Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 3

Auditing Code Assignment
Audit the following cases to determine whether the correct codes have been reported in the correct order. If a coding mistake has been made, state the correct code and your reason for assigning it.
A. Chart note for Henry Blum, date of birth 11/4/53:
Examined patient on 12/6/2018. He was complaining of a facial rash. Examination revealed generalized pustular psoriasis and extensive seborrheic dermatitis over his upper eyebrows, nasolabial fold, and extending to the subnasal region.
The following codes were reported:
B. Physician's notes, 2/24/2018, patient George Kadar, DOB 10/11/1940:
Subjective: This seventy-five-year-old patient complains of voiding difficulties, primarily urinary incontinence. No complaints of urinary retention.
Objective: Rectal examination: enlarged prostate. Patient catheterized for residual urine of 200 cc. Urinalysis is essentially negative.
Assessment: Prostatic hypertrophy, benign.
Plan: Refer to urologist for cystoscopy.
The following code was reported: N40.1.
C. Patient: Gloria S. Diaz:
Subjective: This twenty-five-year-old female patient presents with pain in her left knee both when she moves it and when it is inactive. She denies previous trauma to this area but has had right-knee pain and arthritis in the past.
Objective: Examination revealed the left knee to be warm and slightly swollen compared to the right knee. Extension is 180 degrees; flexion is 90 degrees. Some tenderness in area.
Assessment: Left-knee pain probably due to chronic arthritis.
Plan: Daypro 600 mg 2-QD 3 1 week; recheck in one week.
The following codes were reported: M25.562, M19.90.