Medical coding test | Accounting homework help

This is an “open book” test with regard to CPT and ICD-10 coding books.

Question number 1-

Please identify the words in the following statement that match at least 4 of the HPI (history of present illness)

elements identified below:

Patient was admitted yesterday with severe asthma exacerbation. She had been trying to

maintain with her inhaler but continued to worsen over the last 24 hours before admit. She

has had 5 breathing treatments and been on 4Lpm O2 for the last 12 hours and now has a

stable 90% sats. ORA she decreases to 78-70%. She has been around her boyfriend’s cat a

lot lately and feels this may have triggered this attack.

Quality ____________________ Modifying Factors ___________________

Context ___________________ Timing ___________________

Duration __________________ Severity __________________________

Question number 2-

Please identify the Level of Medical Decision Making (MDM) in the following statement:

1. Chest pain- new since last visit

2. DOE (dyspnea on exertion) – worsening

I have discussed this with him, and we will screen for ischemia with stress myocardial

perfusion imaging. If Abnl test, then this may represent a high probability for CAD and angio

should be considered. If test is low risk, then may follow syndrome clinically, and seek other

causes of chest pain. The patient was instructed to avoid strenuous physical activity until

complete stress test results are known.

F/U OV the week after these studies to consolidate eval and recommend further investigations

as indicated.

Low __________ Moderate _________ High___________

2 | Page

Question number 3-

Please select the level of History (HX) documented in the following statement:

Patient comes in today complaining of 4 days history of cough and congestion. No Fever,

Chest pain or dyspnea. Cough is mildly productive. He has been using Sudafed and Nyquil

with some relief.

Past Medical History-Seasonal allergies

Past Surgical History-tonsillectomy

Past Family History- Asthma—Father and Brother

Smoking status: Smokeless tobacco: Alcohol Use:2 drink(s) per week

Allergies-Cephalexin/Penicillin’s- Rash

Review of systems: Positive for malaise/fatigue. Positive for cough and sputum production

(scant, clear). Negative for shortness of breath and wheezing. All remaining 10 point ROS and

are negative.

HPI- # of Elements__________ PFSH- # reviewed_______ ROS- # of systems ________

History Level __________________

Question number 4-

Please select the level of Exam Both 95 and 97 guidelines documented in the following statement:

Constitutional: He is oriented to person, place, and time. He appears well-developed and

well- nourished.

Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear:

Tympanic membrane normal. Nose: No mucosal edema or rhinorrhea.

Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal. Eyes:

EOM are normal. Pupils are equal, round, and reactive to light.

Neck: Normal range of motion. Neck supple. No thyromegaly present.

Cardiovascular: Normal rate, regular rhythm and No murmur heard.

Pulmonary/Chest: Effort normal and breath sounds normal.

Lymphadenopathy:He has no cervical adenopathy.

Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry.

No rash noted. Psychiatric: He has a normal mood and affect. His behavior is normal.

Judgment and thought content normal.

95 Guidelines Detailed________ Comprehensive___________

3 | Page

97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______

Question number 5-

Please choose the most accurate way of documenting a Review of System (ROS) in a comprehensive history

__________ ROS complete

__________ 14 point review of system performed

__________ Positive for Shortness of Breath, Negative for Chest Pain. All other systems reviewed and are


_________ ROS is not needed for a comprehensive history

Question number 6-

Please select the level of service documented in the following visit note:

CC: Brought by ambulance – evaluate for non- responsiveness

44 yo man BIBA from Rockies game after being found slouched over on the ground. Pt reports

having too much alcohol to drink today and recalls going over to sit against a wall. He then

closed his eyes and was found by a bystander. no witnessed szr activity. emesis x 1 (NBNB)

in route. pt has no complaints at present. Pt denies fall/trauma.


Vital signs reviewed, Patient afebrile, Pulse normal,Blood pressure normal, Respiratory rate

normal, Patient appears non toxic, pain free. Patient alert and oriented to person, place and

time. HEAD: atraumatic, normocephalic. EYES: Pupils equally round and reactive to light,

Sclera normal. ENT: Nose exam normal, dried blood left nare, no active bleeding. NECK:

Neck exam included findings of normal range of motion, Trachea midline. RESPIRATORY

CHEST: no respiratory distress, Breath sounds clear. CARDIOVASCULAR: Regular rate

and rhythm, Heart sounds normal, normal S1, normal S2. ABDOMEN: nontender, Bowel

sounds normal. BACK: normal inspection, range of motion normal.

UPPER EXTREMITY: inspection normal, Range of motion normal Bilaterally

LOWER EXTREMITY: bilaterally Range of motion normal, no edema.

NEURO: Speech normal. SKIN: warm, dry no abrasions PSYCHIATRIC: intoxicated.

(Continued on next page)

4 | Page

ASSESSMENT/PLAN: Acute alcohol intoxication- Breath EtOH 114 on arrival. No evidence

of significant trauma by exam or history. Will obvs until sober then d/c. Pt refused EKG.

Disposition: D/C Home.

INSTRUCTION: Follow up with your primary care doctor in 1 week. Return to the emergency

department for worsening symptoms, including worsening headache, numbness, weakness,

tremors, seizure, or any other concerns.

A. 99221

B. 99222

C. 99223

D. None of the above

Question number 7-

Please select the level of service documented in the following statement:

Patient is a 42yr female who presents today with complex migraines since she was a teenager.

Now on relpax. No current migraine today but does need refills of relpax. Patient also on

Prozac and needs a refill of that. Today she is quite depressed and tearful.

ROS-Per HPI-All other systems reviewed and negative.

Vitals – BP 122/60 Temp- 97.4 Height 5′ 10″ Weight 178 lbs

Patient is tearful and upset about a recent breakup with her boyfriend. We discussed in detail

treatment options for her including increased dosage of Prozac, adding Welbutrin, yoga, and

structured counseling. I asked the patient to follow up with my office in a month, unless her

symptoms increase or worsen. I spent 35 minutes in face to face time with the patient 25

minutes of which were spent in counseling and coordination of care.

If New Patient 99202_______ 99203 _________ 99204 _________

If Established Patient 99213 ______ 99214 ________ 99215 ________

5 | Page

Question number 8-

For a Level 4 new patient, please choose the proper documentation requirements

_______ Detailed History and Comprehensive Exam and Moderate Medical Decision Making

_______ Comprehensive History and Comprehensive Exam and High Medical Decision Making

_______ Comprehensive History and Comprehensive Exam and Moderate Medical Decision Making

________Comprehensive History or Comprehensive Exam and Moderate Medical Decision Making

Question number 9-

Please select the correct level of service based on the documentation below:

I spent 40 minutes in face to face time with the patient and family. 50 % or more was spent in counseling and

coordination of care. We discussed alternative therapies, options for medications, referrals for second opinions,

etc. Risks, benefits and considerations were discussed with patient and family. They will let us know what they


If Established Patient 99214 ________ 99215 _________

If New Patient 99203_________ 99204 _________

Question number 10-

Please circle the correct definition of Critical Care:

A. High-complexity decision-making to assess, manipulate and support vital system function(s) to treat

single or multiple organ system failure and/or to prevent further life-threatening deterioration

B. Direct personal management and Frequent personal assessment

C. Record demonstrate the patient has acute impairment of one or more vital organ systems and has a high

probability of imminent or life-threatening deterioration

D. The interventions of a nature that failure to initiate these interventions on an urgent basis would likely

result in sudden clinically significant or life-threatening deterioration in the patient’s condition

E. All of the Above

6 | Page

Question number 11-

Please circle the examples of a correctly documented Chief Compliant:

A. Follow up on DM meds

B. Left Knee Pain

C. Follow up

D. Annual Exam

Question number 12-

Please circle the correct time documentation for a 99214 if you are doing time based coding:

A. 30 minutes was spent with the patient today in my office discussing proper dosage of new


B. The patient was in my office for two hours receiving hydration and counseling regarding

food poisoning side effects

C. 25 minutes was spent in face to face time with the patient. 50% or more was spent in

counseling and coordination of care concerning dosage of new medications and possible

side effects.

D. I spent 25 minutes with the patient and 20 minutes were in counseling.

7 | Page

Coding Quiz Operative Report 1:




PROCEDURE: Lumbar laminectomy, bilateral L4-5.

SURGEON: Ima Neurosurgeon, MD.

ASSISTANT: Hesmy Assistant, PA-C.


INDICATIONS: The patient is a pleasant 85-year-old woman with symptoms of

neurogenic claudication. Her symptoms were refractory to conservative

care. Her imaging studies revealed severe stenosis at L4-L5, relatively

modest stenosis at ____ level. Given these findings, after a careful

explanation of risks, benefits, likely outcome, the patient and family

agreed to proceed with surgery.

NARRATIVE: The patient was brought to the operating room. After suitable

induction of general anesthetic, the patient was carefully positioned

prone on the operative table. All pressure points were padded as

confirmed by me and the anesthesia team. Using surface landmarks and a C-

arm, the incision was planned. The patient was prepped and draped in the

usual sterile fashion. After infiltration of local anesthetic, incision

was made with a #10 blade. Hemostasis was obtained with Bovie

cauterization. The incision was carried down to the level of the lumbar

dorsal fascia. Ligamentous muscular attachments were elevated at the L4-5

region. X-ray once again confirmed our position.

Leksell rongeur was then used to remove the spinous processes and portion

of the lamina.

The operative microscope was brought into the field. High speed drill was

then used to thin the lamina. A curet was used to then separate the

lamina from the ligamentum flavum. With that complete, the remainder of

the bone was removed.

With careful dissection, I was able to then dissect the ligamentum flavum

from the dura. There is perhaps a small fenestration was made in the

dura. This was closed with interrupted 4-0 Nurolon. The facet joints were

undercut laterally on both sides. The remainder of the ligament was also


Once I was satisfied that the decompression was adequate, the seal was

placed over the area where the suture had been placed. The Duragen was

also placed prior to placement of the Tisseel sealant.

The wound was closed with multiple layers of Vicryl followed by a running

locking Prolene.

The patient tolerated the procedure well.

Sponge and instrument counts were correct at the end of the case.

Of note, at the end of the case, the neural monitoring unit had placed

its leads. There were no untoward findings with the neuromonitoring.

8 | Page

The patient tolerated the procedure well, was turned over to anesthesia

for awakening.

DICTATED BY: Ima Neurosurgeon, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________


9 | Page

Coding Quiz Operative Report 2:


PREOPERATIVE DIAGNOSIS: Left subtrochanteric femur fracture.


PROCEDURE: Intramedullary nailing of left subtrochanteric femur fracture.

SURGEON: Shesa Doctor, MD.

ASSISTANT: Hesher Helper, MD. Please note, Mr. Helper was medically

necessary for this patient to help position the patient, to help hold

retractors during the procedure, to help reduce the fracture and to

assist with wound closure.

ANESTHESIA: General endotracheal anesthesia.



DISPOSITION: The patient was successfully awakened and extubated in the

operating room and returned to the postanesthesia care unit in stable


BRIEF PREOPERATIVE NOTE: The patient is a 63-year-old gentleman who was

riding his bicycle when he had a terrible accident, landing directly onto

his left hip. He sustained a comminuted complex proximal femur fracture

which was also complicated by the fact that he was on anticoagulants and

his INR was 3.38. Upon presentation to the hospital. Overnight, he was

given vitamin K and prior to surgery given FFP to get him to a more

normalized INR. The risks and benefits of this procedure were explained

to the patient. The patient asked appropriate questions. After all

appropriate questions were answered, informed consent was obtained and

placed on the chart. At this time, the patient did agree to proceed to

the operating room for the above listed operative procedure.

BRIEF OPERATIVE NOTE: The patient was brought to the operating room,

first in his hospital bed general anesthesia was administered. Next, the

patient was transferred to the fracture table where the endotracheal tube

was in placed under the general anesthetic at that time. The left lower

extremity was placed into a well padded longitudinal traction and the

right lower extremity was placed into a well padded, well leg holder.

Next, image intensifier was brought into the field to ensure that we

could get adequate closed reduction. After significant traction,

adduction and internal rotation of the leg, we were able to get an

adequate reduction. Next, the left lower extremity was prepped and draped

in the usual orthopedic sterile fashion. Next, a 3.2 mm guidewire for the

trochanteric fixation nail was then passed in an intramedullary position.

Next, the opening awl was passed without complication. Next, a ball

tipped guidewire was passed into the canal and measured to the distal

femur 460, but we placed a 420 mm trochanteric fixation nail with a 130

degree helical blade setting. Next, the nail was passed without

complication. Next, the outrigger was placed for placement of the helical

blade. Guide pin was passed for the helical blade in a center-center

position into the femoral neck and head measured a 105 mm. The outer

lateral cortex was drilled without complication, then the triple reamer

10 | Page

was passed. Next, the 105 mm helical blade was passed without

complication and locked into position. Next, the outrigger was removed.

Orthogonal x-rays showed near anatomic alignment of the proximal femur.

Next, attention was then paid distally to the distal femur for perfect

circles and one 5.0, 52 mm locking bolt was then placed without

complication. Again, orthogonal x-rays showed near anatomic alignment of

the proximal femur, no evidence of hardware failure. At this time, all

wounds were thoroughly irrigated with bacitracin-laden normal saline.

Next, the deep layer was closed with a #1 Vicryl in an interrupted

fashion. The wound was infiltrated with 30 mL of 0.5% Marcaine without

epinephrine. The deep subcuticular layer was closed with an 0 Vicryl,

skin reapproximated with 2-0 Vicryl and then skin staples. Next, sterile

dressings were applied.

Next, the patient was taken out of traction and returned to the hospital

bed. General endotracheal anesthesia was terminated. The patient

tolerated the procedure without complication, was successfully awakened

and extubated in the operating room, returned to the postanesthesia care

unit in stable condition.

DICTATED BY: Shesa Doctor, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________


Coding Quiz Operative Report 3:

11 | Page


SURGEON: Fixer Upper, MD.



1. Symptomatic asymmetrical mammary hypertrophy.

2. Cervicalgia.

3. Thoracic pain.


OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.

INDICATIONS FOR SURGERY: The patient is a 66-year-old female who requests

reduction mammoplasty for symptoms related to large and heavy breasts.

The patient has nod only severe tilt of the shoulder with the right

breast larger and lower, but has bra strap grooves. The size is

consistent with a 38 G to H size. She has rounded forward anterior

displaced shoulders, large pendulous ptotic asymmetrical breasts, bra

strap grooves and nonfocal, tightness and tenderness in the trapezius,

interscapular and paraspinal musculature. The patient requests reduction

mammoplasty in an attempt to improve symptoms from large and heavy


PROCEDURE: Markings made preoperatively for a medial pedicle vertical

type reduction mammoplasty accounting for the dyssymmetry. The patient

taken to the operating room, placed on the operating table in the supine

position. All bony prominences were well padded. PAS stockings were in

place and functioning. General anesthesia was induced bilateral upper

extremities were abducted to under 80 degrees on arm boards. Prepping and

draping was performed in a sterile fashion.

Of note, the patient has severe compromised skin envelope with striate

and severe ptosis. Stab incision was made in the area of intended

vertical excision and using a blunt infiltration cannula on each side 500

mL of 0.03% lidocaine with adrenalin 1:1 million was infiltrated on each

side. The operation was performed similarly on each side. First,

attention was directed to the right side after adequate epinephrine

effect, a 45 mm areola was incised. De-epithelization of the medial

pedicle was performed. Incision was made in the upper keyhole in vertical

area, keeping the lower extent of excision 4 cm up from the inframammary

fold. Composite resection was performed after isolating the pedicle by

sharp dissection and adequate at least 2 cm vertical pillars were

Coding Quiz Operative Report 3:

preserved and further resection laterally was performed removing on the

right side 716 grams. Meticulous hemostasis obtained with

electrocauterization. Irrigation was performed with saline. The vertical

pillars repaired with #1 Vicryl sutures. The vertical closure for 8 cm

was performed using gathering 4-0 Monocryl deep dermal sutures, running

12 | Page

subcuticular 3-0 V-Loc suture. The nipple areolar complex was sutured to

surrounding flaps using interrupted simple 4-0 Monocryl for the deep

dermis, running subcuticular 4-0 Monocryl for the skin. Because of severe

skin envelope laxity, the patient’s body habitus, was necessary to

perform dog ear excision of skin and subcutaneous tissue in the neo-

inframammary fold for contouring purposes. Closure in this area, after

hemostasis obtained with electrocauterization was accomplished using

interrupted 3-0 Vicryl to deep dermis, running subcuticular 3-0 V-Loc

Monocryl for the skin. Next, attention was directed to the left side

where resection of 757 grams was performed, hemostasis obtained with

electrocauterization, closure and dog ear excision was performed in a

similar fashion. The patient’s areola to neo-inframammary fold was 8 cm

on each side with symmetrical mounds created. Specimen was sent to

pathology. After completion of bilateral reductions, the wounds were

dressed with Dermabond and Tegaderm. General anesthesia was then

terminated. The patient went to the recovery room in stable condition.

There were no complications. Sponge and instrument counts correct.

Estimated blood loss was minimal. The patient was discharged with

instructions to resume usual diet and medications with the exception of

holding aspirin and Advil/ibuprofen. The patient will ambulate q.i.d. She

will drink plenty of fluids. She will avoid pressure on her chest. She

will be seen tomorrow in follow up. She will begin Lovenox at 0800 on

07/15/2014. The patient will call for problems, questions or concerns.

Final pathology is pending at the time of dictation.

DICTATED BY: Fixer Upper, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________

Case Study 1:

Please select the level of History (HX) documented in the following statement:

• HPI: The patient is an 87-year-old white female who lives in a skilled nursing facility. She tells

me that her phone was ringing and she tried to reach over to get the phone but fell out of bed and

ended up on the floor. She reports yelling for help. She was brought to the emergency room with

a facial fracture. She was also found to have a small right frontal intracerebral hemorrhage. She

is being admitted for observation and treatment. She also has a Colles fracture.

• ROS: Constitutional: Denies fevers. Neurologic: She denies a headache. Eyes: She denies any

vision problems. Thinks she has had some cataract surgery. Notes no vision problems right now.

ENT: Denies recent cyanosis or respiratory infection or chronic headache problems.

13 | Page

Cardiovascular: Denies heart problems or chest pains. Respiratory: Denies shortness of breath or

breathing problems. Gastrointestinal: Denies nausea or diarrhea. Musculoskeletal: Has chronic

back pain mentioned above. Skin: Denies any rashes. Psychiatric: Acknowledges a history of

low-grade depression but has not been problematic recently.

• Patient has a past medical history positive for parkinsons, frequent UTIs and chronic low back

pain. She does not smoke and rarely drinks alcohol. Both parents are dead.

List the HPI elements:

List the ROS:

List the level of history this documentation supports:

For an inpatient admission, would this documentation support a 99221, 99222, or 99223? Please

explain your reasoning.

ICD-10 Code(s): ____________________________________________________