This is an “open book” standard delay contemplate to CPT and ICD-10 coding books.

Question calculate 1-

Please warrant the signification in the subjoinedcited declaration that similar at fineest 4 of the HPI (truth of bestow indisposition)

elements signed below:

Patient was advanceted yesterday delay rigorous asthma exacerbation. She had been opposed to

maintain delay her inhaler but continued to worsen balance the ultimate 24 hours precedently advance. She

has had 5 existent compositions and been on 4Lpm O2 for the ultimate 12 hours and now has a

sconsultation 90% sats. ORA she decreases to 78-70%. She has been encircling her boyfriend’s cat a

lot freshly and feels this may entertain triggered this onslaught.

Quality ____________________ Modifying Factors ___________________

Context ___________________ Timing ___________________

Duration __________________ Severity __________________________

Question calculate 2-

Please warrant the Raze of Medical Decision Making (MDM) in the subjoinedcited declaration:

1. Chest suffering- new since ultimate scrutinize

2. DOE (dyspnea on labor) - worsening

I entertain discussed this delay him, and we conquer protect for ischemia delay importance myocardial

perfusion imaging. If Abnl standard, then this may rebestow a tall chance for CAD and angio

should be considered. If standard is low induce, then may prosper syndrome clinically, and trace other

causes of chest suffering. The enduring was instructed to elude vigorous tangible earnestness until

thorough importance standard results are disclosed.

F/U OV the week subjoined these studies to solder eval and praise aid investigations

as implied.

Low __________ Modereprove _________ High___________

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Question calculate 3-

Please excellent the raze of Truth (HX) documented in the subjoinedcited declaration:

Patient comes in today fretful of 4 days truth of cough and redundancy. No Fever,

Chest suffering or dyspnea. Cough is mildly efficient. He has been using Sudafed and Nyquil

delay some refreshment.

Past Medical History-Seasonal allergies

Past Surgical History-tonsillectomy

Past Nativity History- Asthma---Father and Brother

Smoking status: Smokeless tobacco: Alcohol Use:2 drain(s) per week

Allergies-Cephalexin/Penicillin’s- Rash

Review of orders: Dogmatic for malaise/fatigue. Dogmatic for cough and sputum production

(scant, transparent). Disclaiming for nonproduction of exhalation and wheezing. All fostering 10 sharp-end ROS and

are disclaiming.

HPI- # of Elements__________ PFSH- # retrospected_______ ROS- # of orders ________

History Raze __________________

Question calculate 4-

Please excellent the raze of Exam Twain 95 and 97 guidelines documented in the subjoinedcited declaration:

Constitutional: He is oriented to idiosyncratic, attribute, and period. He appears polite-developed and

well- nourished.

Head: Normocephalic and atraumatic. Fair Ear: Tympanic membrane natural. Left Ear:

Tympanic membrane natural. Nose: No mucosal edema or rhinorrhea.

Mouth/Throat: Oropharynx is transparent and entertaining and mucous membranes are natural. Eyes:

EOM are natural. Pupils are similar, thorough, and reerratic to bright.

Neck: Natural rove of tumult. Neck limber. No thyromegaly bestow.

Cardiovascular: Natural reprove, customary rhythm and No whisper heard.

Pulmonary/Chest: Effort natural and exhalation sounds natural.

Lymphadenopathy:He has no cervical adenopathy.

Neurological: He is ready and oriented to idiosyncratic, attribute, and period. Skin: Bark is enthusiastic and dry.

No audacious glorious. Psychiatric: He has a natural dislie and move. His bearing is natural.

Judgment and proprospect gladdend natural.

95 Guidelines Detailed________ Comprehensive___________

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97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______

Question calculate 5-

Please adopt the most accureprove way of documenting a Retrospect of Order (ROS) in a indicative truth

__________ ROS thorough

__________ 14 sharp-end retrospect of order effected

__________ Dogmatic for Nonproduction of Breath, Disclaiming for Chest Pain. All other orders retrospected and are

negative

_________ ROS is not scarcityed for a indicative truth

Question calculate 6-

Please excellent the raze of advantage documented in the subjoinedcited scrutinize hush:

CC: Brought by ambulance – evaluate for non- responsiveness

44 yo man BIBA from Rockies frolic subjoined being base slouched balance on the premise. Pt reports

having too greatly alcohol to drain today and recalls going balance to sit resisting a bastion. He then

determined his eyes and was base by a witness. no witnessed szr earnestness. emesis x 1 (NBNB)

in passage. pt has no complaints at bestow. Pt denies fall/trauma.

PHYSICAL EXAM

Vital signs retrospected, Enduring afebrile, Pulse natural,Blood influence natural, Respiratory reprove

normal, Enduring appears non toxic, suffering liberal. Enduring ready and oriented to idiosyncratic, attribute and

time. HEAD: atraumatic, normocephalic. EYES: Pupils similarly thorough and reerratic to bright,

Sclera natural. ENT: Nose exam natural, dried race left nare, no erratic bleeding. NECK:

Neck exam included findings of natural rove of tumult, Trachea midline. RESPIRATORY

CHEST: no respiratory embarrass, Exhalation sounds transparent. CARDIOVASCULAR: Customary reprove

and rhythm, Center sounds natural, natural S1, natural S2. ABDOMEN: nontender, Bowel

sounds natural. BACK: natural omission, rove of tumult natural.

UPPER EXTREMITY: omission natural, Rove of tumult natural Bilaterally

LOWER EXTREMITY: bilaterally Rove of tumult natural, no edema.

NEURO: Speech natural. SKIN: enthusiastic, dry no abrasions PSYCHIATRIC: drunk.

(Continued on next page)

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ASSESSMENT/PLAN: Intelligent alcohol intoxication- Exhalation EtOH 114 on mien. No exemplification

of indicative trauma by exam or truth. Conquer obvs until abstemious then d/c. Pt refused EKG.

Disposition: D/C Home.

INSTRUCTION: Prosper up delay your earliest thrift schoolman in 1 week. Return to the casualty

department for worsening symptoms, including worsening dissipation, hebetude, feebleness,

tremors, seizure, or any other concerns.

A. 99221

B. 99222

C. 99223

D. None of the balance

Question calculate 7-

Please excellent the raze of advantage documented in the subjoinedcited declaration:

Patient is a 42yr effeminate who bestows today delay tangled migraines since she was a teenager.

Now on relpax. No ordinary migraine today but does scarcity furnishs of relpax. Enduring too on

Prozac and scarcitys a furnish of that. Today she is totally undistinguished and depressing.

ROS-Per HPI-All other orders retrospected and disclaiming.

Vitals – BP 122/60 Temp- 97.4 Height 5' 10" Weight 178 lbs

Patient is depressing and balancebalance about a fresh breakup delay her boyfriend. We discussed in detail

composition options for her including acceptiond dosage of Prozac, adding Welbutrin, yoga, and

structured counseling. I asked the enduring to prosper up delay my action in a month, eventual her

symptoms acception or worsen. I late 35 minutes in visage to visage period delay the enduring 25

minutes of which were late in counseling and coordination of thrift.

If New Enduring 99202_______ 99203 _________ 99204 _________

If Established Enduring 99213 ______ 99214 ________ 99215 ________

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Question calculate 8-

For a Raze 4 new enduring, gladden adopt the appertinent documentation requirements

_______ Detailed Truth and Indicative Exam and Modereprove Medical Decision Making

_______ Indicative Truth and Indicative Exam and Tall Medical Decision Making

_______ Indicative Truth and Indicative Exam and Modereprove Medical Decision Making

________Comprehensive Truth or Indicative Exam and Modereprove Medical Decision Making

Question calculate 9-

Please excellent the set-fair raze of advantage fixed on the documentation below:

I late 40 minutes in visage to visage period delay the enduring and nativity. 50 % or gone-by was late in counseling and

coordination of thrift. We discussed choice therapies, options for medications, referrals for relieve opinions,

etc. Risks, benefits and considerations were discussed delay enduring and nativity. They conquer let us apprehend what they

decide.

If Established Enduring 99214 ________ 99215 _________

If New Enduring 99203_________ 99204 _________

Question calculate 10-

Please foe the set-fair specification of Critical Care:

A. High-complexity decision-making to assess, manage and maintenance animate order action(s) to treat

single or multiple organ order want and/or to neutralize aid life-threatening retrogradation

B. Direct idiosyncratical administration and Numerous idiosyncratical assessment

C. Record demonstreprove the enduring has intelligent dilution of one or gone-by animate organ orders and has a tall

chance of threatening or life-threatening retrogradation

D. The interventions of a constitution that want to prepare these interventions on an pressing plea would slight

result in unexpected clinically indicative or life-threatening retrogradation in the enduring’s predicament

E. All of the Above

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Question calculate 11-

Please foe the examples of a set-rightly documented Chief Compliant:

A. Prosper up on DM meds

B. Left Knee Pain

C. Prosper up

D. Annual Exam

Question calculate 12-

Please foe the set-fair period documentation for a 99214 if you are doing period fixed coding:

A. 30 minutes was late delay the enduring today in my action discussing appertinent dosage of new

medications

B. The enduring was in my action for two hours receiving hydration and counseling contemplateing

food poisoning laterality property

C. 25 minutes was late in visage to visage period delay the enduring. 50% or gone-by was late in

counseling and coordination of thrift touching dosage of new medications and possible

laterality property.

D. I late 25 minutes delay the enduring and 20 minutes were in counseling.

7 | Page

Coding Quiz Active Report 1:

DATE OF PROCEDURE: 07/01/2017

PREOPERATIVE DIAGNOSIS: Lumbar stenosis L4-5.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE: Lumbar laminectomy, bilateral L4-5.

SURGEON: Ima Neurosurgeon, MD.

ASSISTANT: Hesmy Assistant, PA-C.

ANESTHESIA: General.

INDICATIONS: The enduring is a gratifying 85-year-old mother delay symptoms of

neurogenic claudication. Her symptoms were recalcitrant to conservative

care. Her imaging studies inspired rigorous stenosis at L4-L5, relatively

modest stenosis at ____ raze. Fond these findings, subjoined a thriftful

explanation of induces, benefits, slight product, the enduring and nativity

agreed to profits delay surgery.

NARRATIVE: The enduring was brought to the exempt compass. Subjoined suitable

induction of unconcealed anesthetic, the enduring was thriftfully lieed

prone on the active consultation. All influence sharp-ends were padded as

confirmed by me and the anesthesia team. Using survisage landmarks and a C-

arm, the incision was adapted. The enduring was prepped and draped in the

habitual desert style. Subjoined infiltration of national anesthetic, incision

was made delay a #10 blade. Hemostasis was obtained delay Bovie

cauterization. The incision was carried down to the raze of the lumbar

dorsal fascia. Ligamentous stalwart attachments were proud at the L4-5

region. X-ray once intermittently confirmed our lie.

Leksell rongeur was then used to displace the spinous processes and portion

of the lamina.

The active microscope was brought into the arena. Tall press ordinate was

then used to slim the lamina. A curet was used to then separeprove the

lamina from the girthum flavum. Delay that thorough, the difference of

the blight was displaced.

With thriftful decomposition, I was telling to then anatomize the girthum flavum

from the dura. There is possibly a fine fenestration was made in the

dura. This was determined delay occasional 4-0 Nurolon. The visaget joints were

undercut laterally on twain lateralitys. The difference of the girth was too

removed.

Once I was content that the decompression was ample, the confirm was

placed balance the area where the reunion had been attributed. The Duragen was

too attributed anterior to attributement of the Tisseel confirmant.

The lacerate was determined delay multiple flakes of Vicryl prospered by a present

locking Prolene.

The enduring tolerated the process polite.

Sponge and means counts were set-fair at the end of the predicament.

Of hush, at the end of the predicament, the neural monitoring part had attributed

its leads. There were no adverse findings delay the neuromonitoring.

8 | Page

The enduring tolerated the process polite, was crabbed balance to anesthesia

for awakening.

DICTATED BY: Ima Neurosurgeon, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________

Comments:

9 | Page

Coding Quiz Active Report 2:

DATE OF PROCEDURE: 07/07/2017

PREOPERATIVE DIAGNOSIS: Left subtrochanteric femur breach.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE: Intramedullary nailing of left subtrochanteric femur breach.

SURGEON: Shesa Doctor, MD.

ASSISTANT: Hesher Helper, MD. Gladden hush, Mr. Helper was medically

expedient for this enduring to succor lie the enduring, to succor hold

retractors during the process, to succor contract the barrive-at and to

assist delay lacerate blank wall.

ANESTHESIA: Unconcealed endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 250 mL.

COMPLICATIONS: None.

DISPOSITION: The enduring was successfully awakened and extubated in the

exempt compass and recrabbed to the postanesthesia thrift part in durable

condition.

BRIEF PREOPERATIVE NOTE: The enduring is a 63-year-old gentleman who was

riding his bicycle when he had a frightful property, landing straightly onto

his left hip. He sustained a comminuted tangled proximal femur breach

which was too perplexed by the deed that he was on anticoagulants and

his INR was 3.38. Upon bestowation to the hospital. Overnight, he was

fond vitamin K and anterior to surgery fond FFP to get him to a gone-by

normalized INR. The induces and benefits of this process were explained

to the enduring. The enduring asked mismisappropriate questions. Subjoined all

misappropriate questions were answered, informed admit was obtained and

placed on the chart. At this period, the enduring did admit to profits to

the exempt compass for the balance listed active process.

BRIEF OPERATIVE NOTE: The enduring was brought to the exempt compass,

first in his hospital bed unconcealed anesthesia was administered. Next, the

enduring was pestilential to the barrive-at consultation where the endotracheal tube

was in attributed inferior the unconcealed anesthetic at that period. The left inferior

termination was attributed into a polite padded longitudinal check and the

fair inferior termination was attributed into a polite padded, polite leg holder.

Next, statue intensifier was brought into the arena to secure that we

could get ample determined diminution. Subjoined indicative check,

adduction and interior order of the leg, we were telling to get an

ample diminution. Next, the left inferior termination was prepped and draped

in the habitual orthopedic desert style. Next, a 3.2 mm guidewire for the

trochanteric fixation nail was then passed in an intramedullary lie.

Next, the opportunity awl was passed delayout confusion. Next, a ball

tipped guidewire was passed into the canal and measured to the distal

femur 460, but we attributed a 420 mm trochanteric fixation nail delay a 130

degree helical blade contrast. Next, the nail was passed delayout

complication. Next, the outrigger was attributed for attributement of the helical

blade. Guide pin was passed for the helical blade in a center-center

lie into the femoral neck and section measured a 105 mm. The outer

lateral cortex was ordinateed delayout confusion, then the triple reamer

10 | Page

was passed. Next, the 105 mm helical blade was passed delayout

confusion and locked into lie. Next, the outrigger was displaced.

Orthogonal x-rays showed neighboring anatomic alignment of the proximal femur.

Next, vigilance was then remunerated distally to the distal femur for perfect

circles and one 5.0, 52 mm locking abscond was then attributed delayout

complication. Again, orthogonal x-rays showed neighboring anatomic alignment of

the proximal femur, no exemplification of hardware want. At this period, all

wounds were utterly irrigated delay bacitracin-laden natural extraordinary.

Next, the abstruse flake was determined delay a #1 Vicryl in an occasional

fashion. The lacerate was infiltrated delay 30 mL of 0.5% Marcaine delayout

epinephrine. The abstruse subcuticular flake was determined delay an 0 Vicryl,

bark reapproximated delay 2-0 Vicryl and then bark staples. Next, desert

dressings were applied.

Next, the enduring was charmed out of check and recrabbed to the hospital

bed. Unconcealed endotracheal anesthesia was terminated. The enduring

tolerated the process delayout confusion, was successfully awakened

and extubated in the exempt compass, recrabbed to the postanesthesia thrift

part in sconsultation predicament.

DICTATED BY: Shesa Doctor, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________

Comments:

Coding Quiz Active Report 3:

11 | Page

DATE OF PROCEDURE: 07/14/2017

SURGEON: Fixer Upper, MD.

FIRST ASSISTANT: None.

PREOPERATIVE DIAGNOSES:

1. Symptomatic awell-proportioned mammary hypertrophy.

2. Cervicalgia.

3. Thoracic suffering.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATIVE PROCEDURE: Bilateral diminution mammoplasty.

INDICATIONS FOR SURGERY: The enduring is a 66-year-old effeminate who requests

diminution mammoplasty for symptoms allied to vast and afflictive breasts.

The enduring has nod merely rigorous tilt of the shoulder delay the fair

breast vastr and inferior, but has bra ligature grooves. The distance is

consistent delay a 38 G to H distance. She has thoroughed presumptuous anterior

displaced shoulders, vast drooping ptotic awell-proportioned breasts, bra

ligature grooves and nonfocal, intentness and delicacy in the trapezius,

interscapular and paraspinal musculature. The enduring requests diminution

mammoplasty in an endeavor to emend symptoms from vast and afflictive

breasts.

PROCEDURE: Markings made preoperatively for a medial pedicle upright

type diminution mammoplasty accounting for the dyssymmetry. The enduring

charmed to the exempt compass, attributed on the exempt consultation in the supine

position. All bony prominences were polite padded. PAS stockings were in

attribute and actioning. Unconcealed anesthesia was imported bilateral excellent

extremities were abducted to inferior 80 degrees on arm boards. Prepping and

draping was effected in a desert style.

Of hush, the enduring has rigorous compromised bark conceal delay striate

and rigorous ptosis. Stab incision was made in the area of intended

upcorrect exsection and using a discourage infiltration cannula on each laterality 500

mL of 0.03% lidocaine delay adrenalin 1:1 pet was infiltrated on each

side. The action was effected similarly on each laterality. First,

vigilance was directed to the fair laterality subjoined ample epinephrine

effect, a 45 mm areola was incised. De-epithelization of the medial

pedicle was effected. Incision was made in the excellent keyhole in upright

area, maintenance the inferior distance of exsection 4 cm up from the inframammary

fold. Composite resection was effected subjoined isolating the pedicle by

sharp decomsituation and ample at fineest 2 cm upcorrect pillars were

Coding Quiz Active Report 3:

preserved and aid resection laterally was effected removing on the

fair laterality 716 grams. Meticulous hemostasis obtained delay

electrocauterization. Irrigation was effected delay extraordinary. The upright

pillars repaired delay #1 Vicryl reunions. The upcorrect blank wall for 8 cm

was effected using muster 4-0 Monocryl abstruse dermal reunions, present

12 | Page

subcuticular 3-0 V-Loc reunion. The nipple areolar tangled was reuniond to

surrounding flaps using occasional mere 4-0 Monocryl for the abstruse

dermis, present subcuticular 4-0 Monocryl for the bark. Because of rigorous

bark conceal languor, the enduring's matter habitus, was expedient to

perform dog ear exsection of bark and subcutaneous work in the neo-

inframammary enenembrace for contouring purposes. Blank wall in this area, subjoined

hemostasis obtained delay electrocauterization was courteous using

occasional 3-0 Vicryl to abstruse dermis, present subcuticular 3-0 V-Loc

Monocryl for the bark. Next, vigilance was directed to the left laterality

where resection of 757 grams was effected, hemostasis obtained delay

electrocauterization, blank wall and dog ear exsection was effected in a

similar style. The enduring's areola to neo-inframammary enenembrace was 8 cm

on each laterality delay well-proportioned mounds created. Specimen was sent to

pathology. Subjoined quantity of bilateral diminutions, the lacerates were

dressed delay Dermabond and Tegaderm. Unconcealed anesthesia was then

terminated. The enduring went to the re-establishment compass in sconsultation predicament.

There were no confusions. Sponge and means counts set-right.

Estimated race damage was minimal. The enduring was discharged delay

instructions to initiate-again habitual cheer and medications delay the qualification of

holding aspirin and Advil/ibuprofen. The enduring conquer ambulate q.i.d. She

conquer drain full-supply of fluids. She conquer elude influence on her chest. She

conquer be seen tomorrow in prosper up. She conquer initiate Lovenox at 0800 on

07/15/2014. The enduring conquer fawn for problems, questions or concerns.

Final pathology is pending at the period of arbitrary.

DICTATED BY: Fixer Upper, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________

Case Study 1:

Please excellent the raze of Truth (HX) documented in the subjoinedcited declaration:

• HPI: The enduring is an 87-year-old unblemished effeminate who lives in a trained nursing adroitness. She tells

me that her phone was ringing and she prepared to arrive-at balance to get the phone but cut out of bed and

ended up on the base. She reports yelling for succor. She was brought to the casualty compass delay

a facial breach. She was too base to entertain a fine fair frontal intracerebral hemorrhage. She

is being advanceted for contemplation and composition. She too has a Colles breach.

• ROS: Constitutional: Denies fevers. Neurologic: She denies a dissipation. Eyes: She denies any

prospect problems. Thinks she has had some cataract surgery. Notes no prospect problems fair now.

ENT: Denies fresh cyanosis or respiratory poison or continuous dissipation problems.

13 | Page

Cardiovascular: Denies center problems or chest sufferings. Respiratory: Denies nonproduction of exhalation or

existent problems. Gastrointestinal: Denies disgust or diarrhea. Musculoskeletal: Has continuous

back suffering mentioned balance. Skin: Denies any audaciouses. Psychiatric: Acknowledges a truth of

low-grade debasement but has not been problematic freshly.

• Enduring has a gone-by medical truth dogmatic for parkinsons, numerous UTIs and continuous low back

pain. She does not fume and rarely drains alcohol. Twain parents are unconscious.

List the HPI elements:

List the ROS:

List the raze of truth this documentation maintenances:

For an inenduring approximation, would this documentation maintenance a 99221, 99222, or 99223? Please

explain your forced.

ICD-10 Code(s): ____________________________________________________