Medical case scenario Q and A, health and medicine homework help

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xevyrl2005

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Read the following Case Scenario

  • Using your ICD-10-CM, CPT, and HCPCS coding manuals, answer the questions in Parts 1 through 4 below for this scenario.
* NOTE: Be sure to assign a history code to indicate previous tobacco dependence.

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BC3030: Week 2 - 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. 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) BC3030: Week 2 - 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 for this scenario. * NOTE: Be sure to assign a history code to indicate previous tobacco dependence. CASE SCENARIO: LOCATION: Outpatient, Hospital PATIENT: Harold White ATTENDING PHYSICIAN: Jeff King, MD SURGEON: Jeff King, MD PREOPERATIVE DIAGNOSES 1. Left true vocal cord mass. 2. Hoarseness. POSTOPERATIVE DIAGNOSIS: Same as Preoperative. OPERATIVE PERFORMED: Direct laryngoscopy with use of operating microscope for excision of a left anterior true vocal cord mass. ANESTHESIA: Endotracheal. INDICATIONS: A 65-year-old male with chronic hoarseness. He has a long-term history of tobacco use but finally was able to quit 2 years ago. Examination reveals a mass involving the anterior portion of the left true vocal cord. PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating room table in the supine position. After an adequate level of general endotracheal anesthesia was obtained, the patient was positioned for direct laryngoscopy. The laryngoscope was placed in position. There were no lesions in the oropharynx or hypopharynx. This was placed into the suspension. The microscope was then brought in. An exophytic mass was noted involving the anterior third of the left true vocal cord extending to the area of the anterior commissure. Utilizing the forceps and the micro scissors, the mass was excised. Hemostasis was achieved with pledgets soaked with 1:100,000 units of epinephrine. The laryngoscope was then removed and the patient turned over to anesthesia. The patient tolerated the procedure well, and there was no break in technique. The patient was extubated and taken to the post-anesthetic care unit in good condition. Pathology Report Later Indicated: Adenocarcinoma, poorly diffused, primary. (See next page to continue) BC3030: Week 2 - 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. Was the laryngoscopy performed direct or indirect? (1 point) Type answer here 4. Does the use of the operating microscope affect the code assignment? If yes, briefly explain how it affects the code choice? (2 points) Type answer here 5. The primary diagnosis is identified based on what report? (2 points) Type answer here 6. What other documented factor affects the ICD-10-CM code assignment? (2 points) Type answer here 7. The physician documented a history of asthma and reflux disease. Is it necessary to assign codes for these conditions, or are they just elements of the patient’s medical history? (2 points) Type answer here (See next page to continue) BC3030: Week 2 - Coding Application TEST 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 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. Briefly describe what is” included” in a laryngoscopy examination according to the guidelines preceding the code choice for this procedure? (2 points) Type answer here PART 3: Diagnosis 1. What is the documented condition to be coded? (1 point) Type answer here (See next page to continue) BC3030: Week 2 - Coding Application TEST 2. What is the main term in the ICD-10-CM Alphabetic Index? (1 point) Type answer here 3. What is the subterm that identifies the condition? (1 point) Type answer here 4. What, if any, are the additional subterms you need to reference? (1 point) Type answer here 5. Are there any cross reference instructions in the Alphabetic Index that should be followed? (1 point) Type answer here 6. What code (s) are listed for the condition in the index? (1 point) Type answer here 7. Are there any instructional notes in the Tabular List that should be followed? (1 point) Type answer here 8. What is the documented history condition to be coded? (1 point) Type answer here 9. What type of history is referenced in the Alphabetic Index? (1 point) Type answer here 10. What is the main term in the ICD-10-CM Alphabetic Index? (1 point) Type answer here (See next page to continue) BC3030: Week 2 - Coding Application TEST 11. What is the subterm that identifies the history of tobacco dependence? (1 point) Type answer here 12. Are there any cross reference instructions in the Alphabetic Index that should be followed? (1 point) Type answer here 13. What code (s) are listed for the condition in the index? (1 point) Type answer here 14. Are there any instructional notes in the Tabular List that should be followed? (1 point) Type answer here 15. Have all documented diagnoses been identified for this scenario? (1 point) Type answer here PART 4: Assigning Codes 1. What is the CPT code for the procedure? (3 points) Type answer here 2. What is the ICD-10-CM code for the first listed diagnosis? (3 points) Type answer here 3. What is the additional ICD-10-CM code reported for this encounter? (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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Explanation & Answer

Hallo, please find the attached file and feel to ask for any clarifications.Regards

BC3030: Week 2- 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. 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-ref...


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