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BC3020 Week 3 Coding Applications

1.RADIOLOGY REPORT

LOCATION: Hospital, Outpatient PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD EXAMINATION: Gallbladder ultrasound. CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

What is the name of the physician that you are coding for? ____________________

2.RADIOLOGY REPORT

LOCATION: Hospital, Outpatient PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD EXAMINATION: Gallbladder ultrasound. CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

What subsection is reviewed for the CPT code? ____________________

3.RADIOLOGY REPORT

LOCATION: Hospital, Outpatient PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD EXAMINATION: Gallbladder ultrasound. CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

What code range is reviewed to select the appropriate CPT code? ____________________

4.RADIOLOGY REPORT

LOCATION: Hospital, Outpatient PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD

ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD

RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD

EXAMINATION: Gallbladder ultrasound.

CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario?

ICD-9-CM: __________

5.RADIOLOGY REPORT

LOCATION: Hospital, Outpatient PATIENT: Dan Diel

ORDERING PHYSICIAN: Daniel G. Olanka, MD ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD RADIOLOGIST: Morton Monson, MD

PERSONAL PHYSICIAN: Ronald Green, MD EXAMINATION: Gallbladder ultrasound. CLINICAL SYMPTOMS: Increased bilirubin.

GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.

IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.

Identify the correct CPT-4 procedure (ICPT) code(s) for the above scenario?

CPT-4: _________ Modifier: __________

6.A patient presents to the laboratory at the clinic for the following tests: thyroid-stimulating hormone, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count (CBC).

Identify the correct procedure (CPT-4) code for this service: CPT-4: __________

7.An 80-year-old female patient with Cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct diagnosis (ICD-9-CM) code for the above scenario. ICD-9-CM: __________

8.An 80-year-old female patient with Cushing’s syndrome presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein (direct measurement, HDL and LDL), and triglycerides.

Identify the correct procedure (CPT-4) code for the above scenario: CPT-4: __________

CPT-4: __________

9.A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct diagnosis (ICD-9-CM) code(s) for the above scenario: ICD-9-CM: __________

10.A physician prescribes digoxin for treating a patient diagnosed with congestive heart failure. After six months, the physician performs a therapeutic drug test to monitor the level of the drug on the patient.

Identify the correct procedure (CPT-4) code(s) for the above scenario. CPT-4: __________