Chapter 19: CPT Evaluation & Management Section Workbook Case 8 Answers and Rationale.
XYZ Nursing Home
Subjective: The patient appears to be a little more altered than normal today. |1| He is in some obvious discomfort. |2| However, he is not able to communicate due to his mental status. |3| Patient does appear fairly anxious.
Physical Exam: Glucoses have been within normal limits. |4| Patient has had poor p.o. intake, |5| however, over the last 2-3 days. |6| Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. |7| Extraocular movements are intact. |8| Oral pharynx is clear. |9| Lungs are clear to auscultation bilaterally. |10| Heart has a regular rate and rhythm. |11| Abdomen is nontender and nondistended. |12| Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. |13| Patient indicates he hurts everywhere.
Ancillary Studies: A.M. labs—none new this morning. X-ray shows no evidence of fracture with definitive arthritis. |14| Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias. |15|
Assessment & Plan:
1.Patient is an 84-year-old Caucasian male who presented after a fall with rib contusion, |16| right shoulder pain and uncontrolled pain since. |17| He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient’s mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning.
2. Patient with elevated blood pressures |18| upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently.
3. Very advanced dementia, |19| will follow, continue on home medications.
4. Coronary artery disease and congestive heart failure. |20| These appear stable at this time.
5. History of atrial fibrillation, |21| sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control.
6. Type 2 diabetes mellitus. |22| Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia.
7. We will follow the patient closely and adjust medications as necessary.
|1| HPI: quality.
|2| HPI: Severity.
|3| The physician is unable to obtain a history due to the patient’s mental status.
|4| ROS: Endocrine.
|5| HPI: Quality again.
|6| HPI: Duration.
|7| Exam: Constitutional.
|8| Exam: Eye.
|9| Exam: Mouth and throat.
|10| Exam: Respiratory.
|11| Exam: Cardiovascular.
|12| Exam: Abdomen.
|13| Exam: Musculoskeletal.
|14| Reviewed X-ray.
|15| Reviewed telemetry.
|16| Primary diagnosis.
|17| Condition is not stable.
|18| Additional diagnosis.
|19| Additional diagnosis.
|20| Additional diagnosis.
|21| Additional diagnosis.
|22| Additional diagnosis.
What are the CPT® and ICD-10-CM code(s) reported?
CPT® Code: 99309
ICD-10-CM codes: S20.211A, M25.511, R03.0, F03.90, I25.10, I50.9, I48.91, E11.9, Z79.84
Rationale:
CPT® code: Subcategory—Subsequent Nursing Facility Care (2 of 3 key components), coded using 1995 guidelines
History: Expanded problem focused (3 HPI, 1 ROS)
Exam: Detailed (7 Organ systems with musculoskeletal detailed)
MDM: Moderate complexity (Extensive diagnosis, 2 items reviewed (X-ray & Telemetry), Moderate Risk (One or more stable chronic illnesses)).
ICD-10-CM codes:
1. Rib Contusion causing pain. In the ICD-10-CM Alphabetic Index, look for Contusion/chest (wall) – see Contusion, thorax. Look for Contusion/thorax (wall)/front referring you to S20.21-. Turn to the Tabular List to complete the code. Complete code is S20.211A. The Physical exam in the case documents that there is bruising over the lateral ribcage on the right side and this is the first time the patient is being seen for this injury reporting the letter A as the 7th character.
2. Shoulder pain. Look in the Alphabetic Index for Pain(s)/joint/shoulder or Pain(s)/shoulder referring you to M25.51-. Go to the Tabular List to complete the code. The Physical exam and the Assessment & Plan in the case documents that there is pain in the right shoulder. Complete code is M25.511.
3. The elevated blood pressure is not stated as hypertension. Because the patient had high blood pressure upon admission and it is still a little high, you will want to query the physician to see if this is elevated blood pressure, or hypertension. Look in the Alphabetic Index for Elevated, elevation/blood pressure/reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension referring you to R03.0. It is coded because there was a medication change and the blood pressure will be monitored. Verify code selection in the Tabular List.
4. Dementia is coded because it is being followed and the home meds will be continued. Look in the Alphabetic Index for Dementia referring you to F03.90. Verify code selection in the Tabular List.
5. CAD is for coronary artery disease. Look in the Alphabetic Index for Disease, diseased/coronary – see Disease, heart, ischemic, atherosclerotic. Look for Disease, diseased/heart/ischemic/atherosclerotic referring you to I25.10. Verify code selection in the Tabular List.
6. CHF is for congestive heart failure. Look in the Alphabetic Index for Failure, failed/heart/congestive referring you to I50.9. Verify code selection in the Tabular List.
7. Patient has history of atrial fibrillation, currently controlled with telemetry monitor. Look in the Alphabetic Index for Fibrillation/atrial or auricular (established) referring you to I48.91. Verify code selection in the Tabular List.
8. Blood glucose is reviewed for type 2 DM. Look in the Alphabetic Index for Diabetes, diabetic/type 2 referring you to E11.9. Verify code selection in the Tabular List.
9. The patient is on long-term glipizide to control his blood sugar, although they are holding it temporarily. Look in the Alphabetic Index for Long-term (current) (prophylactic) drug therapy (use of)/oral/hypoglycemia referring you to Z79.84.
Verify code selection in the Tabular List.