Bc3030 Wk 2 Coding Test

3723 words 15 pages
Course BC3030X: Billing and Coding Applications with Simulations (12-17-2012) Section 8
Test Week 2 - Coding Applications Test
• Question 1
Needs Grading LOCATION: Outpatient, Hospital
PATIENT: Kim Fields
PHYSICIAN: Gregory Dawson. MO
ENTRANCE DIAGNOSIS: Dyspnea on ascending hills and stairs. Frequent wheezing and productive cough in a patient with a 0.75-pack-year smoking history; quit 1 year ago. Gave good consistent effort.
I. Baseline spirometry is normal with maybe a hint of concavity towards the volume axis at the terminal portion of the curve. The spirometry does show only a 61%
FEF2S-7S indicating peripheral dysfunction, i.e., mild COPD/emphysema.
II. Baseline FEVI of 3.02. which was 84% of
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0 silk stay sutures were placed on either side of the trachea through the second and third rings. An incision was then made in the second and third rings, also creating a low pocket so that a #8 Shiley trach tube could be placed. After the opening was made, the endotracheal tube was pulled back so that the tracheostomy tube through the neck could be placed. Once it was in place, it was hooked to ventilation. The stay sutures were left in place. The tracheostomy tube was then tied around the trachea opening. The skin was injected with 0.5% Marcaine with epinephrine; a total of 8 cc was used. The patient tolerated the procedure and returned to the intensive care unit in stable condition.
CPT SERVICE CODE(S): ___________________________________________________
ICD-9-CM DX CODE(S): _______________________________________________
Selected Answer: [None Given]
Correct Answer:
Professional Services: 31600-22-78 (Tracheostomy, Planned)
ICD-9-CM DX: 518.81 (Failure/failed, respiration/respiratory, acute), 486 (Pneumonia), V46.11 (Dependence, on, respirator [ventilator])
The service is a planned tracheostomy reported with 31600. The report indicates that due to the patient's short neck, the operation was more difficult. Modifier -22 (unusual procedural service) was added to indicate that the procedure was more difficult than usual. The return to the operating room for a related procedure during the postoperative period as was indicated in the directions


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