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Practical Application Workbook Medical Auditing Training: CPMA ® 2023
ii www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations. US Government Rights This product includes CPT ® , which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 330 N. Wabash, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. AMA Disclaimer CPT ® copyright 2022 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT ® , and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT ® is a registered trademark of the American Medical Association. Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially, they are as one would find them in a coding setting. © 2022 AAPC 2233 South Presidents Dr. Suite F, Salt Lake City, UT 84120 800-626-2633, Fax 801-236-2258, www.aapc.com Updated 10262022. All rights reserved. Print ISBN: 978-1-646317-875 CPC ® , CIC ® , COC ® , CPC-P ® , CPMA ® , CPCO ® , and CPPM ® are trademarks of AAPC.
2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 57 Chapter 3 Case 1 Initial Inpatient Hospital E/M Admission Re: Richard Johnson Date of Service: January 5, 20XX MR # 300-1 Family Medicine History and Physical Re: Richard Johnson Date of Service: January 5, 20XX MR # 300-1 HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old patient of Dr. Williams, with a history of adult-onset diabetes controlled with oral hypoglycemic and he is admitted today because of dysuria and fever, having recently been started on Cipro as an outpatient no improvement. Requested office and hospital records, including the consult note from Dr. Martinez of Urology today. Three days before this admission he began to have burning with urination. His temperature was 102 degrees yesterday and he became very weak to the point that he could not stand, and his daughter brought him to Emergency Department. The burning urination has not been improving and his temperature was 100 degrees today. His other urologic history is per the urology consult note. PAST MEDICAL HISTORY: Includes coronary artery disease, chronic kidney disease and easy bruising tendency, hyperlipidemia, hypertension, hypokalemia, intermittent claudication. MEDICATIONS: Nursing reconciliation includes Cipro, which was recently started. ALLERGIES: NKDA FAMILY HISTORY: Includes a brother with frequent UTIs. There is no personal or family history of DVT or pulmonary embolism. SOCIAL HISTORY: He lives alone and has 2 daughters that live close to him. He is an engineer and had worked at Westinghouse. Is currently continuing to work as a consultant. He denies any smoking, alcohol, or drug history. He says he has a living will, but would be a full code in this situation. REVIEW OF SYSTEMS: Weak. Nauseous and had a decreased appetite, no vomiting. No abdominal pain. He has chronic constipation, with a bowel movement 2 days ago. No chest pain. No shortness of breath PHYSICAL EXAMINATION: GENERAL: He is quite pleasant, well appearing, and alert with normal affect. Patient in no acute distress. HEENT: Oral mucosa appropriately moist. TMs Normal. PERRLA, EOM clear. Conjunctivae and sclerae clear. NECK: No thyromegaly appreciated. No carotid bruits, no lymphadenopathy. VITAL SIGNS: Temperature in the Emergency Department at 99.5 degrees and subsequently 98.9 degrees, oxygen saturation 96% on room air, blood pressure was 117/63. HEART: Normal rate, regular rhythm with II/VI systolic ejection murmur. He says he has a chronic heart murmur.
58 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 LUNGS: Clear. No wheezes, rhonchi, or rales. ABDOMEN: Obese, soft, nontender, nondistended, normoactive bowel sounds. No masses, rebounding, or guarding. No hepatosplenomegaly. EXTREMITIES: No pretibial edema or calf tenderness. Patient is too weak to examine gait and station. GENITOURINARY: Genitalia with circumcision normal. No masses, infection, no hernias. No pain felt with examination of the kidney area on both sides and with percussion. No CVA tenderness. LABORATORY DATA: Sodium is 120, potassium 3.9, chloride 89, CO2 20, BUN 28, creatinine is 1.77, and liver function tests remarkable for mildly low protein and albumin. White count 17.8, hemoglobin is 10, platelets are 141, MCV is 91.5. Urinalysis remarkable for 77 white cells, 2 red cells, leukocyte esterase 2+, urine nitrite is negative, and by way of comparison sodium was 131 in October 20XX, and hemoglobin was 12.8 in January 20XX. Other pertinent office labs included hemoglobin A1c of 6.8 on April 23 rd of last year and BMP on June 3 rd showed BUN 25 and creatinine 1.4. Sodium was 131 and PSA was normal at 1.14 on March 20, 20XX. TSH was 0.78, but this was in August 20XX, vitamin B12 level was above normal. Last EKG in the system was January 20XX, showing normal sinus rhythm and inferior Q-waves and old MI. CT abdomen and pelvis without contrast ordered today and shows evidence of enlarged prostate and heavily diseased abdominal aorta without dilations. IMPRESSION AND PLAN: 1. Complicated urinary tract infection with fever. Patient on Cipro. His fever was improving, but he has been seen by Urology while in the ER and was switched to cefepime. It will be important to get the culture result if it is available from the office. Cultures including blood cultures were repeated here and he has been put on normal saline IV. 2. Severe hyponatremia, with previous history of milder hyponatremia and chronic kidney disease, which is probably worse due to dehydration. He is getting hydrated with normal saline and I will consult Nephrology regarding this and repeat a TSH. 3. Hypertension and hypertensives have been ordered. EKG ordered. 4. History of coronary artery disease. We will not pursue this further, unless he might need an operation, which is doubtful. 5. Adult-onset diabetes, well controlled and will hold oral medications. Will put him on a sliding scale insulin. Electronically authenticated at end of document. Dictated by: Bradley Young, MD Authenticated by Bradley Young, MD on 1/5/20XX 07:01:06 AM Inpatient Hospital Coding Fee Ticket Patient Name Richard Johnson Medical Record Number/Account Number 300-1 Physician Bradley Young, MD Insurance Company UPMC for Life Comments Date of Service Facility Place of Service CPT ® Code(s) Diagnosis Code(s) Modifier Quantity Fee 1/5/20XX AAPC Hospital 23 99222 N39.0 E87.1 I10 E11.9 D64.9 1 $210.00 Total $210.00
2023 Medical Auditing Training: CPMA® Practical Application Workbook www.aapc.com 59 Chapter 3 1. The level of medical decision making documented in the medical record based on the audit result is? A. Straightforward B. Low complexity C. Moderate complexity D. High complexity 2. You are conducting an audit of the medical record for the inpatient hospital admitting physician. What E/M code is supported by the documentation? A. 99221 B. 99222 C. 99223 D. 99284 3. When meeting with this physician post audit, what issues need to be addressed? A. The audit was documented and billed correctly. B. CT of the abdomen and pelvis should be reported. C. Chief complaint documentation and diagnosis coding are incorrect. D. Place of service reporting, diagnosis coding, and EM level reported by the physician are incorrect. Case 2 Initial Inpatient Hospital E/M Admission Re: Greg A. Morris Date of Service: January 5, 20XX MR # 300-2 Family Medicine History and Physical Mr. Morris is a 38-year-old patient followed at his group home by Dr. Moore and admitted this afternoon. He has a history of cerebral palsy with seizures related to anoxia during surgery at age 2. He was sent to the Emergency Department by his aide because of concerns about possible seizures. The Emergency Department physician doubted seizure activity based on his conversation with the aide. He was found to have an intestinal fecal impaction, which is a recurrent problem for him. I am familiar with this patient from previous admissions and follow-ups at his group home. History was obtained from his records and I had a discussion with the nurse coordinator at our practice. I read the Emergency Department documentation which indicated episodes of unresponsiveness today. PAST MEDICAL HISTORY: Per the Emergency Department and the patient’s aide, the patient’s history was obtained. The aide denies any history of meningitis.
60 www.aapc.com CPT® copyright 2022 American Medical Association. All rights reserved. Chapter 3 MEDICATIONS: His only medication is a multivitamin daily and this was confirmed with the nurse. ALLERGIES: NKDA except baclofen side effects. REVIEW OF SYSTEMS: (FROM AIDE) CONSTITUTIONAL: Denies fever, recent chills, fatigue, decrease in appetite. NEUROMUSCULAR: Extremity and head movements, typical for his cerebral palsy DERMATOLOGY: Denies rash, abrasions, or lacerations. FAMILY HISTORY: Mother: Alive. Father: Unknown. SOCIAL HISTORY: No smoking, alcohol or drug use. He lives in a group home and has an aide with him 24/7 PHYSICAL EXAMINATION: GENERAL: Extremity and head movements, typical for his cerebral palsy. HEART: Normal rate, regular rhythm without murmurs. LUNGS: Clear. ABDOMEN: Non-tender and non-distended. EXTREMITIES: No pretibial edema. HEENT: TMs and oral mucosa are normal. An additional note regarding social history is that he goes outside the facility and does some sort of bowling program, which is hard to believe but confirmed with our nurse. LABORATORY DATA: Ordered today - CBC was normal. Comprehensive metabolic panel essentially unremarkable except total bilirubin 1.2. Lipase was normal. Chest X-ray today, no acute changes. CT of head without contrast, markedly motion degraded with no gross evidence of hemorrhage. CT abdomen and pelvis without contrast is severely limited by artifact but showing severe fecal impaction of the colon without evidence of stercoral colitis. Distention of the stomach and small bowel was felt to be secondary to fecal impaction. There was no free air. He has an intraspinal catheter. Nasogastric tube placement was to be considered. I was told by the Emergency Department that the NG tube would be placed but it was not done; I imagine because it had been difficult to place. He has an IV but no IV fluids were started. I talked to Emergency Department physician who was able to disimpact a small amount of stool, and then gave him an enema. He produced only a small amount of solid stool. An NG tube placement was attempted but not tolerated. It was noted that he was not vomiting. According to the nurse, his diet at the group home is normal. IMPRESSION AND PLAN: 1. Questionable episodes of unresponsiveness, which according to the Emergency Department physician are typical from previous episodes but not felt to be seizures. He had an EEG last year which was only mildly abnormal 2. Recurrent fecal impaction and our nurse says that his aide has been giving him senna, MiraLax, and Colace. I am not sure how consistently but we will go ahead and feed him clear liquids as tolerated. I ordered other laxatives including Dulcolax suppository and I am going to see if I can disimpact him any further this evening. I have consulted GI and I spoke with his mother who lives in Texas. She confirms that he would be full code. She wonders if some diet changes would be needed due to his constipation and certainly, we will address that.
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