BC3020: Week 1 - 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) BC3020: Week 1 - 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: Mike Bahas ATTENDING PHYSICIAN: Loren White, MD CONSULTANT: Timothy Pleasant, MD REASON FOR CONSULTATION: Rule out neck injury. HISTORY: This patient is a 17-year-old male who was involved in a motor vehicle accident last night. He remembers driving down the road and the next thing he remembers was trying to reach for his cell phone at a stop sign after the accident. He does not remember any of the details. The car apparently went off the road and hit a tree. The patient is amnesiac for the event but does not believe he lost consciousness. His vehicle was apparently traveling 35-40 miles an hour. There was no report that he was ejected from the vehicle. PAST MEDICAL HISTORY: He had childhood asthma. MEDICATIONS: None. ALLERGIES: None. FAMILY HISTORY: Noncontributory to the present problem. SOCIAL HISTORY: He chews tobacco. Alcohol use is rare. EXAMINATION: Vital signs show he is afebrile. Pulse 64. Blood pressure 110/50. Neurologic: He is awake, alert, and fully oriented. His cranial nerves are grossly intact. HEENT: His extraocular movements are full. His eyes are conjugate. His pupils are equal. His facial strength is intact. On motor examination, he has grossly normal motor strength bilaterally in the upper and lower extremities. His reflexes are normal and symmetric at the biceps, triceps, and brachioradialis. The ankle jerks and the knee jerks are normal and symmetric. Gait is not tested. Sensory examination is grossly intact to light touch. Spine examination: The patient's cervical collar was removed. He has no tenderness to palpation of the cervical spine whatsoever. The x-rays of the cervical spine, as well as the CT scan of the cervical spine, were reviewed. No fractures or subluxations are noted. CT scan of the head was reviewed, and it is negative for any intracranial pathology. IMPRESSION/PLAN: In summary, we have a 17-year-old male involved in a motor vehicle accident. He has a mild concussive head injury, as evidenced by his amnesia, and I believe he did lose consciousness for a brief period; however, the exact amount of time for his loss of consciousness is unknown. There is no evidence of any cervical spine injury. The patient is neurologically normal. He does not need to wear a cervical collar. I explained to him and his mother, Gloria, that if the patient develops any weakness, numbness, or tingling in the arms or legs, trouble with his balance, sleepiness, vomiting, weakness of one side of the body, or any other symptoms, they should call their physician immediately. I want to thank Dr. White for asking me to see this patient. BC3020: Week 1 - Coding Application TEST (See next page to continue) BC3020: Week 1 - Coding Application TEST PART 1: Abstracting 1. What is the name of the physician performing the E/M service? (1 point) Loren White M.D 2. What type of E/M service is being reported? (2 points) 99201 3. What is the place of service and the patient status? (2 points) Outpatient 4. How many key components need to be met for this type of E/M service? (1 point) 3 5. What is the level of history for this E/M service? (2 points) Type answer here 6. What is the level of examination for this E/M service? (2 points) Type answer here 7. What is the level of medical decision making for this E/M service? (2 points) Type answer here PART 2: Evaluation and Management Service 1. What code range is listed in the Alphabetic Index for this type of E/M service? (1 point) Type answer here (See next page to continue) BC3020: Week 1 - Coding Application TEST 2. What section in the Tabular List of the CPT manual did you find the code(s)? (1 point) Type answer here 3. What is the name of the subheading where the correct code is located? (1 point) Type answer here 4. Are there any relevant guidelines or parenthetic notes associated with the E/M service that should be referenced? (1 point) Type answer here 5. What is the level of service for this E/M service? (1 point) Type answer here PART 3: Diagnosis 1. What is the documented condition to be coded? (1 point) Type answer here 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 (See next page to continue) BC3020: Week 1 - Coding Application TEST 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. What is the category code referenced in the Tabular List? (1 point) Type answer here 8. Are there any instructional notes in the Tabular List that should be followed? (1 point) Type answer here 9. Have all documented diagnoses been identified for this scenario? (1 point) Type answer here 10. What is the documented external cause for the condition to be coded? (1 point) Type answer here 11. What is the name of the index referenced for the external cause code? (1 point) Type answer here 12. What is the main term in the ICD-10-CM External Cause Index? (1 point) Type answer here 13. What is the subterm that identifies the specific external cause? (1 point) Type answer here (See next page to continue) BC3020: Week 1 - Coding Application TEST 14. What, if any, are the additional subterms you need to reference? (1 point) Type answer here 15. Are there any cross reference instructions in the External Cause Index that should be followed? (1 point) Type answer here 16. What code (s) are listed for the condition in the index? (1 point) Type answer here 17. What is the category code referenced in the Tabular List? (1 point) Type answer here 18. Are there any instructional notes in the Tabular List that should be followed? (1 point) Type answer here PART 4: Assigning Codes 1. What is the CPT code for the Evaluation and Management service? (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