Medical coding

Part A: Answer each of the following questions in one or two paragraphs.

1. Code the following operative report.

Preoperative Diagnosis: Left flank soft tissue mass

Postoperative Diagnosis: Left flank soft tissues mass

Surgeon: John Doe, DO

Operations: Excision of left flank soft tissue mass with layered closure measuring 4 cm , with margins, prior to excision

Anesthesia: sedation with 1% lidocaine with epinephrine and sodium bicarbonate

Operative Indications: this is a pleasant female who come in with soft tissue lesion in the left

flank over what appeared to be a Spigelian Hernia site as well. However, it was not reducible and did not appear to be consistent with a hernia. Consequently, the procedure, risk, benefits, and alternative of excision of this lesion were discussed with the patient, and she understood and wished to proceed with the excision.

Operative Findings: Large soft tissue lesion measuring about 6 cm in greatest dimension

Operative procedure: The patient was brought into the operation room after informed consent was obtained. The patient then underwent sedation with a sterile prep and drape. We then anesthetized with 1% lidocaine with epinephrine and sodium bicarbonate, made a 4-cm incision, and used sharp dissection to dissect circumferentially around this soft tissue lesion, being careful to make sure that we were not entering any kind of hernia sac secondary to Spigelian hernia. As we continued to dissect circumferentially around it without sharp dissection, it was noted that it did go down to a muscle, but no evidence of hernia was identified. The lesion was excised in its entirety and electrocautery was used to control hemostasis. We then irrigated with saline solution and closed the subcutaneous tissue with 3-0 Vicryl interrupted and sutures. We then used 4-0 Vicryl sutures to close the skin in a subcuticular fashion. Benzoin and Steri-Strips were then applied. Blood loss was minimal. The patient tolerated the procedure well and remained in stable condition throughout the procedure.

CPT CODE:

ICD-10 CM CODE:

2. Discuss tow differences between inpatient and outpatient coding.

3. Discuss coding for obstetrics in relation to the global fee for antepartum and postpartum periods of a normal pregnancy.

Part B. Answer each of the question in one to four sentences.

1. What is the difference between Excludes1 and Excludes2 notes in the ICD-10?

2. As a hospital outpatient coder, how would you explain evaluation and management to a health information technology intern?

3. What are the three type of wound repair, and what must be documented to code them?

4. How do the types of immunization differ?

5. A patient with a preexisting diagnosis of congestive heart failure was seen in the emergency room for treatment of pneumonia and admitted to the hospital where they discovered the patient was again in congestive heart failure. What guidelines apply to coding these diagnoses, which one would be the principal diagnosis, and why?

6. General Anesthesia is provided for a patient undergoing an upper gastrointestinal endoscopy. Discuss why Current Procedural Terminology codes are used for anesthesia. Who assigns an anesthesia code? What guidelines apply to coding these diagnoses, which one would be the principal diagnosis, and why?

7. A patient has a five-year history of diabetes mellitus. The patient is admitted to the hospital due to insulin pump malfunction. Discuss the ICD-10-CM coding guidelines for underdoing and overdosing of insulin due to insulin pump malfunction.

8. What are some of the problems associated with modifiers- 51 and -59?

9. Explain how evaluation and management (E/M Codes are grouped.

10. A 10-year-old patient is admitted for multiple injuries after begin hit by a car while riding his bike. Discuss the coding guidelines for reporting injuries.