Aapc Cpc Practice Exam notes

CASE 1 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. (Indications for surgery.) POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. (An excision with intermediate closure was performed.) INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlargin...

CASE 1 10-Year-old established patient (The patient is established.) presents today for well child check (Patient presents for a preventive exam.) with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient coopera...

CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week f...

CASE 1 CRNA performed anesthesia (Use Modifier QX to indicate CRNA services with medical direction by a physician.) Anesthesiologist medically directing two cases (Use modifier QK to indicate medical direction of two cases.) Anesthesia Time: 9:30 to 10:06 Physical Status 3 (Physical status 3 - use P3 modifier.) PREOPERATIVE DIAGNOSIS: Cyst on knee POSTOPERATIVE DIAGNOSIS: Baker's Cyst (Use post-operative diagnosis.) PROCEDURE: Excision of Baker's Cyst, knee (Excision is an open procedur...

CASE 1 Location: Regional Hospital(Performed at the hospital, the radiologist will only code for the professional component.) CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast (Three separate CT scan performed: Thorax (chest), Abdomen, Pelvis) EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX. COMPARISON: CT chest Regional Hospital 7/8/20XX. HISTORY: Non-small-cell lung cancer. (Pt has non-small cell lung CA.) ...

CASE 1 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the...

CASE 1 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer.(Report this diagnosis if no further findings are found in the notes.) Procedure Performed: Video-assisted thoracoscopy,(Indication the procedure is being performed by Video Assisted Thoracic Surgery (VATS).) lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position....

CASE 1 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introd...

Diagnosis: Calcification left basal ganglia. Where are the basal ganglia located? - Cerebral Cortex Diagnosis: Vesicoureteral reflux. What is this a reflux of? - Urine backflow from bladder into ureters Documentation: The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. In this statement, what does "os" stand for? - Ostium (opening) Hysterosalpingogram report: "Right cornual contour abnormality." Where is the cornu (plural cornua) found anatomical...

A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. - A. Mother's insurance plan Which managed care plan has the patient receiving care from participating p...

A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. - A. Mother's insurance plan Which managed care plan has the patient receiving care from participating p...

CASE 1 Location: Regional Hospital(Performed at the hospital, the radiologist will only code for the professional component.) CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast (Three separate CT scan performed: Thorax (chest), Abdomen, Pelvis) EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX. COMPARISON: CT chest Regional Hospital 7/8/20XX. HISTORY: Non-small-cell lung cancer. (Pt has non-small cell lung CA.) ...

CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week f...

CASE 1 CRNA performed anesthesia (Use Modifier QX to indicate CRNA services with medical direction by a physician.) Anesthesiologist medically directing two cases (Use modifier QK to indicate medical direction of two cases.) Anesthesia Time: 9:30 to 10:06 Physical Status 3 (Physical status 3 - use P3 modifier.) PREOPERATIVE DIAGNOSIS: Cyst on knee POSTOPERATIVE DIAGNOSIS: Baker's Cyst (Use post-operative diagnosis.) PROCEDURE: Excision of Baker's Cyst, knee (Excision is an open procedur...

CASE 1 ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal ...

CASE 1 10-Year-old established patient (The patient is established.) presents today for well child check (Patient presents for a preventive exam.) with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient coopera...

CASE 1 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the...

CASE 1 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer.(Report this diagnosis if no further findings are found in the notes.) Procedure Performed: Video-assisted thoracoscopy,(Indication the procedure is being performed by Video Assisted Thoracic Surgery (VATS).) lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position....

CASE 1 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introd...

CASE 1 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. (Indications for surgery.) POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. (An excision with intermediate closure was performed.) INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlargin...