Medical Coding

Medical Coding

BC3020: Week 4 – Coding Application TEST About The coding application provides you the opportunity to apply the coding skills you’ve learned this week. As the courses progress and your skills increase, the rigor of the coding application will increase as well. Every professional coder will tell you the more you code, the better coder you become so practice, practice, practice. To do well on the coding application, you must read the assigned chapters and complete the exercises in your textbook.

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It is recommended that you look over the questions before reading the case scenario to give you an idea of what information you will be asked to answer. Be sure to read every question completely as some are asking for a written response while others are asking you to assign a code. Steps for Coding Steps for correct CPT coding: 1. 2. 3. 4. 5. 6. 7. 8. 9. Determine the procedure, test, or service to be coded Identify all terms Locate each main term in the Alphabetic Index Review and select the subterms indented below the main term Note the code number(s) found opposite the selected main term or subterm Verify the code in the Tabular List Review coding notes and coding conventions Determine modifiers when applicable Repeat steps for additional code(s) Steps for correct ICD coding: 1. 2. 3. 4. 5. 6. 7. 8. Identify all terms in the diagnosis Locate each main term in the Alphabetic Index. Refer to any subterms indented under the main term. Follow cross-reference instructions if the needed code is not located under the first main entry consulted. Verify the code in the Tabular List. Read and be guided by any instructional terms in the Tabular List. Assign codes to the highest level of specificity. Code the diagnosis until all elements are completely identified. (See next page to continue) BC3020: Week 4 – Coding Application TEST Coding Test: 45 points Directions:   Read the following Case Scenario Using your ICD-10-CM, CPT, and HCPCS coding manuals, answer the questions in Parts 1 through 4 below. CASE SCENARIO: LOCATION: Inpatient, Hospital PATIENT: Lucy Bates ATTENDING PHYSICIAN: Marcus Willis, MD SURGEON: Gary Sanchez, MD PREOPERATIVE DIAGNOSIS: Right breast cancer. POSTOPERATIVE DIAGNOSIS: Right breast cancer. PROCEDURE PERFORMED: Right modified radical mastectomy. ANESTHESIA: General. PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. An elliptical incision was made around the right nipple to include the biopsy site, and flaps were created superiorly, inferiorly, medially, and laterally down to the pectoralis superiorly to the rectus fascia inferiorly, sternum medially, and latissimus laterally. We then took the breast off the pectoralis fascia and entered the axillary space. Perforating vessels were either cauterized or ligated with 3–0 Vicryl suture ligatures. We entered the axillary space. We could feel several lymph nodes. We took the lymph nodes. We could see the thoracodorsal nerve easily and kept this free from our dissection. We were unable to identify the long thoracic nerve. Once we had stripped the lymph nodes free, we irrigated with saline. We could easily see the axillary vein superiorly, the latissimus dorsi laterally, and the pectoralis medially and had cleaned all the lymph nodes out of this space. We then irrigated with sterile water and placed two Jackson-Pratt drains, a lateral drain going into the axilla and a medial drain going underneath the skin flaps. We then closed in two layers with a deep layer of 3–0 Vicryl. Steri-Strips and sterile Band-Aids were applied. All sponge and needle counts were correct. The patient tolerated the procedure well and was taken to recovery in stable condition. (See next page to continue) BC3020: Week 4 – Coding Application TEST PART 1: Abstracting 1. What is the name of the physician performing the procedure? (1 point) Type answer here 2. What is the procedure, test, or service to be coded? (2 points) Type answer here 3. Which breast is the physician performing the procedure on? (1 point) Type answer here 4. Is the ligation or cauterization of blood vessels reported separately? (2 points) Type answer here 5. Is the lymph node dissection reported separately? (2 points)Medical Coding Type answer here 6. Was skin grafting performed? (2 points) Type answer here 7. Is the closure of the surgical site reported separately? (2 points) Type answer here PART 2: Surgical Procedure 1. What are all possible terms for the surgical procedure used in the Alphabetic Index of the CPT coding manual? (2 points) Type answer here (See next page to continue) BC3020: Week 4 – Coding Application TEST 2. What subterm(s) are identified under the main term in the Alphabetic Index? (1 point) Type answer here 3. What code(s) are listed in the Alphabetic Index? (1 point) Type answer here 4. What section in the Tabular List of the CPT manual did you find the code(s)? (1 point) Type answer here 5. Are there any relevant guidelines or parenthetic notes associated with the procedure code that should be referenced? (1 point) Type answer here 6. What is described as” excluded” in this procedure code that would indicate the service is modified from another type of mastectomy? (2 points) Type answer here PART 3: Diagnosis 1. What is indicated on the Pathology report regarding the diagnosis? (1.5 points) Type answer here 2. What is the documented condition to be coded? (1.5 points) Type answer here 3. What is the main term in the ICD-10-CM Alphabetic Index? (1.5 points) Type answer here (See next page to continue) BC3020: Week 4 – Coding Application TEST 4. What is the subterm that identifies the condition? (1.5 points) Type answer here 5. What, if any, are the additional subterms you need to reference? (1.5 points) Type answer here 6. Are there any cross reference instructions in the Alphabetic Index that should be followed? (1.5 points) Type answer here 7. What code (s) are listed for the condition in the index? (1.5 points) Type answer here 8. What is the category code referenced in the Tabular List? (1.5 points) Type answer here 9. Are there any instructional notes in the Tabular List that should be followed? (1.5 points) Type answer here 10. Have all documented diagnoses been identified for this scenario? (1.5 points) Type answer here PART 4: Assigning Codes 1. What is the CPT code for the surgical procedure? (3 points) Type answer here 2. What, if any, modifier is assigned for the radiology service? (3 points) Type answer here (See next page to continue) BC3020: Week 4 – Coding Application TEST 3. What is the ICD-10-CM code for the diagnosis? (3 points) Type answer here 4. Have all identified procedures, services and diagnoses been reported with these codes? (1 point) Type answer here
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