AAPC Certified Professional Coder (CPC) Exam

View MR 005398

MR 005398

Operative Report

Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.

Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.

Procedure: Right nephrectomy with partial ureterectomy.

Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.

What CPT coding is reported for this case?

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View MR 003396

MR 003396

Operative Report

Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease

Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease

Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery

Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.

What CPT coding is reported for this case?

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View MR 007400

MR 007400

Radiology Report

Patient: J. Lowe Date of Service: 06/10/XX

Age: 45

MR#: 4589799

Account #: 3216770

Location: ABC Imaging Center

Study: Mammogram bilateral screening, all views, producing direct digital image

Reason: Screen

Bilateral digital mammography with computer-aided detection (CAD)

No previous mammograms are available for comparison.

Clinical history: The patient has a positive family history (mother and sister) of breast cancer.

Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.

Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.

What CPT coding is reported for this case?

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View MR 099405

MR 099405

CC: Shortness of breath

HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.

Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.

ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.

PMH: Asthma

SH: Lives with both parents.

FH: Family hx of asthma, paternal side

ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child's family and no changes reported.

PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.

Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva

Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.

Lymph nodes: normal.

Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.

Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.

GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly

Skin: normal warm and dry. Pink well perfused

Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.

Assessment: Asthma, acute exacerbation

Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.

What E/M code is reported?

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A Medicare patient that is on dialysis for ESRD is seen by the nurse for a Hep B vaccination. This patient is given a dialysis patient dosage as part of a three-dose schedule. The nurse administers the Hep B vaccine in the right deltoid. The physician reviews the chart and signs off on the nurse's note.

What procedure and diagnosis codes are reported for the scheduled vaccine injection for this Medicare patient?

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