HIT 251 CODING PRACTICUM (MEDICINE SECTION ENCOUNTERS) What are the CPT and ICD-10-CM codes? Date of...

HIT 251 CODING PRACTICUM (MEDICINE SECTION ENCOUNTERS)

What are the CPT and ICD-10-CM codes?

Date of Exam: 3/16/2012

Time of Exam: 3:20:41 PM

Patient Name: Smith, Anna Anna shows minimal treatment response as of today. Anna continues to exhibit symptoms of a generalized anxiety disorder. Symptoms continue the same in frequency and intensity, and no significant improvement is noted. Symptoms of this disorder occur more days than not. Sleep difficulty continues unchanged. Feelings of increased muscular tension across neck and shoulders continue unchanged. Anna describes feeling irritable. Continuing difficulty concentrating is described. Feelings of fatigue are described as continuing unchanged. Medication has been taken regularly. She has to force herself to socialize with others. A fair night's sleep is described. Sleep was not continuous and not completely restful. Content of Therapy: Anna admitted to feeling overwhelmed and anxious even when completing the smallest project. Becoming easily frustrated was also discussed by the patient. "When will this jumpiness end?" Therapeutic Interventions: The main therapeutic techniques used this session involved helping to identify areas of difficulty and to develop coping skills and to manage stress. This session the therapeutic focus was on improving the patient's self-compassion. Patient will make positive statements regarding self and the ability to cope with the stresses of life. MENTAL STATUS: Anna is irritable, distracted, and fully communicative, casually groomed, and appears anxious. She exhibits speech that is normal in rate, volume, and articulation and is coherent and spontaneous. Language skills are intact. Mood is entirely normal with no signs of depression or mood elevation. Her affect is congruent with mood. There are no signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content is appropriate. Homicidal ideas or intentions are convincingly denied. Cognitive functioning and fund of knowledge is intact and age appropriate. Short and long term memory is intact, as is ability to abstract and do arithmetic calculations. This patient is fully oriented. Clinically, IQ appears to be in the above average range. Insight into illness is fair. Social judgment is intact. There are signs of anxiety. Anna is fidgety.

DIAGNOSES: Axis I: Generalized Anxiety Disorder (Active) Medicine 016

INSTRUCTIONS / RECOMMENDATIONS / PLAN: Link to Treatment Plan Problem: Anxiety Short Term Goals: Anna will have anxiety symptoms less than 50% of the time for one month. Target Date: 4/25/2012 In addition, Anna will exhibit increased self-confidence as reported by client on a selfreport 0-10 scale weekly for two months. Target Date: 5/23/2012 ---------------------- No progress in reaching these goals or resolving problems was apparent today. Recommend continuing the current intervention and short term goals. It is felt that more time is needed for the intervention to work. Return 1-2 weeks or earlier if needed. Time spent providing psychotherapy services: 45 min Session start: 2:00 PM Session end: 2:50 PM Liz Lobao, MD

Expert Solution

*CPT and ICD-10-CM CODE denotes signs,symptoms,diseases,condition and injuries.They are often used together with CPT codes to update the patient's medical record and then reported to a payer for reimbursement.
ICD-10-CM :The International Classification of Diseases,tenth revision,Clinical Manifestation.

*F41.1 is a billable /specific ICD-10-CM code for generalized anxiety dieorder

*RECOMMENDATIONS FOR SHORT TERM GOALS-
-Cognitive–behavioral therapy is used successfully to treat anxiety disorders.
-Positive reframing means turning negative messages into positive messages.
-Decatastrophizing involves the therapist’s use of questions to more realistically appraise the situation.
-Assertiveness training helps the person take more control over life situations

*Tips for managing stress include the following:
-Keep a positive attitude and believe in yourself.
-Accept there are events which cannot control.
-Communicate assertively with others: talk about your feelings to others and express your feelings through laughing, crying, and so forth.
-Learn to relax.
-Exercise regularly.
-Eat well-balanced meals.
-Limit intake of caffeine and alcohol.
-Get enough rest and sleep.
-Set realistic goals and expectations and find an activity that is personally meaningful.
-Learn stress management techniques, such as relaxation, guided imagery, and meditation; practice them as part of your daily routine

Nightingale answered 2 years ago

Assign CPT and ICD-10-CM codes to the following Medicine Section Service. LOCATION: Outpatient, Clinic PATIENT: Paula...

Assign CPT and ICD-10-CM codes to the following Medicine Section Service. LOCATION: Outpatient, Clinic PATIENT: Paula Leachman PHYSICIAN: Rapheal White, M.D. DIAGNOSIS: Cancer of the tonsil Ms. Leachman comes into the clinic today for infusion of Amifostine 500 mg for prophylactic treatment of her cancer of the tonsil. The Amifostine is given by IV push.

USE CPT CODES AND ICD-10-CM CODES 1. A lab test was performed to identify nucleic acids....

USE CPT CODES AND ICD-10-CM CODES 1. A lab test was performed to identify nucleic acids. The test included molecular diagnostic procedures involving both reverse transcription and nucleic acid transfer. An interpretation and report was produced. All services were provided in a freestanding physician owned lab. How should these services be reported? In preparation for a transfusion, the lab thawed three units of fresh frozen plasma. How should these services be reported? Cytopathology slides prepared from a cervical specimen were...

Explain ICD-10-CM and CPT-4

In general, describe the purpose and benefit of clinical coding. What are ICD/10 and CPT/4 coding...

In general, describe the purpose and benefit of clinical coding. What are ICD/10 and CPT/4 coding structures?

Assign CPT and ICD-10-CM codes to this Radiology Service. LOCATION: Inpatient, Hospital PATIENT: Jessie Gunderson PHYSICIAN:...

Assign CPT and ICD-10-CM codes to this Radiology Service. LOCATION: Inpatient, Hospital PATIENT: Jessie Gunderson PHYSICIAN: Robert Brown, M.D. RADIOLOGIST: Morton Monson, M.D. EXAMINATION OF: X-Ray Chest CLINICAL SYMPTOMS: Acute Respiratory failure PORTABLE CHEST, 5:00 a.m.: Comparison is made with the previous study. The cardiac silhouette is again enlarged. Since the previous study, endotracheal tube and nasogastric tube have been apparently removed. Central venous catheter is unchanged in position. There again appears to be evidence of an aortic balloon pump...

Assign CPT and ICD-10-CM codes to this Surgery Musculoskeletal System Service. LOCATION: Inpatient, Hospital PATIENT: Debbie...

Assign CPT and ICD-10-CM codes to this Surgery Musculoskeletal System Service. LOCATION: Inpatient, Hospital PATIENT: Debbie Pedersen PRIMARY CARE PHYSICIAN: Frank Gaul, MD SURGEON: Mohomad Almaz, MD DIAGNOSIS: Left type II closed supracondylar humerus fracture, posterior lateral displacement, after fall from playground equipment. INDICATIONS: Debbie is an 8-year-old girl who fell today from the playground and suffered a type II closed supracondylar humerus fracture with posterior lateral displacement. I have spoken with her parents and reviewed the intended procedure, risks,...

how to use the following coding systems: CPT, ICD-10, HCPCS level II coding system.

Assign appropriate CPT and ICD-10-CM codes and modifiers 3. PREOPERATIVE DIAGNOSIS: Left tibial tubercle avulsion fracture....

Assign appropriate CPT and ICD-10-CM codes and modifiers 3. PREOPERATIVE DIAGNOSIS: Left tibial tubercle avulsion fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left distal end of the tibia PROCEDURE: Open reduction and internal fixation of left tibia. ANESTHESIA: General. The patient received 10 ml of 0.5% Marcaine local anesthetic. TOURNIQUET TIME: 80 minutes. ESTIMATED BLOOD LOSS: Minimal. DRAINS: One JP drain was placed. COMPLICATIONS: No intraoperative complications or specimens. Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw...

week 5 Surgery for Outpatient assign CPT and ICD-10-CM codes? Surgery Case-003 PREOPERATIVE DIAGNOSIS: Retained metal,...

week 5 Surgery for Outpatient assign CPT and ICD-10-CM codes? Surgery Case-003 PREOPERATIVE DIAGNOSIS: Retained metal, left knee. POSTOPERATIVE DIAGNOSIS: 1. Retained metal, left knee 2. Tear anterior horn of medial meniscus 3. Type II Diabetes PROCEDURES PERFORMED: Arthroscopic examination of the left knee with metal (screws) removal, medial meniscectomy. ANESTHESIA: Spinal. ESTIMATED BLOOD LOSS: Minimal. This 39-year-old male suffered with discomfort in his left knee due to retained hardware from a previous ORIF of a medial femoral condyle fracture....

define rules of coding cardiovascular services when codes from the medicine section are used?

Question