Certified Professional Coder (CPC) Quiz: Code Full Case Scenario

OFFICE NOTE: Patient is a 62-year-old male with a known diagnosis of Type 2 diabetes mellitus, managed on metformin and insulin. Lab results today show an eGFR of 42 mL/min/1.73m2, consistent with Stage 3 chronic kidney disease. The physician documents: 'Type 2 diabetic chronic kidney disease, Stage 3.' Plan includes nephrology referral and ACE inhibitor therapy.

Which ICD-10-CM code is assigned for the diabetic kidney complication?

OPERATIVE NOTE: On Monday, a surgeon performed a right simple mastectomy for ductal carcinoma in situ (DXIS Stage 0). The patient remained within the global postoperative period. Fourteen days later, the same surgeon performed a planned right breast reconstruction with tissue expander placement, which had been discussed and scheduled before the mastectomy.

Which modifier is appended to the reconstruction procedure to indicate it is a staged, planned procedure by the same surgeon during the postoperative period?

OFFICE NOTE: A general surgeon performs an office consultation with a patient referred for evaluation of a symptomatic gallstone. At the conclusion of the visit, the surgeon decides to schedule an open cholecystectomy to be performed the following morning. An E&M service is documented on the date of the consultation.

Which modifier is appended to the E&M service reported by the surgeon for the consultation visit?

PROCEDURE NOTE: Patient is a 68-year-old male who underwent a total right knee arthroplasty 5 days ago. He presents today with significant right knee swelling and pain. The treating orthopedic surgeon (same surgeon who performed the arthroplasty) takes the patient back to the operating room and performs open drainage of an acute postoperative hematoma of the right knee, related to the prior arthroplasty.

Which modifier is appended to the hematoma drainage procedure to indicate a return to the operating room for a complication of a prior procedure during the global period?

OPERATIVE NOTE: Patient is a 55-year-old female undergoing elective laparoscopic sleeve gastrectomy. Pre-operatively, the anesthesiologist's note requests a routine preoperative evaluation by the internist. The internist's visit note documents a complete history and physical examination, review of labs, and clearance for anesthesia. No cardiovascular abnormalities are identified.

Which ICD-10-CM code is assigned as the primary reason for the internist's preoperative evaluation encounter?

OFFICE NOTE: Patient is a 71-year-old female with Type 2 diabetes mellitus managed on oral agents. She presents today reporting numbness and tingling in both feet for the past year. Neurological examination demonstrates decreased monofilament sensation bilaterally. The physician documents: 'Type 2 DM with peripheral diabetic neuropathy, unspecified.'

Which ICD-10-CM code is assigned for the diabetic neuropathy?

OPERATIVE NOTE: A dermatologist performs paring and cutting of a hyperkeratotic skin lesion (plantar callus) (11056) and separately excises a different benign lesion from an unrelated anatomic site (11401) during the same encounter. Both procedures are fully documented. The dermatologist submits both codes on the same claim.

Which modifier is appended to the lower-value secondary procedure to indicate multiple procedures were performed in the same session?

OFFICE NOTE: Patient is a 52-year-old female presenting to the dermatologist for a scheduled cryotherapy treatment of an actinic keratosis on the forearm. During the same visit, the patient mentions a new, mildly pruritic rash on the trunk. The dermatologist performs a complete separate evaluation, documents findings consistent with contact dermatitis, and prescribes a topical corticosteroid. Both the cryotherapy and the evaluation of the new rash are fully documented.

Which modifier is appended to the E&M service to allow it to be separately reported on the same date as the cryotherapy?

OPERATIVE NOTE: Patient is a 67-year-old male with right-sided colon cancer. The surgeon performs a laparoscopic right hemicolectomy. During the procedure, moderate omental adhesions are encountered and lysed to facilitate adequate visualization and mobilization of the right colon. The surgeon notes 'adhesiolysis performed to complete the colectomy.' No separate procedure report for adhesiolysis is generated.

May the surgeon additionally report CPT 44180 (laparoscopic lysis of adhesions) on this claim?

EMERGENCY DEPARTMENT NOTE: Patient is a 61-year-old male presenting with acute crushing substernal chest pain radiating to the left arm, diaphoresis, and ST elevations in the inferior leads (II, III, and aVF) on ECG. Troponin elevated. Cardiology is contacted and the patient is taken emergently to the cardiac catheterization laboratory. Working diagnosis: acute inferior ST-elevation myocardial infarction.

Which ICD-10-CM code category is assigned for this acute inferior STEMI?

OFFICE NOTE: Patient is a 28-year-old female who has had Type 1 diabetes mellitus since childhood, currently managed with an insulin pump. She presents today for evaluation of a new non-healing ulcer on the plantar surface of the right foot. The physician documents: 'Type 1 DM with right foot ulcer (plantar surface).' An additional code is required for the ulcer site.

Which ICD-10-CM code is assigned for the diabetic foot ulcer in a patient with Type 1 DM?

OFFICE NOTE: Patient is a 50-year-old male who had an open inguinal hernia repair 12 days ago. He presents to the operating surgeon's office for his routine 2-week postoperative wound check. The wound is healing well, sutures are intact, no complications are noted. No new or unrelated conditions are addressed at this visit.

How should the surgeon code this routine postoperative follow-up visit?

REHABILITATION NOTE: Patient is a 69-year-old male presenting for outpatient physical therapy evaluation 4 months after suffering a left hemisphere cerebral infarction. The acute stroke has resolved; however, the patient has persistent right-sided hemiparesis affecting his dominant right hand and arm, limiting his ADLs.

Which ICD-10-CM code is assigned for this late-effect presentation?

OFFICE NOTE: Patient is a 74-year-old male with a long-standing history of essential hypertension, currently managed with an ACE inhibitor. He also has systolic heart failure (EF 35%) diagnosed 2 years ago and attributed by his cardiologist to his hypertension. The visit note documents: 'hypertensive heart disease with systolic heart failure.'

Which ICD-10-CM code combination is assigned for this patient's documented conditions?

OFFICE NOTE: A surgeon evaluates a new patient in the office for symptoms consistent with a large-bowel obstruction. After reviewing imaging and clinical findings, the surgeon makes the decision to perform an open right colectomy (major surgery, 90-day global period) as urgent intervention, discusses the risks and benefits, obtains informed consent, and documents the operative decision. The colectomy is performed later that same day at the hospital.

Which modifier is appended to the E&M service to allow it to be separately reported on the day of the major surgery?

OFFICE NOTE: Patient is a 66-year-old male presenting for a routine cardiology follow-up. He had a drug-eluting coronary stent placed in the left anterior descending artery 2 years ago for stable coronary artery disease. He is asymptomatic today, on aspirin and a statin, with no new symptoms or ischemia. The cardiologist documents 'stable coronary artery disease, native vessel.'

Which ICD-10-CM code is assigned as the primary diagnosis for this encounter?

OPERATIVE NOTE: A urologist serves as the surgical assistant during a complex radical cystectomy performed by a gynecologic oncologist. The urologist's role is limited to providing assistance with ureteral dissection and hemostasis. The urologist submits a claim for assistant surgeon services.

Which modifier is appended to the urologist's claim to indicate the assistant surgeon role?

OFFICE NOTE: Patient is a 45-year-old female who had a laparoscopic appendectomy performed 10 days ago by her surgeon. She presents today to the same surgeon's office complaining of a sore throat, nasal congestion, and low-grade fever over the past 2 days. The surgeon examines her and confirms she has an upper respiratory infection with no wound-related issues. The surgeon documents and manages only the URI.

Which modifier is appended to the E&M service to indicate it is an unrelated service during the postoperative global period?

PROCEDURE NOTE: Patient is a 47-year-old female undergoing lysis of intraperitoneal adhesions during laparoscopic cholecystectomy. The surgeon documents that dense adhesions between the omentum and the gallbladder were lysed to gain access to the triangle of Calot and complete the primary procedure. No separate lysis of adhesions procedure was independently indicated.

How should the lysis of adhesions (44180) be reported in relation to the laparoscopic cholecystectomy (47563)?

OFFICE NOTE: Patient is a 58-year-old male presenting for a 3-month follow-up visit after a myocardial infarction that occurred 7 weeks ago. The patient is asymptomatic, cardiac rehabilitation is progressing well, and the prior MI is documented as healed and resolved. No current ischemia or active cardiac event is noted.

Which ICD-10-CM code is assigned for the prior myocardial infarction at this follow-up visit?