Free Billing And Coding4/21/2021
You decide to e-mail a screenshot of the chart to the Coding Manager.
![]() After passing the AAPC medical coding exam, a medical coder earns the Certified Professional Coder (CPC) credential. The medical coding exam has 150 multiple choice questions and five hours and forty minutes is given to complete the exam. ICD-10CM guidelines state there is a casual relationship assumed between CKD and hypertension unless the provider specifically states that the hypertension is not related to the CKD, giving this patient hypertensive chronic kidney disease instead of regular hypertension. The provider performs the following exam in addition to patients height, weight and blood pressure check: General: Well-developed, well nourished, in no acute distress Ears: external ears normal, TM bilaterally intact Neck: Supple, no thyromegaly Extremities: No edema Cardiovascular: RRR, no bruits Lungs: Clear to auscultation The patient is prescribed ciprofloxacin and given a diagnosis of acute cystitis without hematuria. The correct coding for this encounter, using 1997 EM guidelines is. Although the patients chart has a detailed history and moderate medical decision making, the provider only reached 11 bullet points, making this level a 99202. N39.0 is not the most specific code for this chart. The provider drapes the patient in the usual fashion, administers lidocaine and uses a scalpel to excise the 2cm cyst and a subcutaneous extension, rinses it with sterile saline, performs an intermediate repair of the wound with a layered closure. The excision is intermediate because it involves subcutaneous extensions and the repair is included with the procedure. The patient receives MMR and DTaP and counseling on vaccines. Each first component of a vaccine (Measles and Diphtheria in this case) are coded as one unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code. DRGs use similar ICD-10CM weights for facility reimbursement and ICD-10CM are used as diagnosis codes for all healthcare settings. The provider runs a test for HIV and notates that the patient has HIV in the chart, but does not have a positive lab test yet. Only the providers statement is needed that the patient has HIV, not a positive lab test. F17.200 is to be assigned when the provider documents smoker, but gives no further clarification (AHA: 2016, 1Q, 36). The provider must specifically state that the infection or condition is not affecting the pregnancy for an incidental code. The patient is experiencing blood in her urine, which gives us the hematuria portion of the diagnosis. She was luckily wearing a sweater which protected her arms. She has partial-thickness burns covering her entire face. What is the correct CPT code to be assigned as the hospital removes chicken, celery and burnt tissue from her face and places dressings on it. The 99100 code is only used for patients under 1 year old or over 70 years old. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately. Sally has her sisters date of birth, her name but not her ID number. She says her sister is too depressed to advocate for herself and Sally just wants the charges reviewed.
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