Questions and Answers
What is the CPT code reported for Mark's case regarding the removal of multiple lipomas?
Which of the following codes are reported for Susan's case with a suspicious neoplasm?
What is the CPT® code reported for the patient with very advanced dementia?
99309
Which ICD-10-CM codes are reported for the patient with coronary artery disease?
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What are the codes reported for the follow-up of bilateral lower extremity swelling for a 37-year-old patient?
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What is the diagnosis noted for the 78 year-old patient with a history of diabetes and hypertension?
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Which CPT and ICD-10-CM codes are reported for the annual physical and pelvic examination case?
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What codes are reported for the case of the 32-year-old male patient with left knee issues?
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Which medications were prescribed upon discharge for the patient diagnosed with cholelithiasis?
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What are the codes reported for the established patient with thoracic spine pain?
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Which is true about the patient's potassium levels?
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What is the diagnosis of the patient during the hospital progress note?
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What is the patient status for the elderly male in nursing home?
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What are the reported ICD-10-CM codes for CASE 9?
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What was the chief complaint of the patient in CASE 8?
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Study Notes
Case 1: Lipomas Removal
- New patient: Mark, 45 years old, presents with multiple lipomas.
- Chief complaint: Desire to have lipomas removed, some are tender.
- Past medical history: None; no allergies or current medications.
- Family history includes melanoma in grandfather.
- Physical examination reveals several subcutaneous masses; largest is 1.3 cm.
- Diagnosis: Multiple tender lipomas; treatment involves surgical excision due to high recurrence with liposuction.
- Risks discussed: Infection and bleeding.
- Reported codes: CPT 99201, ICD-10-CM D17.21, D17.22, D17.1.
Case 2: Suspicious Neoplasm
- Established patient: Susan, 67 years old, referred for a suspicious neoplasm on the left arm.
- Growth trajectory: Lesion present for a year, rapid growth last few months.
- Medical history includes hypertension and arthritis; medications: Benicar and Vytorin.
- Physical examination: Raised, reddened lesion with surface bumpiness.
- Medical decision: Biopsy and lesion shaving performed; differential diagnosis includes wart or keratoacanthoma.
- Follow-up planned to discuss biopsy results.
- Reported codes: CPT 11300, ICD-10-CM D49.2, Z85.828.
Case 3: Bilateral Lower Extremity Swelling
- Established patient: 37-year-old female for follow-up visit.
- Chief complaint: Bilateral swelling in lower extremities, resolved with diuretics.
- Medical history: Dyslipidemia and chronic pain; recent diagnosis of pulmonary hypertension.
- Next steps include evaluating pulmonary hypertension's etiology and scheduling a sleep study.
- Assessment indicates the possibility of underlying causes for lower extremity swelling.
- Reported codes: CPT 99212, ICD-10-CM M79.89, I27.20.
Case 4: Annual Physical Examination
- Established patient: 33 years old, for comprehensive annual physical and pelvic exam.
- Reports recent episode of syncope; all tests normal upon ER visit.
- Medications include Lunesta, Prozac, Levothyroxine, Meloxicam, and others; social history notes tobacco use.
- Comprehensive physical examination reveals normal systems with a focus on pelvic health.
- Assessment includes unspecified acquired hypothyroidism.
- Reported codes: CPT 99395, ICD-10-CM Z00.00, Z01.419, E03.9.
Case 5: Left Knee Issues
- New patient: 32-year-old male presents with knee pain and swelling.
- Symptoms began 4 months ago; diagnosed with medial meniscus tear via MRI.
- Past medical history: Denies major issues except for appendix surgery.
- Physical examination shows limited knee range of motion and pain with movement.
- Treatment options discussed; prescription for physical therapy provided.
- Reported codes: CPT 99203, ICD-10-CM M65.162, M24.562.
Case 6: Thoracic Spine Pain Management
- Established patient with chronic conditions: rheumatoid arthritis, thoracic spine compression fracture, alcoholism, depression.
- Improvement noted in thoracic spine pain, but ongoing issues with low back pain.
- Current management includes multiple medications, review of recent DEXA scan indicating low bone density.
- Plans include cyst aspiration and ongoing monitoring of rheumatoid arthritis symptoms.
- Reported codes: CPT 99213-25, ICD-10-CM M06.041, M06.042, M71.342, M80.08XD.
Case 7: Nursing Home Patient Assessment
- 84-year-old male presented after a fall; complains of rib contusion and shoulder pain.
- Discomfort noted; patient has advanced dementia contributing to care considerations.
- Recent medical adjustments made; close monitoring of blood pressure, diabetes, and other chronic conditions.
- Overall management plan includes physical therapy and medication review.
- Reported codes: CPT 99309, ICD-10-CM S20.211A, M25.511, R03.0, F03.90, I25.10, I50.9, I48.91, E11.9, Z79.84.
Case 8: Hospital Admission for Gastroenteritis
- 78-year-old female with recent discharge for gastroenteritis; readmitted with nausea, vomiting, and weakness.
- Relevant medical history includes diabetes, hypertension, osteoporosis.
- Social history indicates retirement and no substance abuse.
- Negative review of systems except for fatigue and malaise.
- Close monitoring and supportive care required during hospitalization.
- Note: Medications under review due to recent symptoms.### Clinical Presentation and Assessment
- Patient exhibits no rhinorrhea, congestion, vision changes, dyspnea, angina, headaches, seizures, anxiety, or depression.
- Positive for intermittent diarrhea and constipation, with no signs of melena or hematochezia.
- Notable rash treated with Benadryl; genitourinary assessment negative for dysfunctional bleeding or dysuria.
Vital Signs and Objective Findings
- Vital signs:
- Max temperature: 98.1°F, Current: 97.6°F
- Pulse: 62 bpm
- Respirations: 20/min
- Blood pressure: 168/65 mmHg
- Oxygen saturation: 95% on room air
- Glucose: 135 mg/dL
- Patient appears in no distress, pleasant demeanor, and is oriented x 3 with Spanish-speaking ability.
- Neurologic exam clear; integumentary exam reveals rash.
Laboratory Findings
- Blood tests indicate:
- Sodium: 125 mEq/L (hyponatremia)
- Potassium: 3.1 mEq/L (hypokalemia)
- Chloride: 90 mEq/L
- CO2: 27 mEq/L
- Glucose: 103 mg/dL
- Creatinine: 0.7 mg/dL
- BUN: 13 mg/dL
- White cell count: 8.3 x 10^3/µL (76% neutrophils)
- Urinalysis shows leukocyte esterase positive, negative nitrites, and mild ketonuria, indicating possible urinary infection.
- Imaging indicates cholelithiasis and evidence of small pleural effusion.
Diagnosis and Management Plan
- Diagnoses include:
- Gastroenteritis with nausea and vomiting
- Cystitis
- Hypokalemia
- Hyponatremia
- Cholelithiasis
- Diabetes mellitus type 2
- Hypertension
- Treatment includes IV hydration, IV Levaquin for infection, and potassium supplementation.
- Surgical consultation for management of gallbladder condition.
Follow-Up Progress and Discharge Summary
- Upon reassessment, patient reports feeling better; no vomiting or diarrhea.
- Vital signs stable and clear urine culture obtained for UTI treatment.
- Eye examination reveals conjunctivitis; treated with Ciloxan eye ointment.
- Discharge instructions include maintaining a cardiac diet, follow-up appointments, and NPO status before surgery.
Discharge Medications
- Levaquin, Ciloxan ointment, Zofran for nausea, Benadryl for rash, blood pressure, calcium, vitamin C, Metformin, Lipitor, and Coreg prescribed for continued management.
Follow-Up
- Scheduled follow-up in one week and on the morning of the planned cholecystectomy.
CPT® and ICD-10-CM Codes
- Codes reported: 99222, R11.2, R19.7, N30.90, E87.6, E87.1, K80.20, E11.9, Z79.84, I10 for initial case and respective codes for follow-up cases.
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Description
This quiz covers two clinical cases involving lipoma removal and a suspicious neoplasm. Participants will evaluate the medical histories, examination findings, and treatment options for each patient. Understanding diagnosis codes and treatment risks is also a key focus.
