CPC Exam Dumps : Certified Professional Coder (CPC) Exam

View MR 099407

MR 099407

Emergency Department Visit

Chief Complaint: VOMITING.

This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).

REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.

PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.

Medications: See Nurses Notes.

Allergies: PCN.

SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.

ADDITIONAL NOTES: The nursing notes have been reviewed.

PHYSICAL EXAM

Appearance: Lethargic. Patient in mild distress.

Vital Signs: Have been reviewed-tachycardic.

Eyes: Pupils equal, round and reactive to light.

ENT: Dry mucous membranes present.

Neck: Normal inspection. Neck supple.

CVS: Tachycardia. Heart sounds normal. Pulses normal.

E D. Course: Insulin IV drip per protocol, at 10 units/hr.

Zofran 8 mg 01:33 Jul 13 2008 IVP.

Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.

Total critical care time: 45 min.

Disposition: Admitted to Intensive Care Unit. Condition: stable.

Admit decision based on need for monitoring and IV hydration and medications.

CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.

What E/M code is reported for this encounter?

A Medicare patient that is on dialysis for ESRD is seen by the nurse for a Hep B vaccination. This patient is given a dialysis patient dosage as part of a three-dose schedule. The nurse administers the Hep B vaccine in the right deltoid. The physician reviews the chart and signs off on the nurse's note.

What procedure and diagnosis codes are reported for the scheduled vaccine injection for this Medicare patient?

The documentation states:

He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger’s lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.

What surgical approach was used for this procedure?