View MR 099403
MR 099403
New Patient Office Visit
Patient presents for initial 1-week well-child visit. Had jaundice since birth but now is resolved. Mother does not have any current concerns, but wants to talk about blood-work. Baby has home health nurse x 1 visit to date. Baby eating well:
approximately 15 minutes each breast.
Having BM qd. Urination: Normal.
Patient accompanied by both parents and older sister; parents have no specific concerns.
Newborn screening is normal.
Diet: Breastfeeds q 2 to 3 hrs. Breastfeeding is going well overall. Patient is interested in nursing. Awakens to nursing regularly: left side 15 minutes, right side 15 minutes. Audible signs of milk transfer. Patient appears satisfied after
breastfeeding; is alternating breasts. Mother does not use feeding supplement. Patient experiencing 6 to 8 wet diapers per day. Stools appear yellow glow and seedy. No difficulties with constipation or diarrhea. Sleeps on back and side.
Wakes up to feed every 2 to 4 hours. Patient alert. Cries intermittently but is easily consoled. Infant able to lift head, turn head side to side and exhibit equal movements on extremities. Patient is able to startle to sound. Alert to voice.
Discussed feeding schedule and feeding tips with parents. Advised no bottle propping. Discussed bathing tips. Discussed: Noisy breathing, burping, cool mist humidifier use, hiccups and immunizations. Discussed bonding and use of pacifier.
Emphasized importance of proper usage of car seat. Also reminded importance of patient sleeping on back. Discussed animals in home and proper precautions.
Past Family Medical and Social History: Reviewed and updated.
Exam:
Weight: 7 lbs. 9 oz. Rectal Temp: 97.9. Height: 19 inches. Head Circ: 18.7
Healthy appearing infant. Well-nourished and alert. Weight: Within normal range for stated age. Mucus membranes: Moist and pink. Capillary refill: Brisk-less than two seconds. Respiratory pattern: Unremarkable. No grunting or nasal flaring.
Umbilical cord: Not present.
Head proportion: Normal. Head: Normocephalic and symmetrical. Palpation reveals smooth, symmetric skull.
Anterior fontanelle: Slightly concave and soft. Posterior fontanelle is present.
PERRLA: EOMI ENMT: External ears: Inspection reveals ears normal in size, position and alignment. Auditory canals are patent. Tympanic membranes: Normal landmarks. No fluid or erythema. Nares: Bilaterally are patent.
Nasal mucosa: No discharge. Palate: Normal in appearance. Rooting reflex: Present. Sucking reflex: Present.
Neck: Supple, no masses.
Resp: Lungs clear bilaterally.
CV: PMI is not displaced. Rhythm: Regular. No heart murmur. Pulses: Femorals 2+ bilaterally.
GI: Abdomen: Non-distended, nontender and soft. Umbilicus: Inverted and absent.
Bowel sounds: Normal and active. No palpable hepatosplenomegaly.
Anus/Perineum: Normal
Musculoskeletal:
Spine: Spinal contour: Normal. Gluteal fold: Normal. Upper Extremities: Normal to inspection and palpation.
Shoulders: Palpate smooth. Clavicles: Normal, stable.
Skin: No rash, lesions or petechiae. No jaundice.
Neurological: Babinski reflex: Present bilaterally. Moro reflex: Present.
Assessment: Routine infant child check: Patient doing well post-op with no obvious sign of jaundice.
What E/M code is reported?
A. 99381View MT 004268
MT 004268
Operative Report
Preoperative Diagnosis: History of colon polyps
Postoperative Diagnosis: Sigmoid diverticulosis
Procedure: Diagnostic colonoscopy
Anesthesia: IV sedation
Technique: The patient was brought to the endoscopy suite and placed in the lateral decubitus position. Digital rectal examination was then performed The colonoscope was then inserted under videoscopic visualization with minimal
insufflation. The scope went beyond the splenic flexure. The sigmoid colon did reveal some diverticulosis. Further advancement of the colonoscope was unable to be accomplished and did not reach the cecum due to retained stool in the
transverse colon. It was decided not to advance the scope further due to poor prep. The colonoscope was then removed and the patient was given instruction to go back after one week for repeat colonoscopy.
How is the surgeon's service reported?
A. 45330A 25-year-old patient, P3, was given general anesthesia by an anesthesiologist for an emergency appendectomy in the lower abdomen. Report the service of the anesthesiologist.
A. 00790-AA-P3, 99140An 85-year-old tripped over a rug and hit her shoulder against a cabinet in her bathroom. The fall resulted in a fractured humeral head. Shoulder X-rays revealed bone fragments and the physician replaced the humeral head with a prosthesis. The patient is taken to the operating room where anesthesia is administered.
Report the CPT coding for the anesthesiologist.
A. 01630, 99100A CRNA is personally performing a case without supervision of an anesthesiologist. What modifier is reported for the CRNA services?
A. QXA Medicare patient in a partial hospitalization program received occupational therapy services from a qualified occupational therapist. What is the HCPCS Level II code for this service?
A. G0128Dr. Roberts called Mr. Davis to discuss the recent change in his asthma medication. Mr. Davis doesn't think the new medication is working as well as the previous medication. Dr. Roberts discussed the pros and cons of the new medication and Mr. Davis decided to continue using it for another month. The phone call lasted 15 minutes.
How would Dr. Roberts report the telephone service?
A. 99442The patient is admitted to observation status, at 10:00 am in the morning, with sharp chest pain when breathing. The physician performs the following: Number and Complexity of Problems Addressed at the Encounter - Moderate Amount and/or Complexity of Data to Be Reviewed and Analyzed - Low Risk of Complications and/or Morbidity or Mortality of Patient Management - Moderate The patient was discharged home from observation status at 10:00 pm on the same day. Discharge diagnosis is costochondritis.
What E/M coding is reported?
A. 99235, 99238During the course of a hospital admission, Dr. Miller requests an orthopedist see his patient for osteoporosis. The orthopedist sees the patient on day 3 of admission. He performs a history and exam. He evaluates the patient's osteoporosis. He orders a bone density study and prescribes Boniva for the patient.
What CPT code is reported by the orthopedist?
A. 99223A 19-year-old college student is seen by his primary care physician for an annual exam. His last exam with the primary care physician was two years ago. He has no complaints. What CPT code is reported?
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