Let’s start with wounds, fractures, burns and surgery (with some E&M codes thrown in for good measure).
Wounds are classified as Simple, Intermediate or Complex. Simple repair is for superficial wounds involving the epidermis or dermis or subcutaneous tissue without significant involvement of deeper structures and require one layer closure. This closure includes anesthesia and chemical or electrocautery of the wound. For our purposes, we will be practicing using only the simple codes. A couple types of fractures are noted, as well as treatment for burns. A few surgical codes are listed for reference. Refer back to the E/M Codes in Chapter 10 to fill those in when needed.
Examples:
Code Description Size
12001* Simple repair of wound of scalp, neck, axillae, external genitalia, trunk
and/or extremities (including hands and feet) 2.5 cm or less
12002* Same 2.6 cm to 7.5 cm
12004* Same 7.6 cm to 12.5 cm
12005 Same 12.6 cm to 20.0 cm
Fractures – Examples:
27530 Closed treatment of tibial fracture, proximal, without manipulation
27535 Open treatment of tibial fracture, proximal plateau, unicondylar, with or without internal or external fixation
Burns – Local Treatment – Examples:
16010 Dressings and/or debridement, initial or subsequent, under anesthesia
16020 * Same as 16010 without anesthesia, office or hospital, small
Surgery – Examples:
44950 Appendectomy; (incidental appendectomy during intra-
abdominal surgery does not usually warrant a separate identification. If necessary add modifier -52 or 09952)
47562 Laparoscopy, surgical; cholecystectomy (any method)
47563 As in 47562 with cholangiography
58150 Total abdominal hysterectomy (corpus and cervix)
As you now know, the above codes are CPT codes. In order for you to do the exercises, you need some ICD codes as well. Listed here are enough codes to do the coding exercise reports. The actual ICD books have thousands of codes and, of course, cannot be reproduced here. The diagnoses are arranged in alphabetic order by condition similar to ICD-9-CM Volume II. When actually doing coding, the alphabetic listing is first located, then checked in Volume I (numeric code listing) to make certain it is the most correct numeric code option. If you are in our Coding Course, you will be using a one-volume Easy Coder.
You will need the above codes in addition to referring back to the E&M codes at the first of the section to select the appropriate one.
EXAMPLES ICD CODES (ALPHA):
Burn
leg 945.00
second degree 945.20
Cellulitis
leg, except foot 682.6
Cholelithiasis 574.5#
Note: Use the fifth digit subclassifcation = 0 (547.50) without mention of obstruction or
1 =574.51) with obstruction
with cholecystitis (chronic) 574.4
acute 574.3
Dehydration 276.5
Diabetes 250.0
Fracture, tibia, open 823.90
Hypertension
essential, unspecified 401.9
Injury, superficial, head, (and other part(s) of face, neck, or scalp, except eye) 910
Keratosis 702.##
seborrheic 702.11
Ketoacidosis 276.2
diabetic 250.1
Noninflammatory disorders of ovary, fallopian tube and broad ligament 620
620.2 Other and unspecified ovarian cyst (serous)
Pain, chest (central) 786.50
wall (anterior) 786.52
Pyelonephritis 590.80
acute 590.10
Scoliosis (acquired)(postural) 737.30
Sprain/strain
ankle 845.00
Tonsillitis (acute) 463
Urinary tract infection (NEC)* 599.0 / (NEC = not elsewhere classified)
Wound, open, scalp 873.0
complicated 873.0
THE REPORTS
The following are actual chart notes/reports. Review each report and select the appropriate CPT (treatment/procedure) and ICD (diagnosis) codes from the previous sections. Then check your answers, which are at the end of the section.
Report 1. The patient is a 7-year-old male who has not been seen in our office before who fell off a bicycle, hit his head and sustained a 3 cm scalp laceration. The wound is linear through the skin and subcutaneous tissue. The child was examined and the wound cleansed with Hibiclens. The area around the wound was infiltrated with 1% Xylocaine with epinephrine. It was repaired with #1-0 chromic and a dressing was placed. The stitches will be removed in 10 days.
1st CPT code: ____________ (hint: exam-E&M)) ICD code:________________
2nd CPT code: ____________ (hint: wound) ICD code:________________
[+ show answers]
Report 2. The patient is an 8-year-old female with a sore throat. Examination showed acute tonsillitis and she was started on penicillin. She has had these bouts in the past for which I have prescribed medication, primarily Pen-Vee K. We will do a culture and let mom know the results.
CPT code: _____________ ICD code: ______________
[+ show answers]
Report 3. The patient has ankle pain and is seen in the physician’s office. He has not been in before. He is examined and diagnosed as having an ankle sprain.
CPT code: _____________ ICD code: ______________
Report 4. The patient is a 16 Y/O male not seen by me before with itching problems on his back. On exam, seborrheic keratoses are noted. Will treat with anti-inflammatory salve and plan on surgical intervention.
CPT code: _____________ ICD code: ______________
[+ show answers]
Report 5. The patient is a 14 Y/O female who has noted back pain. She was referred here by Dr. Frame. On examination a beginning scoliosis is noted. She is referred for x-rays and will counsel with parents when those return with a treatment plan.
CPT code: _____________ ICD code: ______________
[+ show answers]
Report 6. This is a 62 Y/O gentleman who noted anterior chest wall pain this a.m. It has subsided some throughout the day. Will send him for chest x-ray and EKG this afternoon, talk to his regular attending physician and see him back tomorrow.
CPT code: _____________ ICD code: ______________
[+ show answers]
Report 7. This is a followup visit on Ms. Tarsal’s ankle sprain. The swelling has decreased; however, is not entirely gone. She is to continue on crutches, ice and elevate it and return here in one week.
CPT code: _____________ ICD code: ______________
[+ show answers]
Report 8. Ms Gardner comes in for recheck on her hypertension. BP is 190/110. Also her blood sugar was a little elevated; will change her insulin to 40 units a.m. and see her back in a week.
CPT code: _____________ ICD code: ______________ / #2_______________________
Report 9.
HOSPITAL DISCHARGE SUMMARY
ADMITTING DIAGNOSIS: 1. Diabetic ketoacidosis
DISCHARGE DIAGNOSIS: 1. Resolving diabetic ketoacidosis,
2. Resolved dehydration
CONDITION ON DISCHARGE: Improved
CHIEF COMPLAINT: Dehydration and tired.
PRESENT ILLNESS: This is a 13-year-old female first admitted to this hospital in November ‘94 with diabetic ketoacidosis and new onset diagnosis of diabetes mellitus. She was successfully treated with fluids, insulin, education and was later able to stop using insulin. Today while visiting grandmother, she apparently had a big argument with parents who left to go home, stating “we don’t want to take care of you any more,” and other relatives brought her to the ER where she was found to be hypoglycemic, acidotic, ketotic and was given saline bolus. In the ER, patient’s glucose was found to be 778 and she received ten units of insulin IV.
PAST MEDICAL HISTORY: Significant for history of febrile seizures as an infant and also six months of age. Patient also had a history of myopia, astigmatism. She also has a history of being moderately obese. Patient also has a history again of being admitted with new onset diabetes in October. She was on insulin for about three months and then discontinued insulin in January. She did not receive any oral hypoglycemics and was followed with having some low blood sugars, had exercise and diet control. She was lost to followup and again went to the clinic where per history she was reportedly
on insulin again briefly and then she was last seen at this facility in February 1996 and at that time was on a small dose of insulin but has been off insulin again for several months.
MEDICATIONS: Patient was using glucose acucheck machine but is not using it recently. Diet is regular for age. No known drug allergies.
FAMILY HISTORY: There is a strong family history of diabetes in the family. There are grandparents in the family with diabetes in the maternal grandparents with her brother receiving insulin and the maternal grandfather is on renal dialysis.
IMMUNIZATIONS: Currently up to date.
SOCIAL HISTORY: Patient is doing well in school, plays basketball, denies sexual intercourse. She does not get along with her parents and at the time of admission, stated she wanted to live with her grandmother.
PHYSICAL EXAMINATION: On admission noted to be obese, but otherwise alert, smiling, cooperative young lady in no distress, not tachypneic. Says she has been feeling tired and thirsty lately. Perfusion is good. Throat is not inflamed, lungs are clear. Breasts normal. Heart is regular rate and rhythm, without murmurs. Abdomen is soft, no pitting edema, no ulcers on feet, pedal pulses are good.
HOSPITAL COURSE: The patient was admitted with diagnosis of diabetic ketoacidosis and poor social structure. Her initial labs revealed her to have ABG of 7.256, with initial electrolytes of sodium 130, potassium 3.9, bicarb of 15, glucose of 778. Patient in the ER received IV normal saline, about 1 liter, also got 10 units of insulin IV. Her urinalysis at that time revealed 2+ ketones and 3+ glucose. Patient was admitted to the floor on just fluids. Her glucose fell to about 400. She was not placed on an insulin drip at that time, was just placed on IV fluids to correct half of her deficits over the first 8 hours, plus maintenance.
Patient’s sugars were monitored closely before meals and at bedtime. She was placed on an 1800 calorie ADA diet ad lib. Her vitals were checked every four hours with blood pressures and she was followed with Shiprock-7 in the morning. Patient’s potassium was low so 2 mEq of KCl plus 2 mEq of Kphos was added and fluids were changed to D5 1/2 normal saline 160 cc an hour on admission. Dietary, diabetes education, social services and optometry were consulted. Patient again during the hospital course continued to have dextrosticks monitored and she was given insulin sub-q regular doses after dextrosticks were obtained to be determined by the doctor. She received a total of 40 units of regular again on a p.r.n. basis, based on the doctor’s recommendation of her glucose in the first 24 hours.
Her sugars ranged between 240 and 430 during her course during that time. Patient was to be placed on a regular dosing of insulin, her sugar dropped down to 120 on 8/12 before meal at 16:30 p.m. and she had received 2 units of NPH and 2 units of regular; sugars remained stable with bedtime snacks through the night and into the next day on 8-13, sugars ranging between 260 and 380. Her final sugar prior to discharge was 188. These sugars were based on her not receiving any insulin since 1630 p.m. on 8-12 which was a dose of no insulin in the 24 hours, again with the last sugar being 188.
Patient’s electrolytes were monitored and she corrected her acidosis by the evening of 8-11-96 with improvement in her venous pH of 7.293. Her electrolytes also did return to normal with sodium and potassium normalizing well by 8-12. Followup labs on 8-13 were also within normal limits with a bicarb of 26. IV fluids were discontinued on the morning of 8-12 when patient was heplocked. A repeat UA also done on 8-11 revealed 1+ ketones and 3+ glucose. Patient continued doing her own acuchecks throughout the day of 8-13-96 and was encouraged to get out of bed and a consult was arranged with physical therapy to encourage her exercise.
ASSESSMENT: This is a 13 and 9/12 year- old female with a history of type II diabetes and obesity diagnosed in October 94. Patient was admitted with diabetic ketoacidosis which resolved largely with IV fluid hydration and some subcutaneous insulin
Patient’s acidosis also resolved and the patient was well hydrated with no neurologic compromise.
CPT: ___________________ (hospital admit)
ICD 1: ___________________ 2: ___________________
Report 10.
HOSPITAL DISCHARGE SUMMARY
ADMISSION DIAGNOSIS: Fracture of right tibia, displaced
DISCHARGE DIAGNOSIS: Same
OPERATION: Open reduction and internal fixation, right tibial fracture
PRESENT ILLNESS: Patient injured his right tibia on 29 July when he fell off his bicycle. He was initially seen in the ER and cast applied, some displacement was noted. On followup visit, displacement had increased and open reduction, internal fixation were felt to be desirable.
PAST MEDICAL HISTORY: Essentially noncontributory.
FAMILY HISTORY: Essentially noncontributory.
REVIEW OF SYSTEMS: Essentially noncontributory.
PHYSICAL EXAMINATION: Was within normal limits except for the deformity of the distal tibia.
LABORATORY DATA: Normal urinalysis. Glucose 99. BUN 7, creatinine 1.0, uric acid 6.8, all others normal. Some of the liver enzymes were somewhat elevated, specifically, AST, LD and CK. CBC showed a hemoglobin of 15 grams, hematocrit of 44.4, white count 7.7 with normal differential. X-rays confirmed the displaced fracture.
HOSPITAL COURSE: On the day following admission, patient was taken to the operating room where an open reduction, stabilization with metal plate and four screws of the fracture site were carried out. Postoperative course has been uneventful. Patient was given six doses of ancef following the surgery. He is to return in 2 weeks or as needed. In two weeks cast will be changed, sutures will be removed. He is to be nonweight-bearing until that time.
FINAL DIAGNOSIS As above.
PROCEDURES: As above.
Fracture CPT: _____________
Admission CPT: _____________
ICD: _____________
Note: Obviously, the x-ray and lab work would all be coded and charged, but in this exercise we are working on the provider (physician) codes.
[+ show answers]
Report 11.
OFFICE VISIT
DIAGNOSIS:
1. Swollen right lower extremity, rule out cellulitis, rule out DVT
PRINCIPAL PROCEDURE: Debridement
PROFILE: Patient is a 30-year-old female seen for the first time by me today. She spilled hot stew on her right leg Monday morning 8-5 sustaining a second-degree burn. She was seen and treated at Clinic with daily cleaning and silvadene dressing changes. Today, she noted rather sudden onset of fever, increased swelling of the right lower leg up to the thigh. She denies URI, gastrointestinal, UTI symptoms. She has had markedly decreased activity over the past week secondary to pain from the burn.
MEDICATIONS: Hydrocodone, codeine.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: C-section in 1986. OB: G1, P1 001.
FAMILY HISTORY: Mother and father and four out of six sisters have diabetes mellitus. There is hypertension in her brother. There is no family history of blood clots.
SOCIAL HISTORY: She is a married housewife, lives with her husband and son. No ethanol, tobacco or drug use. Last recorded PPD in 1973.
PHYSICAL EXAMINATION: Weight 242, temperature 100.7, pulse 97, blood pressure 149/97. Exam was remarkable for second-degree burn over the medial right ankle extending posterior. There is marked swelling over the right lower leg up to the lower thigh with erythema of the anterior shin and around the wound. There was also tenderness in the posterior calf and popliteal fossa, though no cords were palpated. Neurological exam was nonfocal.
LABORATORY DATA: Platelet count 301,000, white count 6.7, hemoglobin 13.7, hematocrit 41.5. Sodium 139, potassium 3.8, chloride 109, CO2 24, BUN 11, creatinine 0.6, glucose 104. Initial PT and PTT – PTT 25/27, PT 12.8/13.1.
INITIAL ASSESSMENT: Five day-old burn with relatively acute onset of swelling and fever, most likely cellulitis, but there is high risk for DVT (deep vein thrombosis), particularly with the history of decreased activity. Because of this, we will put her on full dose heparin until a venous Doppler can be obtained.
TREATMENT: I debrided the ulcer wound and applied a dressing. She was also started on penicillin and gentamicin. The heparin was titrated to maintain a PT between 1 and 1/2 and 2 1/2 x control. She will return here for followup in 2 days.
CPT debridement: ___________ ICD: ______________
CPT office visit: ___________ ICD: ______________
Note: The type of accident would have been coded under the “E” codes, which explain how the accident occurred. None were included in your reference material.
[+ show answers]
Report 12.
FOLLOWUP: [on patient in Report 11]
Patient in for followup of burn and cellulitis; after contacting Dr. Cardio, he did a Doppler on the possible DVT, which we discussed at some length; he has ruled it out for now, but I will continue to monitor her progress and the possibility. The cellulitis is slightly improved, but she’ll continue the antibiotics. She had the dressing changed today after debridement.
CPT followup: ______________ ICD: _______________
CPT debridement: ______________ ICD: _______________
Report 13.
INITIAL HISTORY AND PHYSICAL – OFFICE
CHIEF COMPLAINT: Nausea and vomiting, diffuse abdominal pain and headache.
PRESENT ILLNESS: This is a 26-year-old woman with a known history of adult onset diabetes since 1990 in her chart (although the patient said that she had only known about it for 5 months). She was on insulin while pregnant, but has not taken any medicine since then and appeared to have a poor understanding of her disease. She complained of onset Tuesday morning, prior to admission, of the above complaints; they were very diffuse without localizing symptoms. She did have generalized aches but she had no dysuria, no frequency, no bright red blood per rectum and no hematemesis. She did have a tactile fever the morning of admission.
PAST MEDICAL HISTORY: Is as above; she is otherwise healthy.
SOCIAL HISTORY: No cigarettes, no ethanol; she lives with her boyfriend.
SURGICAL HISTORY: Negative.
GYN: She is G5, P4, and had a miscarriage five months ago. LMP was current.
MEDICATIONS: Formerly NPH 10 units sub-q q.a.m.
FAMILY HISTORY: Very positive for diabetes mellitus; both her parents are on dialysis secondary to diabetes. She had no known drug allergies.
IMMUNIZATIONS: Her immunization status was unknown.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION: 8-8-96: temperature was 101, pulse was 103, blood pressure 134/69. Generally, she was an uncooperative and tired appearing young woman. She was normocephalic and atraumatic. Her extraocular movements were intact. Pupils were equal, round, reactive to light. Her throat was negative. Teeth were OK. Chest exam showed a few crackles in her right lower lobe. Her abdomen had normal bowel sounds and was soft and nontender. There were no masses. Her liver span was 7 cm in the midclavicular line. Her heart showed a normal rate and regular rhythm without murmurs, rubs or gallops. Her extremities were negative. Back showed no costovertebral angle tenderness.
LABORATORY DATA: Laboratory studies have been ordered.
ASSESSMENT AND PLAN: Diagnoses: (1) Diabetic ketoacidosis, and (2) acute pyelonephritis, although the patient did not have any costovertebral angle tenderness (she did have positive urine studies and culture which grew out E. coli). Plan was to treat with insulin, ampicillin and gentamicin.
CPT: _____________ ICD 1:_______________ 2:_________________
[+ show answers]
Report 14.
HOSPITAL DISCHARGE SUMMARY
ADMITTING DIAGNOSIS: Symptomatic cholelithiasis
DISCHARGE DIAGNOSIS: Same
PRESENT ILLNESS: This is a 76-year-old female with a 3 to 4 year history of fatty food intolerance resulting in epigastric pain. The pain sometimes radiates to the back and lasts for several hours. She denies nausea and vomiting and she reports that the attacks occur approximately weekly. She denies fever or jaundice. She did have peptic ulcer disease many years ago. She has no history of hepatitis. She does have a history of coronary artery disease and is status post angioplasty in 1992, and now denies chest pain. Right upper quadrant ultrasound done 3/96 showed multiple gallstones; bile duct was normal.
PAST MEDICAL HISTORY: Significant for coronary artery disease and mild dementia and hypertension. Past surgical history is significant for appendectomy.
MEDICATIONS: Aspirin, enteric coated, 325 mg p.o. q.day, nitroglycerin sublingual prn, use on an occasional basis.
ALLERGIES: Reported to codeine, causing dizziness.
REVIEW OF SYSTEMS: She describes occasional chest pain and denies edema or cough.
PHYSICAL EXAMINATION: Vital signs: temperature 98.7, pulse 49, blood pressure 129/72, weight 46.9 kg. In general, she is an elderly female in no acute distress. She is alert. She perseverates slightly. HEENT: normocephalic, atraumatic. Extraocular movements are intact. Pupils equal, round, reactive to light, sclera anicteric, conjunctiva clear, mouth moist without lesions. Throat is without erythema or exudate. Neck is nontender without masses. Carotid pulses are 2+ and equal. Lungs are clear to auscultation and equal. Back is CVA nontender. Heart is bradycardic without murmur. Abdomen is soft and flat and nontender without masses. There is a well-healed lower midline scar. Extremities are without cyanosis, clubbing or edema. Neurologic exam was nonfocal.
HOSPITAL COURSE: She was admitted to the hospital as an a.m. admission for surgery. She was taken to the operating room, where, under general endotracheal anesthesia, she underwent laparoscopic cholecystectomy with intraoperative cholangiogram. Findings at the time of surgery were a single, large obstructing stone in the gallbladder. The intraoperative cholangiogram was within normal limits. She tolerated the procedure well. Postoperatively, she was taken to the recovery room and subsequently returned to the ward. She had an uneventful postoperative course. She was started on a liquid diet on the evening following surgery and advanced to a regular diet on the following day. She tolerated the low fat diet well and is discharged home in good condition on the first postoperative day.
FINAL DIAGNOSIS: Acute cholelithiasis and cholecystitis
PROCEDURES: Cholecystectomy with intraoperative cholangiogram
CPT admit code: _____________ ICD code:______________________
CPT surgical code:_____________ ICD code:______________________
Report 15.
HOSPITAL DISCHARGE SUMMARY
DIAGNOSIS:
1. Left ovarian papillary serous cystadenoma
PROCEDURES:
1. Total abdominal hysterectomy
REASON FOR ADMISSION: Patient is a 54 year old gravida 5, para 5-0-0-4, post menopausal woman with a long history of left lower quadrant pain. Left adnexal mass was diagnosed on ultrasound on 4-22, 5 x 6 cm, complex, solid and cystic. Patient had been scheduled for surgery on May 1 but did not present for surgery. She then presented complaining of continued abdominal and back pain and desired surgery.
PHYSICAL EXAMINATION: Significant for left lower quadrant/left adnexal mass and an ultrasound done on 4-22-96 showed a 5 x 6 x 7 cm left adnexal mass, septated, sonolucent, with positive internal echoes, no free fluid. Appearance consistent with a serous cystadenomna or ovarian carcinoma.
HOSPITAL COURSE: The patient was admitted on the evening of 7-31-96 preoperatively. Her preop labs were within normal limits with a hemoglobin of 14.7, platelets of 367. Potassium 4.1. Normal EKG. Negative chest x-ray. Patient underwent surgery on 8-1-96, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy and peritoneal washings under general anesthesia without complications. Estimated blood loss 350 cc. Findings were significant for a small uterus; the left ovary had multiple fluid-filled cysts with smooth walls, no internal papillations, but a very firm, white, solid area in the center of the mass. The appendix was grossly normal. There was no ascites and no other evidence of metastases. Patient had a benign postoperative course. She remained afebrile throughout with good urine output. Her postoperative hemoglobin was 12.0. She was advanced to clears on postop day 1. By postop day 2, had tolerated a soft diet and was anxious for discharge. Her examination was benign and she was considered stable for discharge home. Staples were removed and steristrips placed over the incision. Patient had a urine culture and sensitivity study, which grew pan sensitive E. coli, and she was treated for the infection.
CPT code for admit: _____________ ICD: ____________________
CPT code for surgery:_____________ ICD: ____________________
CPT code for incidental surgery:____________
Other notable ICD:____________ [Hint: See postop problems]
SCORING: There are 46 questions. Take your total number of correct answers and divide by 46 to get your score. My score: ___________