Question

Medical Coding

1. This is a 25-year-old female status post assault. The patient sustained a C5 compression fracture. MRI scan showed compression with evidence of posterior ligamentous injury. The patient was subsequently set up for the surgical procedure. The procedure was described in detail, including the risks. The risks included but not limited to bleeding, infection, stroke, paralysis, death, cerebrospinal fluid (CSF) leak, loss of bladder and bowel control, hoarse voice, paralyzed vocal cord, death, and damage to adjacent nerves and tissues. The patient understood the risks. The patient also understood that bank bone instrumentation would be used and that the bank bone could collapse and the instrumentation could fail or break or the screws could pull out. The patient provided consent.

The patient was taken to the OR. The patient was induced. Endotracheal tube was placed. A Foley was placed. The patient was given preoperative antibiotics. The patient was placed in slight extension. The right neck was prepped and draped in the usual manner. A linear incision was made over the C5 vertebral body. The platysma was divided. Dissection was continued medial to the sternocleidomastoid to the prevertebralfascia. This was cauterized and divided. The longus colli was cauterized and elevated. The fracture was visualized. A spinal needle was used to verify location using fluoroscopy. The C5 vertebral body was drilled out. The bone was saved. The disks above and below were removed. The posterior longitudinal ligament was removed. The bone was quite collapsed and fragmented. Distraction pins were then packed with bone removed from the C5 vertebral body prior to implantation. A plate was then placed with screws in the C4 and C6 vertebral bodies. The locking screws were tightened. The wound was irrigated. Bleeding was helped with the bipolar. The retractors were removed. The incision was approximated with simple interruptedVicryl. The subcutaneous tissue was approximated and skin edges approximated subcuticularly. Steri-Strips were applied. A dressing was applied. The patient was placed back in an Aspen collar. The patient wasextubated and transferred to recovery.

QUESTION: The code reported for the anesthesiologist service was 00060-P3-AA

Is this correct?

True or False

What is the correct code?

2. INDICATIONS: The patient is a 9-year-old male brought to the emergency room by his father. He was helping his father hang a mirror in the bedroom when it fell and shattered. The boy suffered lacerations on his left hand and left leg.

PROCEDURE: The patient was placed on the table in supine position. Satisfactory anesthesia was obtained. The area was prepped, and attention to the deeper laceration of the left palm of the hand was rst. A layered repair was performed and the 5.1-cm laceration was closed successfully with sutures. The lacerations on the lower extremity, a 2-cm laceration on the left leg at the base of the patella and a 3-cm laceration on the left shin, were successfully closed with 4-0 Vicryl as well. The patient tolerated the procedures well and was transported to the recovery room.

QUESTION: The procedure codes reported are: 12040-LT, 12003-51-LT

Is this correct?

True or False

What is the correct code?

3. Pt is a 37-year-old female hurt during a waterskiing accident. She was performing in a ski show at Water World Adventure Park when she came off the ski jump ramp in the wrong angle and hit the water unevenly, twisting her knee. Her physician, Dr. Faslzone, ordered her to use a wheelchair for the next?6 weeks.

I delivered a standard wheelchair with fixed full-length arms and swing-away, detachable footrests to the patient’s home. I spent 20 minutes instructing the patient on the proper way to use the chair, transfer from the chair to standard furniture and back, and transfer to other function furniture, including the toilet and the bed. She was instructed on how to stop and start the chair with the least amount of strain on her upper extremities and how to apply the brakes. Patient stated she clearly understood all instructions.

DX: Torn meniscus, lateral, bucket-handle, left knee?

P: Patient given instruction booklet and technical support number

QUESTION: The principal diagnosis code reported for this encounter is: S83.252A

Is this correct?

True or False?

What is the correct code?

Answer 1

1.false

Compression fracture S00_T88 injury, external causes

S10_S10 injuries to the neck

S10 fracture of cervical vertebrae and other part of neck

Fracture of fifth cervical vertebrae S12. 4

2.false

R20.0

R20-R20 SYMPTOMS ,signs and abnormal clinical and laboratory finding

R2O_R2O symptoms and signs involving the skin and subcutaneous tissue

R2O disturbance of skin sensation

R2O. 0 ISO A used for diagnosis for reimbursement purpose

2018 edition ICD 10 CMAI R2O. 0 became effective on October 1.2017

American version ICD 10 CMAI version R2O. 0 other internationalversion of ICD R2O. 0

3.correct

S83.252A is a billable /specific ICD_10-CMAI code that can be used to indicate a diagnosis for reimbursement purpose.

Short description; bucket hndl tear of late mensc,current injury, I knee,init

The 2018 edition of ICD _10CM S83.252A became effective on October 1,2017

American ICD-10-CM version of September S83.252A other international version ICD_10 S83.252A may differ.

S00-T88 injury and external causes

S80_S89 injuries to the knee and lower leg

S83-dislocation and sprain of joints and ligaments of knee