Assignment: Intermediate Medical Coding

.Dr. Hansen, an orthopedist, is seeing Andrew, a 72 year old established male patient today who has complaints of severe knee pain in both knees and repeated falls over the past 2 months. Dr. Hansen completes a detailed history and exam with medical decision making of moderate complexity, including X-rays of each knee which show worsening osteoarthritis. Because the patient has been experiencing repeated falls, Dr. Hansen provides the patient with an adjustable tripod cane with instructions for safe use. Dr. Hansen recommends the patient begin taking OTC glucosamine chondroitin sulfate, anti-inflammatories for pain as needed, and schedules the patient for a follow up appointment in one month. E&M code:______________________________

ICD-10-CM code: ________________________

ICD-10-CM code: ________________________

CPT code: ______________________________

HCPCS code: ___________________________

2. Andrew returned for his follow up visit last week with increased pain and edema in his right knee and was scheduled for an arthroscopy. He presents to the surgical center today for a right knee diagnostic arthroscopy with synovial biopsy. Anesthesia is being performed on this 72-year-old male patient by a CRNA with medical supervision by a physician. Other than osteoarthritis, Andrew has essential hypertension, which is well-controlled. Postoperatively the patient was placed in a prefabricated canvas longitudinal knee immobilizer. CPT:___________________________________

Anesthesia: _____________________________

Concurrent Care Modifier: __________________

Physical Status Modifier: ___________________ HCPCS:_____________________________

 

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