The patient experienced acute breathing difficulty

Review Test Submission: Week 5 - Certification Test

Submitted 2/3/17 9:47 PM

Due Date 2/5/17 11:59 PM

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REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins.

LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.
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IMPRESSION:
Severe exacerbation of CHF
Poorly controlled HTN
Worsening ARF due to cardio-renal syndrome

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What CPT? code should be reported?

75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of Cerebral Palsy and Type II Diabetes and is currently on his meds.

A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?

Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency
Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular
tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. The time the provider spent on CPR was 15 minutes. What are the appropriate procedure codes for this encounter?

60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr.

Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit. Prescriptions for Chantrix and Tetracylcine were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

32 year old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

28-year-old female patient is returning to her physician’s office with complaints of RLQ pain and heartburn with a temperature of 100.2. The physician performs a detailed history, detailed exam and determines the patient has mild appendicitis. The physician prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

70-year-old patient with chronic obstructive asthma is brought to the urgent care center with increased wheezing and coughing. The physician initiated an Albuterol inhalation treatment, one dose, delivered by nebulizer. After treatment, the patient’s exacerbation was somewhat improved but the physician determined a second treatment was necessary. What codes are reported?

2, J44.1

55-year-old male has had several episodes of tightness in the chest. His physician ordered a PTCA (percutaneous transluminal coronary angioplasty) of the left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel.

64-year-old patient came to the emergency department complaining of chest pressure. The physician evaluated the patient and ordered a 12 lead EKG. Findings included signs of acute cardiac damage. Appropriate initial management was continued by the ED physician who contacted the cardiologist on call in the hospital. Admission to the cardiac unit was ordered. No beds were available in the cardiac unit and the patient was held in the ED. The cardiologist left the ED after completing the evaluation of the patient. Several hours passed and the patient was still in the ED. During an 80-minute period, the patient experienced acute breathing difficulty, increased chest pain, arrhythmias, and cardiac arrest. The patient was managed by the ED physician during this 80-minute period. Included in the physician management were a new 12 lead EKG, endotracheal intubation and efforts to restore the patient’s breathing and circulation for 20 minutes. CPR was unsuccessful, the patient was pronounced dead after a total of 44 minutes critical care time, exclusive of other separately billable services. What CPT® codes are reported by the physician?

49 year old patient had several episodes of esophageal reflux and underwent a gastroesophageal reflux test to measure the pH balance (a measure of the degree of acidity or alkalinity). The test was performed with a mucosal attached capsule. The physician provided an interpretation and report. The physician stated the diagnosis as gastroesophageal reflux. What CPT® and ICD-10-CM codes are reported?

A teenager has been chronically depressed since the separation of her parents 1 year ago and included moving to a new city. Her school grades continued to slip and she has not made new friends. She has frequent crying episodes and is no longer interested in

Using your CPT® Index, look up anesthesia for an appendectomy. What CPT® code is reported for the anesthesia?

0 out of 0.6 points

What CPT® and ICD-10-CM codes are reported?