Exam 2: Hospital Coding Overview

ICD-10 Assign the appropriate ICD-10-CM diagnostic code and CPT procedure code for the following scenario: Patient presents to the OR for excisional breast biopsy of a suspicious right breast mass. Patient was prepped and draped in the usual sterile manner. An incision was made around the mass, and it was removed in toto. The mass was approximately 2.5 cm $\times$ 0.5cm, and it was sent to surgical pathology for evaluation. The wound was irrigated and closed with simple closure.

ICD-10-CM and CPT Assign ICD-10-CM diagnostic codes and CPT codes to the following: Closed reduction and manipulation of left distal radial and ulnar styloid fracture After satisfactory anesthesia was accomplished, the patient's left upper extremity was placed in finger trap traction and gentle closed reduction performed using C-Arm visualization. Long arm plaster cast was then applied and alignment was once again checked with C -Arm.

What are the six major categories or chapters in the CPT book?

Modifier codes are _____-digit codes that are appended to some CPT codes to describe services for unusual circumstances.

Assign CPT codes and any appropriate modifiers to the following scenario: Patient presented for excision of multiple lesions of the trunk, arm, and leg. Excision of a 2-cm lesion from the lower back was performed as well as excisions of lesions of the right upper arm and left lower leg-each were 2 cm in diameter. All wounds were repaired by simple closure. The surgical path indicated that the back lesion was malignant, whereas both the arm and the leg lesions were benign.

ICD-9-CM and CPT Assign ICD-9-CM diagnostic code and CPT codes to the following: The scope was introduced and passed easily to the cecum. There was a small polyp in the ascending colon as well as the distal transverse colon. Both of these were removed with snare polypectomy. An additional polyp was found in the descending colon and this was removed with hot biopsy forceps. The patient tolerated the procedure well and was transferred to the recovery room in good condition.

The facility coder has many responsibilities, which include documenting charts and diagnosing patients' illnesses when the provider does not provide adequate information.

Both physicians and facilities utilize evaluation and management codes. Explain the different key components used to assign the codes.

Facilities use codes on the UB-04 (CMS-1450) to receive reimbursement for services rendered, procedures, and to provide the medical reason for which the services were furnished.

The acronym HCPCS stands for:

The codes V70-82 in ICD-9-CM are used for patients without reported diagnoses, including patients receiving which services?

ICD-9/10 procedure codes describe what services were performed during the encounter.

The patient presents with multiple abrasions, fractures, and bruises. What order would the injuries be assigned codes? Explain your answer.

When the documentation does not specify if a fracture is open or closed, the coder must assign the least significant diagnosis-closed.

New growths are also referred to as:

When coding a chart for ICD-9/10-CM, the word "and" can be interpreted as "and" or "or."

ICD-9-CM and CPT Assign ICD-9-CM diagnostic codes and CPT code as appropriate for the following: Screening colonoscopy for family history of colon cancer Under IV sedation, video colonoscope was introduced to the cecum. The patient had pockets of retained fecal matter, but a reasonable view of the colon was still able to be performed. There was no blood throughout the lower GI tract; no evidence of polyps or malignancy. Patient tolerated the procedure well and was stable at the end of the procedure.

The diagnosis that is the chief reason for the admission following performance of all diagnostic services is known as the primary diagnosis.

For the purpose of ICD-10-PCS procedural coding, if the procedure is performed on both the left and the right side of the body and the documentation supports a bilateral procedure was performed, the service should be coded twice to ensure appropriate reimbursement unless code descriptor includes the word "bilateral"

The Evaluation and Management section is utilized primarily by professional/physician coders.