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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777 Exercise 1
1-1A INITIAL HOSPITAL CARE ________________________________________
Professional Services: 99221 (Evaluation and Management, Hospital)
ICD-10-CM DX: E10.10 (Diabetes, type 1, with, ketoacidosis), J45.909 (Asthma, asthmatic)
Professional Services: 99221 (Evaluation and Management, Hospital)
ICD-10-CM DX: E10.10 (Diabetes, type 1, with, ketoacidosis), J45.909 (Asthma, asthmatic)
Explanation
Verified
Verified
The HPI included a total of 6 elements: location (stomach, legs), quality (persistent vomiting), duration (since 5 AM), timing (continued, recurrent emesis), modifying factors (Humalog × 2, Ultralente), and associated signs and symptoms (confused, cramping in legs, sore throat, abdominal discomfort, emesis), for a level 4 or comprehensive HPI.
The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears and mouth), cardiovascular (cardiac), respiratory (chest), genitourinary, musculoskeletal, neuro-logic, psychiatric, hematologic, and immunologic (infectious disease), for a level 4 or comprehensive ROS.
All 3 of the PFSH (past, family, social history) elements were reviewed for a level 4 or comprehensive PFSH.
A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place the history level at a level 4 or comprehensive history.
The examination elements include 4 constitutional items (blood pressure, pulse, respi-rations, and general appearance [sluggish]), which equals 1 organ system. There were 2 BAs: neck (supple) and chest (symmetrical). There were 6 OSs: ophthalmologic (eyes), otolaryngologic (ears, mouth), cardiovascular (heart and good pulses), respiratory (clear to auscultation), lymphatic (neck and axillary nodes), and gastrointestinal (abdomen, some tenderness). There were 9 BAs/OSs reviewed, which would ordinarily place this examina-tion in the level 4 or comprehensive physical examination, but for a comprehensive level, only the OSs are counted and the BAs are disregarded.
![The HPI included a total of 6 elements: location (stomach, legs), quality (persistent vomiting), duration (since 5 AM), timing (continued, recurrent emesis), modifying factors (Humalog × 2, Ultralente), and associated signs and symptoms (confused, cramping in legs, sore throat, abdominal discomfort, emesis), for a level 4 or comprehensive HPI. The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears and mouth), cardiovascular (cardiac), respiratory (chest), genitourinary, musculoskeletal, neuro-logic, psychiatric, hematologic, and immunologic (infectious disease), for a level 4 or comprehensive ROS. All 3 of the PFSH (past, family, social history) elements were reviewed for a level 4 or comprehensive PFSH. A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place the history level at a level 4 or comprehensive history. The examination elements include 4 constitutional items (blood pressure, pulse, respi-rations, and general appearance [sluggish]), which equals 1 organ system. There were 2 BAs: neck (supple) and chest (symmetrical). There were 6 OSs: ophthalmologic (eyes), otolaryngologic (ears, mouth), cardiovascular (heart and good pulses), respiratory (clear to auscultation), lymphatic (neck and axillary nodes), and gastrointestinal (abdomen, some tenderness). There were 9 BAs/OSs reviewed, which would ordinarily place this examina-tion in the level 4 or comprehensive physical examination, but for a comprehensive level, only the OSs are counted and the BAs are disregarded. With a total of 7 OSs, this examination is a level 3 or detailed physical examination. The MDM includes extensive diagnoses/management options, minimal/no data to review, and high risk of death or complication if not treated for a level 4 or high MDM. Ketoacidosis is very serious if left untreated, and there is a high risk of death. At the very minimum, there may be compromises to the brain. The diabetes is the reason for the care the patient receives (E10.10). The asthma is reported because it is a significant condition (J45.909). The nausea and vomiting are not coded, as they are symptoms of the diabetic condition that was reported as the primary diagnosis.](https://storage.examlex.com/SM3838/11eddf5e_67dc_8bbc_80fe_39efafe424da_SM3838_00.jpg)
![The HPI included a total of 6 elements: location (stomach, legs), quality (persistent vomiting), duration (since 5 AM), timing (continued, recurrent emesis), modifying factors (Humalog × 2, Ultralente), and associated signs and symptoms (confused, cramping in legs, sore throat, abdominal discomfort, emesis), for a level 4 or comprehensive HPI. The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears and mouth), cardiovascular (cardiac), respiratory (chest), genitourinary, musculoskeletal, neuro-logic, psychiatric, hematologic, and immunologic (infectious disease), for a level 4 or comprehensive ROS. All 3 of the PFSH (past, family, social history) elements were reviewed for a level 4 or comprehensive PFSH. A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place the history level at a level 4 or comprehensive history. The examination elements include 4 constitutional items (blood pressure, pulse, respi-rations, and general appearance [sluggish]), which equals 1 organ system. There were 2 BAs: neck (supple) and chest (symmetrical). There were 6 OSs: ophthalmologic (eyes), otolaryngologic (ears, mouth), cardiovascular (heart and good pulses), respiratory (clear to auscultation), lymphatic (neck and axillary nodes), and gastrointestinal (abdomen, some tenderness). There were 9 BAs/OSs reviewed, which would ordinarily place this examina-tion in the level 4 or comprehensive physical examination, but for a comprehensive level, only the OSs are counted and the BAs are disregarded. With a total of 7 OSs, this examination is a level 3 or detailed physical examination. The MDM includes extensive diagnoses/management options, minimal/no data to review, and high risk of death or complication if not treated for a level 4 or high MDM. Ketoacidosis is very serious if left untreated, and there is a high risk of death. At the very minimum, there may be compromises to the brain. The diabetes is the reason for the care the patient receives (E10.10). The asthma is reported because it is a significant condition (J45.909). The nausea and vomiting are not coded, as they are symptoms of the diabetic condition that was reported as the primary diagnosis.](https://storage.examlex.com/SM3838/11eddf5e_67dc_8bbd_80fe_abfd35550356_SM3838_00.jpg)
With a total of 7 OSs, this examination is a level 3 or detailed physical examination. The MDM includes extensive diagnoses/management options, minimal/no data to review, and high risk of death or complication if not treated for a level 4 or high MDM. Ketoacidosis is very serious if left untreated, and there is a high risk of death. At the very minimum, there may be compromises to the brain.
The diabetes is the reason for the care the patient receives (E10.10). The asthma is reported because it is a significant condition (J45.909). The nausea and vomiting are not coded, as they are symptoms of the diabetic condition that was reported as the primary diagnosis.
The ROS included 10 elements: ophthalmologic (eyes), otolaryngologic (ears and mouth), cardiovascular (cardiac), respiratory (chest), genitourinary, musculoskeletal, neuro-logic, psychiatric, hematologic, and immunologic (infectious disease), for a level 4 or comprehensive ROS.
All 3 of the PFSH (past, family, social history) elements were reviewed for a level 4 or comprehensive PFSH.
A comprehensive HPI (level 4), comprehensive ROS (level 4), and comprehensive PFSH (level 4) place the history level at a level 4 or comprehensive history.
The examination elements include 4 constitutional items (blood pressure, pulse, respi-rations, and general appearance [sluggish]), which equals 1 organ system. There were 2 BAs: neck (supple) and chest (symmetrical). There were 6 OSs: ophthalmologic (eyes), otolaryngologic (ears, mouth), cardiovascular (heart and good pulses), respiratory (clear to auscultation), lymphatic (neck and axillary nodes), and gastrointestinal (abdomen, some tenderness). There were 9 BAs/OSs reviewed, which would ordinarily place this examina-tion in the level 4 or comprehensive physical examination, but for a comprehensive level, only the OSs are counted and the BAs are disregarded.
With a total of 7 OSs, this examination is a level 3 or detailed physical examination. The MDM includes extensive diagnoses/management options, minimal/no data to review, and high risk of death or complication if not treated for a level 4 or high MDM. Ketoacidosis is very serious if left untreated, and there is a high risk of death. At the very minimum, there may be compromises to the brain.The diabetes is the reason for the care the patient receives (E10.10). The asthma is reported because it is a significant condition (J45.909). The nausea and vomiting are not coded, as they are symptoms of the diabetic condition that was reported as the primary diagnosis.
The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
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