Podcast
Questions and Answers
What is the CPT code reported for Mark's case regarding the removal of multiple lipomas?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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.
