Coding Assignment
For this assignment you have four clinical scenarios below. You are provided with the clinical diagnosis now find the correct ICD-10 diagnosis code, CPT code and E/M service code. In addition to the coding worksheet provided in Module 6, here are a couple of resources for ICD 10 codes:
http://www.icd10data.com/ICD10CM/Codes
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243514.html
Clinical Scenario 1
CC: Rash
HPI: 45 y/o male complains of
Site on the body: rash left lower back at the belt line and right chin
Duration: that started 2 weeks ago.
Quality: itchy and dry rash
He had similar rash in the right axillae for a few weeks, but this resolved prior to the new rash.
Modifying factors: He has a history of eczema and was treated by previous PCP with prescription steroid cream in the past with relief. She believes she has eczema.
Modifying factors: include worse after hot shower and cold weather. She has tried eucerin cream over the counter and hydrocortisone cream over the counter 0.1% with minimal relief.
Medications: Yasmine
Allergies: No Known Allergies
Past Medical History: Asthma, no surgical history, immunizations are up to date
Family History: Asthma and allergies
Social History: Non-smoker, no smokers in the house
Social alcohol, denies recreational drug use, exercise about 3 times per week.
Occupation: Financial Advisor
Living Situation: Lives in a home with wife and 2 children ages 7 and 10 no pets
ROS:
Constitutional: No fevers, chills or sweats, feels well
CV: Denies cardiac symptoms
Respiratory: no complains of cough, shortness of breath or wheezing
Skin: Complains of itchy rash, see HPI
Physical Exam:
VS: Temp 98.3, BP 110/70, P 76, General Alert in no acute distress
Lymphatic- no head or neck LAD, no axillary LAD
Respiratory: lungs clear to auscultation, respirations are unlabored, no use of accessory muscles, no retractions,
CV: Regular rate and rhythm, no murmurs, no abnormal heart sounds
Skin: Left lower back erythemic base, dry flaky skin about 3 cm in diameter, erythemic patch with rough surface right chin about 1.5 cm in diameter, right axillae 2 healing patches discolored skin with smooth surface.
Assessment/Plan
Clinical Diagnosis: Atopic Dermatitis
ICD-10 Code: _______________
RX: triamcinalone acetonide 0.1% ointment apply twice a day to rash for 2 weeks
Cetaphil lotion and cleaner to face, only use fragrance free and dye free products
Luke warm water for bathing
Eucerin plus and aquaphor for moisturizing
Patient handout on Atopic Dermatitis given and teaching points reviewed
Recommended follow up if no improvement in 3-4 days or if it gets worse or no resolution in the next 2 weeks
E/M level: ________________
Coding Scenario #2
CC: Ear Pain
HPI: 4 year old female established patient presents with mother for 2 day history of severe R ear pain, nocturnal waking with pain, intermittent fevers and loss of appetite; child is crying and holding her ear. Has had cough and nasal congestion for 2 weeks. Mom has tried an old RX of Auralgan and Childrens Motrin with minimal symptom relief. Last does of antipyretic 3 hours ago.
PMFSX: Medications: Albuterol MDI PRN, Auralgan Ear Drops; NKDA. PMHx: Mild Asthma; Last Otitis Media was one year ago. IMM: Fully IMM and UTD. SocialHx: Father of child smokes-usually outside
ROS: Fevers (101-102-forehead scan). Clear nasal discharge, cough is mostly dry, with occasional wheezing resolved with use of inhaler. Denies nausea, vomiting, diarrhea, but mother reports decreased fluid intake for past 24 hours.
PE: VS: Temp (Oral) 103.2; Pulse 120; Respirations 20; BP 80/50; Wt: 42 lb General: Non-toxic, but crying intermittently during exam. Neck: FROM. Ears: Left TM opaque with effusion, obscured landmarks. Right TM red, bulging with purulent effusion. No discharge in canals. Nares: Erythematous, swollen mucosa; clear discharge; Mouth/Throat: Lips dry, and chapped. Oral mucosa sticky; no lesions; throat without erythema, swelling or exudate. Lungs: Clear to auscultation, no increased respiratory effort. Cardiac: RRR w/o murmurs; Capillary refill sluggish at 3 seconds. Skin: Good turgor; no tenting. Psych: Age appropriate behavior and response to questions.
Clinical DX: Primary: Acute Otitis media right ear
Clinical Diagnosis Secondary: Asthma Exacerbation, Asthma Classification is mild intermittent
ICD 10 DX Primary: ___________
ICD 10 DX Secondary: ____________
Plan: RX: Augmentin ES /Clauvulanate 600-42.9mg/5ml 7ml every 12 hours for 10 days; Return to PCP/Clinic if no improvement of fever in 24 hours, ear pain in 48 hours, or if any new symptoms; A/B Otic 5 ml 2-4 drops in affected ear 4 times daily; Childrens Ibuprofen suspension 100mg/5 ml 10 ml every 6-8 hours as needed for pain and fever. Continue Albuterol MDI as directed by PCP as needed for wheezing. Follow up with PCP in 2-3 weeks for possible tympanography. Advised mother speak with spouse re: smoking cessation but no smoking inside home/car.
MDM Assessment: The patient has 2 diagnoses which were addressed and would impact care of the patient.
E/M Level: ________________
Scenario #3
CC: Follow up on High Blood pressure
HPI:
36 y/o female newly diagnosed with HTN about 2 months ago. Started on HCTZ 12.5mg for multiple BP readings of 146/90. Labs/EKG WNL and patient dx with benign HTN. 1 month follow up patients BP 118/70, feeling well without symptoms at the time. Here for follow up and BP re-check. She reports feeling well, taking her medications regularly checking BP at home daily and reports it is running about 110/70- 116/76 over the past month. Denies any problems at this time.
Medical Hx:
Medications: HCTZ 12.5 mg
Allergies: none known
PMH: HTN, surgical: none
ROS:
General- feels well
HEENT: denies blurred vision, no tinnitus
Respiratory- breathing comfortable, no cough
CV: no chest pain, palpitations
Neuro- denies headache or dizziness
PE:
Vs: Temp 98.6, RR: 18, BP 118/74 Pulse: 74
General alert, no acute distress
HEENT: PERRLA
Respiratory:: clear to auscultation
CV: RRR no murmurs
Neuro- grossly normal
Assessment/Plan
Clinical Diagnosis: Hypertension, controlled
ICD-10 code: ________________
Continue HCTZ 12.5 mg (patient has refills at pharmacy does not need new script)
Continue home monitoring at least 3-4 times per week
Return to clinic in 3 months for follow up or sooner if BP is running high on home monitor
E/M Level: ________________
Clinical Scenario #4
CC: follow up on diabetes
HPI: 524y/y female with type 2 diabetes, diagnosed 14 months ago. Currently taking Metformin, here to follow up on HbA1C 8.4 last visit 3 months ago and medication increase to Metformin 100 mg bid. States she is having difficulty with diet/exercise. She went for her eye exam last week and was told that she has changes in her eyes due to the diabetes and is noticing that sometimes her vision is blurry.
ROS:
General: Some general fatigue
HEENT: vision blurry at times, no other c/o
CV: no chest pain or palpitations
Respiratory: denies sob, cough
Abd: no nausea or vomiting, no diarrhea no stomach upset
Musculoskeletal: denies muscle aches
Skin: no rashes, no pain, no ulcerations
Neuro: No tingling or headaches
PMH:
Medications: Metformin 100 mg bid
Allergies: Erythromycin
PMSH: T2DM, Seasonal allergies, Surgical- appendectomy, Immunizations up to date
Family Hx: DMI- sister HTN- mom
Social Hx: Non- smoker, no hx of smoking, no one in house that smokes
Married, no children
Works as a 6th grade teacher
Rare alcohol, no recreational drugs
PE: Vitals: temp 98.6 P: 90 RR: 18 BP: 110/74
General: Alert , appears comfortable, no distress
HEENT: conjunctiva and lids are clear to inspection, vision test 20/40 both eyes; mouth WNL
Lymphatic: No lymphadenopathy noted. Of head, neck or groin
Neck: supple, symmetrical, Full rom
Respiratory: Lungs clear to auscultation bilaterally. Respirations are unlabored, no use of accessory muscles, no retractions noted
CV: RRR, no murmurs
Musculoskeletal: ambulates without limp or alteration of gait
Neuro: grossly intact
Diagnostic Testing: CPT CODE: ____________
HbA1C test: 8.0
Assessment/Plan
Clinical Diagnosis: T2DM uncontrolled with diabetic retinopathy
ICD 10 Code: _____________
Medication: Metformin 100 mg bid, Add Victoza 0.6 mg subcu once a day x one week, then return for evaluation and adjustment.
Referral to diabetic educator
Patient education handout on diabetes and retinopathy given and reviewed
Follow up if no improvement in 48 hours or sooner if symptoms get worse
E/M Level: ________________
Assignment: Billing and Coding
1 points for each Scenario with Diagnosis/CPT/EM level attempted (cite your source)
There will be 4 patient scenarios to code = 4 points total
There will be 1 additional point awarded for attempting this assignment.
Total points 5/5 which will be 5% of your total grade
Coding is difficult so you get credit for your attempt to code accurately even if you select the incorrect code.
