopic esophagitis, and evaluation to rule out Barrett’s Esophagus.
Diffuse mildly erythematous mucosa with no bleeding was found in the gastric antrum. Biopsies were taken with a cold forceps for histology. Biopsies were taken with a cold forceps for Helicobacter pylori testing. The examined duodenum was normal. Biopsy with a cold forceps was performed for histology, evaluation of celiac sprue, evaluation of celiac disease, and evaluation of chronic inflammation
Impression: GERD
Mild antral gastritis/gastric mucosal abnormality characterized by erythema. Normal examined duodenum.
Recommendations: Continue current medications, use sucralfate tablets, await pathology results.
Flag question: Question 11Question 110.5 pts
What are the ICD-10-CM diagnosis code(s) assigned?
Group of answer choices
K21.9, K29.60
K21.9, K29.61
Flag question: Question 12Question 121 pts
What is the CPT surgical code assigned?
Flag question: Question 13Question 130.5 pts
What are the APC and estimated total reimbursement?
Group of answer choices
05301; $345.07
05301: $916.81
05300; $7301.00
Flag question: Spacer
Case #4
Patient Name: Lucas Blankstein
Age: 5
Gender: Male
Admission and discharge date from the ED: 09/29/22
The patient is seen in the ED. The patient has acute lymphoblastic leukemia and has had a fever per his parents for the last 24 hours. It has been nine days since his last chemotherapy treatment which was his first. Dr. Manning sees Lucas in the ED. Dr. Manning documents a comprehensive history. On examination, the skin over his Hickman site is extremely red and starting to break down. No other abnormal findings are documented on the noted comprehensive exam. Labs show that the patient is not neutropenic. Final diagnoses: ALL not in remission, infected Hickman. The patient is given 770 mg of Ceptaz over 10 minutes via a new peripheral IV site. The medical decision-making documented by Dr. Manning is of a moderate level.
Code this ED visit.
Flag question: Question 14Question 141 pts
What is the ICD-10-CM primary dx code?
Hint for the ALL
Flag question: Question 15Question 151 pts
What is the secondary or additional ICD-10-CM diagnosis code?
Group of answer choices
T82.7XXA, Y83.1
T85.79XA
T82.7XXA, R50.9
Flag question: Question 16Question 161 pts
What is the E/M code assigned?
Flag question: Question 17Question 170.5 pts
What is the APC assigned per the encoder for this case?
Flag question: Question 18Question 180.5 pts
What is the estimated total reimbursement per the encoder for this case?
Flag question: Spacer
Case #5
Patient Name: Lois Harris
Age: 69
Date of service: 09/17/22
Lois is seen in the medical office of Drs. Pratt & Pratt. Lois has been a patient at this office for 14 years. Her last visit was with Dr. Zoe Pratt on 09/01 of the current year. Both physician are family doctors. Today, Mrs. Harris is seen by Dr. Oliver Pratt. Today, Lois is complaining of increasing shortness of breath, weakness, and a cough. This is an ongoing chronic presentation for Lois but she does note her shortness of breath has increased. The patient is already on supplemental oxygen at home and uses it daily. The patient receives an order for an outpatient chest x-ray and blood is drawn in the office for stat lab. The patient wishes outpatient therapy and does not want to go to the hospital. Dr. Pratt documents a detailed history, an expanded-problem focused exam and medical decision making of a moderate level of complexity.
What are the ICD-10-CM diagnosis (ies) code(s)?
What is/are the CPT code(s) assigned?
There is no APC for this service, since it was rendered in a medical office. No encoder is required for this one case.
Flag question: Question 19Question 190.5 pts
What are the ICD-10-CM codes assigned?
Group of answer choices
R06.89, J44.1
J44.1
J44.1, Z99.81
J96.00, Z99.81
Flag question: Question 20Question 200.5 pts
What is the E/M code assigned?
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