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Hello,
I am taking a practice exam for annual training purposes. I work in an out paitient setting and this practice exams has case studies for in patient coding. I am really having a hard time with four of them. Is anyone willing to go over them with me and show me how to code these case studies correctly. I would really appreciate it.
Thanks
Coding Disaster
B. Instructions: Code the following inpatient record exercises properly sequencing the principal diagnosis and (if applicable) the principal procedure. (Be sure to code all the secondary diagnoses/procedure(s).) Read and follow all instructions carefully. (40 points – 10 points each)
1. Do not assign codes for abnormal findings listed on ancillary reports unless the physician documents clinical significance.
2. Assign E codes only for those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered (E930-E949).
3. Code all procedures that fall within the code range of 01.01 through 86.99, but do not code 57.94 (Foley catheter)
4. Do not code procedures that fall within the code range 87.01 through 99.9, except the following:
a. Cholangiograms 87.51-87.54
b. Retrogrades, urinary systems 87.74 and 87.76
c. Arteriograph and angiography 88.40-88.58
d. Radiation therapy 92.21-92.29
e. Psychiatric therapy 94.24-94.27
f. Alcohol/drug detoxification and rehabilitation 94.61-94.69
g. Mechanical ventilation 96.70-96.72
h. ESWL 98.51-98.59
i. Chemotherapy 99.25
5. Assign history codes to those conditions that impact on patient care or condition – such as smoking history, personal history of neoplasm, etc.
CASE #1
Admission Date: 6/18/200X Discharge Date: 6/22/200X
HOSPITAL COURSE: This 71-year-old male was admitted to the hospital about a month ago and signed himself out on admission. The patient has a history of dizzy spells and complete syncope with increasing frequency recently. Patient has a blood pressure discrepancy in both of his arms.
Patient has known hypertension and is on a pill of unknown type, which he takes once a day. Patient has claudication in both lower extremities, which limits him to approximately 1 to 2 blocks of walking. There is no other history of vascular disease. Risk factors relative to arterial disease include 2-3 packs of cigarette smoking a day.
The patient was admitted for DSA arch and renals and cardiac evaluation. The patient was placed on IV fluids with 40 meg KCL added. The day after admission, the patient underwent a DSA arch and renals, which showed 90 percent ulcerated right internal carotid stenosis, 40 percent left internal carotid stenosis. It showed occluded vertebral still, left to right. There was right common iliac occlusion, with internal iliac stenosis. A 98 percent right subclavian stenosis proximally was found. The patient had a stress thallium, which showed significant coronary artery disease at that time, a heart catheterization and consideration for myocardial revascularization was recommended in conjunction with carotid surgery. This was discussed with the patient at that time; he stated he preferred to do nothing and refused a heart catheterization.
LABORATORY AND X-RAY DATA: Urinalysis was normal. Chemistry profile on 6/18 showed a potassium of 3.4, blood urea nitrogen 13, creatinine 1.1, cholesterol 240, triglycerides 287, otherwise within normal limits. Hem-8 on 6/18 showed a hemoglobin of 15.2, hematocrit of 42.9, otherwise within normal limits. Repeat chemistry profile on 6/19 showed a potassium of 3.3. Repeat chemistry profile on 6/20 and 6/21 showed potassium’s of 3.5 and 3.6 respectively. Arteriography on 6/19 showed the following impression: 1) flow limiting stenosis within the proximal right subclavian artery, 2) 70 percent stenosis within the proximal right internal artery, 3) occluded right proximal common iliac artery, with reconstitution via collateral pathways. PA and lateral chest on 6/19 showed chronic obstructive pulmonary disease. EKG on 6/18 showed normal sinus rhythm with left atrial enlargement. Echocardiogram on 6/19 showed normal sinus rhythm with left atrial enlargement. Echocardiogram on 6/19 showed 1) aortic sclerosis, but no evidence of hemodynamically significant aortic stenosis, 2) concentric left ventricular hypertrophy with normal left ventricular contractility, 3) otherwise normal echocardiogram.
The need of heart catheterization was discussed with the patient. The patient refuses to have heart catheterization done at this time and states he wishes to go home. On 6/22, the patient was discharged home and will be followed in the office.
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CASE #2
Date of Admission: 11/15/200X Discharge Date: 11/19/200X
HISTORY OF PRESENT ILLNESS: This 69-year-old female was admitted for left focal seizures involving the leg and arm. Medications on admission include Clonidine 0.2 mg bid, Lasix 40 mg q am, Procan SR 500 mg po bid, and Dilantin 100 mg po tid.
HOSPITAL COURSE: While in the hospital, the patient did well and had no further episodes. CT scan of the brain showed mild to moderate generalized cerebral atrophy with no other abnormality. Chest x-ray showed borderline cardiomegaly, consistent with compensated congestive heart failure. Carotid Doppler showed minimal plaquing but no significant abnormality. EKG did show nonspecific ST&T wave changes suspected to represent an inferior infarct, age indeterminate. EEG was within normal limits. Thyroid function tests were within normal limits. Vitamin B-12 was high at 1067, folate acid was normal at 10.3, Serum electrophoresis was normal. SMA-18 did reveal a glucose of 293 on admission, creatinine was 1.5, BUN was 26, cholesterol 214, LDH was 213 on admission. CBC revealed a hemoglobin of 11.7, hematocrit 35.4, MCV 80.7, sedimentation rate 130 mm per hour. RPR was nonreactive. CEA was 3.2, the upper limits of normal being 3.0. Repeat sedimentation rate done 11/16 was 48 mm hour; rheumatoid factor was negative. While in the hospital, the patient was found to have a Dilantin level of 6.8. The Dilantin was increased. LE prep was negative. Dilantin was 17.6 on 11/18 and 18.4 on 11/19.
The patient was discharged on the same medications as admission. Discharge activity was as tolerated. Diet was 1800-calorie ADA.
FINAL DIAGNOSIS:
1. Left focal seizures
2. Cerebral atrophy
3. Compensated CHF
4. History of MI, age indeterminate
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CASE #3
Admission Date: 1/15/200X Discharge Date: 1/29/200X
BRIEF HISTORY: This is a 70-year-old male with a 5-6 year history of insulin-dependent diabetes mellitus, severe peripheral vascular disease involving his right lower extremity. He recently developed unstable angina pectoris and underwent cardiac catheterization, which revealed significant coronary artery and left main coronary artery disease. He is now admitted for coronary revascularization.
PERTINENT LABORATORY FINDINGS: Admission urinalysis showed 50+ WBCs. Repeat U/A the next day showed 10-15 WBCs. Urine culture grew Escherichia coli with colony count less than 10,000 organisms/ml.
HOSPITAL COURSE: The patient underwent a coronary artery bypass grafting x4 to include left internal mammary artery anastomosed to the left anterior descending artery. Reverse saphenous vein bypass grafts were anastomosed to the diagonal, mid-obtuse marginal, and the left ventricular branch of the right coronary artery. Post-operatively, the patient’s course was prolonged secondary to intermittent atrial arrhythmias for approximately a week and elevated blood sugars requiring endocrinology monitoring to control them. The patient was also treated for E. coli urinary tract infection. The skin edges of the left thigh wound spontaneously dehisced without evidence of infection. This was treated using normal saline, wet to dry gauze dressings. At the time of discharge, his wound appears to be granulating nicely. Patient was discharged home on the following medications: Aspirin 80 mg one po qd and Insulin NPH 28 units and regular 20 units subcutaneously q am and NPH 12 and regular subcutaneously q pm.
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CASE #4
Admission Date: 12/17/200X Discharge Date: 1/12/200X
BRIEF HISTORY: This is a 50-year-old male admitted with severe internal penile prosthesis infection and purulent drainage at the base of the left corpora. The patient had a history of non-insulin-dependent diabetes mellitus for 11 years. Blood glucose on admission was 690. The patient is admitted with a temperature of 99.2 and a blood pressure of 138/88.
HOSPITAL COURSE: On 12/28, and after 24 hours of hydration, the patient was taken to the OR, where removal of an inflatable penile prosthesis was performed. Upon removal of the prosthesis, it was noted that there was the possibility of erosion into the urethra due to purulence per urethral meatus. Quarter-inch Penrose drains were placed in the reservoir space, bilateral corpora and in the pump space. The patient tolerated this procedure well and was taken to the recovery room in good condition. The patient received two weeks of oral antibiotics. On 1/10, the patient was taken back to the OR, where cystoscopy and a suprapubic tube placement percutaneously was performed. Upon cystoscopy, it was found there was no clear evidence of urethral disruption. 14 French Stanley suprapubic percutaneous cystotomy was performed without complications and the position of the tube checked with cystoscopy and determined to be good. The patient was discharged on 1/12. Discharge medications were Cipro 500 mg po bid and Tylenol #3. The patient was discharged with an Accu-chek machine to monitor his blood glucose levels and will be seen in my office next week.
LABORATORY DATA:
Blood glucose (normal values 65-110)
12/28 0600 122 1/1 0703 162
12/28 1520 145 1/8 0703 152
12/28 2020 128 1/11 0703 130
12/29 0600 140
12/31 0703 134
Blood Urea Nitrogen (normal values 7-23)
12/27 = 33 12/28 = 31 12/29 = 22 12/31 = 13
Hemoglobin and Hematocrit (H/H)
12/27 = 10.5/30/6 12/28 = 8.0/23.4 1/11 = 8.6/25/9
Urinalysis
12/17 WBC = 5-10 RBC = 1-5 Blood = small Sp. Gr. = 1.030
Urine C&S = Beta-hemolytic Strep Group B; colony count greater than 10,000
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