Intermediate Medical Coding

WRITING GUIDELINES 1

INSTRUCTIONS 2

GRADING CRITERIA 4

SUBMITTING YOUR PROJECT 5

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OVERVIEW As a medical coder, you’ll assign CPT codes for physician procedures and services. This graded project is designed to

1. Test your knowledge of CPT coding principles and procedures

2. Gauge your ability to accurately apply coding guidelines with regard to CPT codes and modifiers

3. Analyze your accuracy with respect to HCPCS code assignment

4. Determine your ability to differentiate CPT and HCPCS

5. Summarize what you’ve learned about CPT and HCPCS coding

WRITING GUIDELINES 1. Open a new Word document and include the following

information at the top of your graded project:

n Name and address

n Student number

n Course title and number (HIT204, Intermediate Medical Coding)

n Research project number (38166000)

2. Copy and paste all exam questions into the Word docu- ment and add answers after reading the assignment and following the instructions carefully.

Intermediate Medical Coding

Intermediate Medical Coding 2

3. After completing the exam, click on File, Save As, Documents, name the file and click Save.

4. Follow the directions on the last page of this assignment to submit your project.

INSTRUCTIONS Your graded project has three parts. Be sure to complete all three parts prior to submitting your project.

Part 1 Review the following scenario. Assign the CPT code(s). Add one or more modifiers, if necessary.

A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is experiencing increased urination, straining during urina- tion, and a continual feeling of fullness after the bladder has been emptied. The physician performs a cystourethroscopy to examine the condition of the bladder and urethra, and then subsequently performs a UroLift transprostatic implant pro- cedure using three adjustable implants.

CPT code(s): ____________________________________________

(Part 1 is worth 20 points of your overall graded project.)

Part 2a Review each of the following procedures. Assign the CPT code(s). Add one or more modifiers, if necessary.

1. An established patient comes to the office complain- ing of migraine headaches. The physician performs an expanded problem-focused history and exam. The phy- sician’s medical decision making is of low complexity. During the office visit, the physician also removes a benign 0.5 cm lesion from the back of the patient’s left hand.

38166000 3

CPT code(s): ____________

________________________________________________________

2. Dr. Kline, a plastic surgeon, is ready to perform a sim- ple repair of a 2.0cm wound on the cheek of a 10 year old boy, but he is concerned about how the child might react. The boy has a neurological disorder that is triggered by anxiety and changes in his normal environment, and he has become combative at past office appointments. Although anesthesia is not typically used for a simple repair of a superficial wound, Dr. Kline has opted to administer the general anesthesia for this procedure. Dr. Kline proceeds with a simple repair of the child’s superfi- cial wound on his face.

CPT code(s): ____________

________________________________________________________

3. A surgeon performs a total abdominal hysterectomy with partial removal of the vagina, lymph node sampling, and removal of the ovary. The coder assigns code 58200-51. Is this code correct or incorrect? Why or why not?

________________________________________________________

________________________________________________________

Part 2b Review each of the following procedures. Assign the HCPCS code(s).

4. A patient weighing 252 pounds sustains a hip fracture. The physician prescribes a Group 2 standard single power wheelchair with a solid seat, solid back, and a sling.

HCPCS code(s): _______________

________________________________________________________

5. A patient comes to the emergency room complaining of a chronic migraine. The nurse administers a 1 unit injec- tion of onabotulinumtoxinA.

HCPCS code(s): _______________

________________________________________________________

Intermediate Medical Coding 4

6. A patient with chronic venous insufficiency comes to the doctor’s office complaining of leg pain. The physician prescribes two thigh-length gradient compression stock- ings, 45 mmHg each.

HCPCS code(s): _______________

________________________________________________________

(Part 2 is worth 60 points of your overall graded project: 30 points for Part 2a; 30 points for Part 2b.)

Part 3 Review the following coding scenario. Assign the CPT code(s) for only the wound repair. A patient comes to the emergency room after sustaining a 12.2-cm wound to the left side of her face. She was cut with a piece of glass during a physi- cal altercation with her husband. The physician performs a detailed history and examination. Medical decision making was of moderate complexity. The physician repairs the facial wound without difficulty; however, the wound requires exten- sive cleaning to remove the glass particles beforehand. The physician also repaired a superficial 2.5-cm wound to the left ear. Both wounds were closed using 4-0 Vicryl.

CPT code(s):__________________

___________________________________________________________

(Part 3 is worth 20 points of your overall graded project.)

Goal Your goal is to demonstrate your understanding of CPT and HCPCS and to assign codes accurately using both code sets.

GRADING CRITERIA Part 1 = 20 points

Part 2 = 60 points (2a = 30 points; 2b = 30 points)

Part 3 = 20 points