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Kathy Rock PT, MBA, CHCA, CRHC, CPC, CHC

Rock Consulting Inc.

150 Questions over case studies

5 hours and 40 minutes – Running time

Scoring breakdown

Anatomy

CPT

Evaluation and Management

HCPCS

ICD 10

Modifier

Practice Management

Scores released within 7-10 business days online and mailed

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Ensure coding resources are prepared for Exam

Confirm understanding of

Procedures and anatomy related to procedures

Medications to include reason for use, billable units and administration method

Common diagnostic services

Modifiers commonly used with E/M and procedures

Diagnoses coding guidelines

Explore Evaluation and Management coding guidelines

Book Preparation 12:00 pm – 1:30 pm

Break 1:30 pm – 1:45 pm

Case Studies 1:45 pm – 3:00 pm

Break 3:00 pm – 3:15 pm

Review of Knowledge 3:15 pm – 4:00 pm

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CPT

ICD-10

HCPCS

1995/1997 Guidelines

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1.The E/M section for this encounter is:

A. Office Consultation

B. Established Patient

C. New Patient

D. Preventive Medicine

2. Based on the '95 guidelines, what is the level of exam?

A. Problem Focused

B. Expanded Problem Focused

C. Detailed

D. Comprehensive

3. What is the level of medical decision making?

A.Straightforward

B. Low

C. Moderate

D.High

4.What is the E/M code?

A.992x1

B.992x2

C.992x3

D.992x4

E.992x5

5. What is the first listed ICD-10-CM diagnosis

code?

A. M06.09

B. M06.4

C. A69.23

D. M24.811, M24.812

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Chief Complaint: Multiple joint pains.

History of Present Illness: Dr. X, the patient's PCP, requested I see the patient for further evaluation

of multiple joint pains. He states to me that his symptoms started about 4 weeks ago, affecting his

shoulders, knees and then both his wrists and hands. He professes to have 2 to 3 hours of

morning stiffness. He feels somewhat better when taking a hot shower and after he takes medi-

cations. He states that in May he had a motorcycle accident and had dislocated hip and broken ribs.

He gradually improved and started to exercise. After a few weeks his multiple joint pains started. He

was put on Celebrex for 3 weeks, which initially helped, and then it did not. He was given Naproxen

without any relief in his symptoms. He is currently taking aspirin, 325 mg, 2 tablets every 4 hours on

an as-needed basis, alternating with Tylenol, 2 tablets every 4 hours. He had multiple blood tests

done within the past few weeks, including herpes virus-6 antibody is negative; uric acid is normal;

CBC is within normal limits except slightly elevated WBC at 11.6, and platelet count 464. RPR was

nonreactive. Complete metabolic panel was normal except slightly elevated alkaline phosphatase. He

had Lyme tests done last week. The results are not available to us. He was put on Doxycycline for

presumable Lyme disease on September 28. He reports that he had multiple insect bites a week

before the pain started. He denies any tick bites or any rash.

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4

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ROS 1

Case Studies Page 1-3

Past Medical History:

1. Hypercholesterolemia.

2. History of colon cancer, status-post surgery in 1997.

3. GERD.

Medications:1. Doxycycline 100 mg. p.o. b.i.d.

2. Aspirin pm.

3. Tylenol pm.

4. Crestor 30 mg p.o. daily.

5. Prevacid 30 mg p.o. daily.

ALLERGIES: NKDA.

Social History: He is a retired military officer. He quit smoking in 1969. He drinks alcohol very

occasionally.

Family History: Father had prostate cancer. Mother had breast cancer. No siblings.

Review of Systems: He denies any constitutional symptoms except intentional weight, on military diet.

He denies any eye or ear symptoms, cardiovascular, respiratory, gastrointestinal, or genitourinary

symptoms. He has physical disability because of pain. He has joint pain and stiffness and difficulty with

making fists. He also has a numbness and tingling sensation in his right hand.

ROS 2

ROS 3 ROS 4

ROS 5

ROS 6 ROS 8ROS 7

ROS 9

ROS 10

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Physical Exam: He is an elderly male in no acute distress. Vital Signs: BP is 138/80, Temp: 98.0, Pulse: 80.

HEENT: Exam reveals no conjunctival injections or scleral icterus. There are oral mucosal ulcers. Chest:

Is clear bilaterally, without any crackles or wheezing. Equal air entry. Heart: Exam is unremarkable, with

SI, S2 regular. There is no murmur.

Abdomen: Benign. Soft, no masses or tenderness. Normal spleen. Neurological: Oriented and alert x 3.

Normal motor and sensory function.

Musculoskeletal Exam: No tenderness on both shoulders, with normal range of motion. There is no

swelling or tenderness on his elbows. He has tenderness on his right wrist with swelling. There is no

swelling on his left wrist. He has a slightly limited range of motion with flexion on both wrists, more on the

right side. He has synovitis across all MCP joints on his right hand, with no tenderness. There is a subtle

synovitis on his few PIP joints on both hands. There is a mild synovitis on his few MCP joints as well. He is

unable to make a fist on both his hands, more pronounced on the right one. He has a loss of the distal

portion of his 3rd and 4th finger at the PIP level on the left hand. He has full range of motion of hips,

without any pain. There is no effusion on his both knees. There is no increased warmth or swelling. There

is no tenderness on his ankles. Skin: Exam is unremarkable, without any nodules or rash. Warm/Dry, no

diaphoresis.

Assessment & Plan: This is a 64-year-old gentleman with inflammatory arthritis multiple sites, most

likely rheumatoid arthritis. I would like to obtain a rheumatoid factor, anti-CCP antibody, ESR and

CRP. I would like to put him on Prednisone, 10 mg in the morning, 5 mg at night for one week, then

decrease it to 5 mg p.o. b.i.d. until I see him. He will be seen in 2 weeks for further management.

He had Lyme tests done last week. The result is not available to me. He is on Doxycycline, I do not have

any clinical suspicion for Lyme disease, although I would rather wait for lab results before we make a

decision on Doxycycline at this point.

Please make sure Dr. X receives my written recommendations.

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1.The E/M section for this encounter is:

A. Office Consultation

B. Established Patient

C. New Patient

D. Preventive Medicine

2. Based on the '95 guidelines, what is the level of exam?

A. Problem Focused

B. Expanded Problem Focused

C. Detailed

D. Comprehensive

3. What is the level of medical decision making?

A.Straightforward

B. Low

C. Moderate

D.High

4.What is the E/M code?

A.992x1

B.992x2

C.992x3

D.992x4

E.992x5

5. What is the first listed ICD-10-CM diagnosis

code?

A. M06.09

B. M06.4

C. A69.23

D. M24.811, M24.812

RA is not definitive dx

AAPC states no

additional work up in

= error bc ordered

labs

Inflammatory Polyarthropathy

Per AAPC “if patient is scheduled for routine blood work to monitor side effects of medication, this would not be considered additional workup”

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A 66-year-old female patient returns for a second infusion of rituximab for her diagnosis of rheumatoid arthritis in multiple sites. She is rheumatoid factor positive. She says the pain in her knees, elbows and neck has slightly improved. She rates the severity of her pain at a 7 on a 10-point scale, which is an improvement from the 8 she reported during her last visit. The patient is currently on 7.5 mg methotrexate by mouth weekly. She reports no fevers, headaches, chest pain, dyspnea, cough, oral ulcers, rashes or depression.

Infusion note: The patient’s blood pressure is 125/88, height is 5’6”, weight is 225 lbs., body mass index is 36.3, and temperature is 97°F.

Diagnosis: Rheumatoid arthritis of multiple joints, rheumatoid factor positive.

Her IV is started with 150 cc of normal saline solution and 1000 mg of rituximab is prepared for the infusion, and 40 mg of methylprednisolone sodium succinate is pushed into the patient’s IV. The rituximab infusion is started at 9:05 a.m. and slow dripped until 1:12 p.m. The patient is observed for 15 minutes and instructed to make a follow-up appointment.

What is ICD 10 code? What CPT and HCPCS codes can be billed?

Case Study Page 29-30

ICD 10: M05.79

CPT Codes:

Infusion Administration 96413, 96415 x 3

Medication J9312 x 100

IV Push 96375 (subséquent to Infusion), J2920

AAPC Question – I changed dose to typical scenario

AAPC Answer – Review due to error

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Which systems are reviewed in the ROS?

A. Respiratory, CardiovascularB. Constitutional, GIC. Constitutional, RespiratoryD. Respiratory, Integumentary

Based on '97 guidelines, what is the level of exam?

A. Problem FocusedB. Expanded Problem FocusedC. DetailedD. Comprehensive

What is the E/M code?

A. 992x1

B. 992x2

C. 992x3

D. 992x4

E. 992x5

What is the first listed ICD-10-CM diagnosis code?

A. M32.10B. M35.9C. K75.4D. K83.8

What are the additional diagnoses codes for this encounter?

A. R76.9,178.8, D70.8B. R68.89,178.1, D70.3C. R68.89,178.8, D70.4D. R76.9,178.1, D70.9

What is neutropenia?

A. Abnormally high number of neutrophilsB. Abnormally low number of neutrophilsC. Irregular shaped neutrophilsD. Enlargement of neutrophils

Subjective: Follow up for history of strongly positive ANA, suspect connective tissue disease. She has

telangiectasias of the fingers; mild leucopoenia that has been intermittent; and possibility of

autoimmune hepatitis was raised, although this really seemed to be cholestatic in nature. She is taking

Urso 500 mg twice a day and she has had no complications. She has a history of asthma on

medications but no inflammatory lung disease. She has a history of a hiatal hernia. No significant

dismotility syndrome. She also has mild osteoarthritis in the fingers. She is feeling fine; she has no SOB

or cough. No fevers or chills. She had some recent Synvisc injections for her right knee that seemed to

work pretty well. Since her last visit, she has had a bladder stimulator implantation for chronic over-

active bladder. This has been present for about a month and has allowed her to stop the Detrol, which

was causing her dryness.

Current Medications: Aspirin once a day, Protonix once a day, Advair Diskus twice a day, Urso 500

mg twice a day, Os-Cal 500 mg twice a day, fish oil 1,000 mg a day, Altace has been discontinued.

ROS 1

ROS 2

Location Severity Assoc SS Timing

Case Studies Page 5-6

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Physical Exam: She is alert and oriented, obese white female. BP: 126/80. Pulse: 70. Respirations: 12.

Lungs: Clear. Heart: Rate and rhythm are regular. Peripheral pulses: 2+ and equal bilaterally. Skin: No

suspicious lesions. There are small telangiectasias of the finger pads, actually unchanged. No sclerodactyly

or morphia or rashes on exam. There are a few scattered dilated capillary nail beds. These are unchanged as

well.

Musculoskeletal Exam: There is bony hypertrophy of the DIP and PIP joints. There is no synovitis.

There is medial joint line tenderness of the knees bilaterally without any effusion.

Review of Laboratory Data: (09/12/xx) Metabolic panel: Normal, GFR greater than 60; transaminases and

alk phos were normal. C-reactive protein .8, urine for micro-albumin is 66 mg/deciliter. But the micro-

albumin to creatinine ratio is 7, which is normal. CBC: WBC 3.9, otherwise normal, sed rate 1. Urinalysis:

No protein, WBCs, RBCs or casts. ANA was confirmed at a titer of 1:1280, which is essentially unchanged.

Assessment: The patient has connective tissue disease with a positive ANA, mild telangiectasias, possible

autoimmune hepatitis versus cholestasis, and mild chronic neutropenia.

Plan: Monitoring is indicated at this time. I would like to see her in six months or certainly sooner as needed.

Repeat labs at that time, which will include a metabolic panel, CBC, complements C3, C4, ANA, and a

urinalysis.

1997 Exam General System

Physical Exam: She is alert and oriented, obese white female. BP: 126/80. Pulse: 70. Respirations: 12.

Lungs: Clear. Heart: Rate and rhythm are regular. Peripheral pulses: 2+ and equal bilaterally. Skin: No

suspicious lesions. There are small telangiectasias of the finger pads, actually unchanged. No sclerodactyly

or morphia or rashes on exam. There are a few scattered dilated capillary nail beds. These are unchanged as

well.

Musculoskeletal Exam: There is bony hypertrophy of the DIP and PIP joints. There is no synovitis.

There is medial joint line tenderness of the knees bilaterally without any effusion.

Review of Laboratory Data: (09/12/xx) Metabolic panel: Normal, GFR greater than 60; transaminases and

alk phos were normal. C-reactive protein .8, urine for micro-albumin is 66 mg/deciliter. But the micro-

albumin to creatinine ratio is 7, which is normal. CBC: WBC 3.9, otherwise normal, sed rate 1. Urinalysis:

No protein, WBCs, RBCs or casts. ANA was confirmed at a titer of 1:1280, which is essentially unchanged.

Assessment: The patient has connective tissue disease with a positive ANA, mild telangiectasias,

possible autoimmune hepatitis versus cholestasis, and mild chronic neutropenia.

Plan: Monitoring is indicated at this time. I would like to see her in six months or certainly sooner as needed.

Repeat labs at that time, which will include a metabolic panel, CBC, complements C3, C4, ANA, and a

urinalysis.

1995 Exam - Extended

Table of Risk – Presenting problem

AAPC worsening?

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Which systems are reviewed in the ROS?

A. Respiratory, CardiovascularB. Constitutional, GIC. Constitutional, RespiratoryD. Respiratory, Integumentary

Based on '97 guidelines, what is the level of exam?

A. Problem FocusedB. Expanded Problem FocusedC. DetailedD. Comprehensive

What is the E/M code?

A. 992x1

B. 992x2

C. 992x3

D. 992x4

E. 992x5

What is the first listed ICD-10-CM diagnosis code?

A. M32.10B. M35.9C. K75.4 Digestive System PossibleD. K83.8 Digestive System Possible

What are the additional diagnoses codes for this encounter?

A. R76.9,178.8, D70.8B. R68.89,178.1, D70.3C. R68.89,178.8, D70.4D R76.9,178.1, D70.9

What is neutropenia?

A. bnormally high number of neutrophilsB. Abnormally low number of neutrophilsC. Irregular shaped neutrophilsD. Enlargement of neutrophils

Penia = deficiency

D70 Neutropenia Pg 506

What is the E/M code?

A. 992x1B. 992x2C. 992x3D. 992x4E. 992x5

What is the appropriate CPT" code for the DEXA

scan that was ordered?

A. 77086B. 77078C. 77081D. 77080

What are the ICD-10-CM diagnosis codes for the

encounter?

A. M15.0, M81.0B. M15.9, M81.6C. M06.09, M81.0D. M06.09, M81.8

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Problem List:

1. Seronegative rheumatoid arthritis

2. Osteoporosis. Last DEXA scan from over one year

3. Hyperlipidemia

4. Anxiety disorder/depression

5. Benign essential tremor

6. Abnormal glucose tolerance

7. Status-post cortisone injection for right trochanteric bursitis on 7/9/xx

Medications:

1. Methotrexate, 7.5 mg p.o. weekly, increased to 12.5 mg p.o. weekly today

Folic acid, 1 mg p.o. daily Fosamax 70 mg p.o. weekly Vitamin D 50,000 units p.o. weekly for 8 weeks. She recently

finished. Zoloft 100 mg p.o. daily Atenolol 50 mg p.o.

2. Laboratory Values: Blood tests reveal normal CBC. Sedimentation rate is normal at 3. Complete metabolic panel is normal. CRP is normal at 0.3.

History: Patient returns for follow-up visit. She states that she has been feeling better, with less pain involving her hands.

She continues to have some stiffness, especially in her hands, wrists, and hips. Also mild swelling in those areas. She is

tolerating the medications well, without any side effects. She is on Methotrexate weekly, along with folic acid. She is also

tolerating Fosamax well, without any difficulties. During the last blood test she was found to have vitamin D deficiency, and

she was put on vitamin D, 50,000 units weekly for 8 weeks. She believes that she took the last dose recently. She did not have

any problem while she was on it.

ROS 1

Case Studies Page 6-8

Physical Exam: General Appearance: She is an elderly woman in no acute distress. Vital Signs: BP is 122/80.

HEENT: Exam reveals no abnormality including conjunctival injections, oral mucous ulcers, or lymphadenopathy.

Musculoskeletal Exam: Normal range of motion of her shoulders and elbows. There is no swelling. She has significantly

limited ROM on her right wrist. She has tenderness on her right wrist with slight swelling. She has slight subluxation of her few

MCP joints on both hands. She has synovitis of the 2nd, 3rd, and 5th MCP on the right hand; 2nd and 3rd MCP on the left hand.

There is synovitis of the left 2nd PIP joint as well. She has tenderness throughout her few MCP and DIP joints as well as her both

wrists. She has reduced range of motion on both hips, with slight discomfort. There is no effusion or tenderness on her knees.

There is no swelling or tenderness on her ankles. Skin exam is unremarkable, without any nodules or any rash.

Assessment & Plan: This is a 68-year-old woman with longstanding seronegative rheumatoid arthritis. She is doing

somewhat better on the current regimen, although she continues to have stiffness and synovitis on examination. I would like to

increase her Methotrexate to 5 tablets weekly, along with folic acid 1 mg p.o. daily. Osteoporosis—She is tolerating Fosamax

well. She was found to have vitamin D deficiency and was treated with 50,000 units of vitamin D for 8 weeks. I advised her to

stay on calcium with vitamin D, 1200 mg/800 units respectively on a daily basis as a maintenance dose. She will need a repeat

DEXA scan in the winter.

I would like to see her in two months. We will obtain CBC, CMP, vitamin D level at that time.

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What is the E/M code?

A. 992x1B. 992x2C. 992x3D. 992x4E. 992x5

What is the appropriate CPT" code for the DEXA

scan that was ordered?

A. 77086B. 77078C. 77081D. 77080

What are the ICD-10-CM diagnosis codes for the

encounter?

A. M15.0, M81.0B. M15.9, M81.6C. M06.09, M81.0D. M06.09, M81.8

AAPC scoring varied – see audit tool; Their

answer was 99213 because they considered RA

diagnosis stable although MTX dose was

increased

How would you determine the appropriate E/M level for

this encounter?

A. Based on history, exam, and medical decision making

B. Based on the amount of time for the visit

C. Based on the MDM and time

D. Based on the exam, MDM, and time

In addition to the E/M service, what additional procedures were performed during the encounter?

A. 36415,86140B. 85025C. 36415, 86140, 85025D. None of the above

What are the appropriate ICD-10-CM diagnosis codes?

A. M35.3, M15.9B. M35.3, M25.50C. M35.3, M15.0, M25.51D. M35.3, M15.3, M25.50

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Current Medications:

Folic acid 400 meg, Tab, 1 tablet daily

Imitrex 50 mg, Tab, prn

Nutritional Supplements, Tab, 760/600, qd

Omega-3 Fatty Acids 1000 mg, Caps, qd

Tylenol Arthritis Pain 650 mg, Taken As Directed, 2 bid

Rheumatology Visit:

The patient presents for follow-up of polymyalgia rheumatica and osteoarthritis. The Dr. reports that she

has been doing fairly well overall. She has multiple areas that are bothering her. Her knees continue to

bother her some. She did quit her leg presses. She has a couple of toes on her right foot that are sore. Her

right fourth PIP is achy and slightly swollen. Her shoulders bother her a bit. She has trouble getting into a

comfortable position in bed at night. None of these are terrible with regard to the amount of pain they

cause. She relates that her low back pain is significantly worse and is there all the time. She finds it to be

puzzling. She isn't certain whether these relate to her polymyalgia or just what is happening. She hasn't

really had symptoms that are like what she had when her polymyalgia was active. She is able to exercise

regularly. She is taking Tylenol Arthritis 2 tablets twice a day. She isn't certain that it is helping all that much

although she has not stopped the Tylenol to see if she is worse without it. Her general health has otherwise

been good.

Case Studies Page 9-11

Vital Signs: Vitals (Adults) -Weight (lbs): 123 Blood Pressure (R) initial: 132/74

GENERAL APPEARANCE:

The patient appears healthy, and thin. She appears to be in no acute distress. The patient's affect is pleasant. The patient is alert

and oriented times three.

Major Joint Exam:

All joints indicated were examined for tenderness, swelling, range of motion, stability, crepitance, warmth, and erythema:

shoulders, elbows, wrists, MCPs, ankles, MTP joints, toes. These joints were found to be without abnormality unless otherwise

indicated. She does have mild bony hypertrophy suggestive of osteoarthritis scattered through the PIPs and DIPs but these do

not limit her mobility. The R 4th PIP has some mild synovial thickening with tenderness today. The other PIPs and DIPs are

nontender. The knees are cool and have no effusions. There is no joint line tenderness. There is some patellofemoral crepitance.

The patient has some clicking in the acromioclavicular joint on the left side with motion of her shoulders. Her range of motion is

full. There is no subacromial tenderness today.

Skin Exam:

There is no rash, swelling, redness, or other lesions involving the skin on the upper or lower extremities.

Extremities Exam:

There is no clubbing, cyanosis, or edema.

Joint Exam Cont'd:

There are degenerative changes in both great toes, right greater than left. There are degenerative changes scattered through the

right toes; the left toes look better. There is no evidence of synovitis through the MTP joints today.

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Conclusion:

Problem #1 Polymyalgia Rheumatica: I don't think her symptoms are consistent with polymyalgia. I can't rule out that the

shoulder symptoms might be consistent but these symptoms are not like what she has had in the past and her symptoms are

not really consistent like I would expect to see if this were due to ongoing inflammation from PMR. We will check her CRP

today.

Problem ?2 Arthralgias: I think most of what she is experiencing relates to degenerative change. I am not finding changes

consistent with an inflammatory process. She understands that polymyalgia can sometimes lead into rheumatoid disease but

at this point I can't make that diagnosis.

Problem #3 Osteoarthritis: The patient has changes of osteoarthritis in scattered joints. She may be having more symptoms

from this as her disease progresses a bit. We talked about having her stop the Tylenol Arthritis to see if her achiness is worse

without the medication. If not there is no sense having her take it. If her achiness is worse, she will restart it as it is the safest

medication she can take. The patient's current pain level is mild. Her functional level is: minimal limitation of activities of

daily living.

Encounter Time:

At least 50% of this visit was spent on counseling and/or coordination of care. Total visit time was: 25

minutes.

Follow-Up Orders:

Follow up: 2 months. The patient will call if there are any problems.

Charge Ticket:

Blood Drawing, C-Reactive Protein

How would you determine the appropriate E/M level for this

encounter?

A. Based on history, exam, and medical decision makingB. Based on the amount of time for the visitC. Based on the MDM and time

D. Based on the exam, MDM, and time

In addition to the E/M service, what additional procedures were performed during the encounter?

A. 36415,86140B. 85025C. 36415,86140,85025D. None of the above

What are the appropriate ICD-10-CM diagnosis codes?

A. M35.3.M15.9B. M35.3.M25.50C. M35.3,M15.0,M25.51D. M35.3.M15.3.M25.50

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What is the ICD 10 Code(s)?

What is the CPT Code(s)?

A 67-year-old female patient with Medicare returns to the office for a follow-up of her age-related

osteoporosis. She states she has an achy pain in her left hip that lasts for 30-40 minutes in the morning.

Currently, she has taken ibandronate sodium and alendronate sodium for the past year, and her pain level

is a 7 out of 10. The patient indicates that she has general fatigue and pain in the left hip. All other systems

are negative. She does not smoke or drink. The rheumatologist performs an expanded problem-

focused examination.

Her last dual-energy X-ray absorptiometry (DEXA) was one year ago. After a treatment course is

discussed with the patient, the physician concludes that a DEXA scan is needed, because the patient is on

a current regimen of glucocorticoids. The physician sends her to the imaging room for a dual-energy X-ray

of the axial skeleton and a vertebral fracture assessment, and schedules her for a follow-up visit in

one month.

12 3

4 ROS Complete

Case Studies Page 19-20

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CPT: 99213-25, 77085

ICD-10: Diagnosis M81.0, Z79.52

The encounter is coded as 99213 as follows:

* History—The history of the present illness was extended. The review of systems was complete, and the past

medical history and Social was documented. This makes the history detailed. Comprehensive

* Examination—The examination was expanded problem focused.

* Medical decision making—The diagnosis was an established problem worsening; an X-ray was ordered and

her prescription drugs were managed.

77085: Dual-energy X-ray absorptiometry (DEXA), bone density study, one or more sites; axial skeleton (e.g., hips,

pelvis, spine), including vertebral fracture assessment. Do NOT REPORT with 77080

M81.0 is age-related osteoporosis without current pathological fracture. Z79.52 is long-term (current) use of

systemic steroids.

What is the ICD 10 Code(s)?

What is CPT Code(s)?

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A 70-year-old female patient comes in for a follow-up visit for pain and stiffness in her left hip. She

injured her hip in a skiing accident three years before and reports the X-rays at that time showed no

fractures. Due to no obvious fracture at the time, she was given ibuprofen and advised to put ice on the

affected area. She is now experiencing increased pain and stiffness in her right hip, usually in the morning,

which has been happening for the past four weeks. She is taking over-the-counter non-steroidal anti-

inflammatory drugs to relieve the pain. The patient does not show any weight loss or gain and has no

complaint of fatigue.

The patient is a fit adult, with a generally good appearance. Her gait is normal. Her muscle strength is

normal in her lower extremities. There is tenderness on palpation of the right hip. There is no swelling or

crepitus. A single-view X-ray of the bilateral hips was done for a comparison. The right hip is normal, but

the left hip shows sclerosis of the superior aspect of the acetabulum, including a single Egger cyst.

The patient is assessed with post-traumatic osteoarthritis of the right hip. Physical therapy is ordered three

times a week for four weeks, and she is prescribed 300 mg ibuprofen twice a day. She is to return for

follow-up in six weeks.

CPT: 99213, 73500-RT, 73500-LT ICD-10: M16.52

This E/M service entailed:

* The history is detailed;

* The examination is expanded problem focused; and

* The medical decision making is of low complexity.

The X-ray reviewed was for radiologic examination, hip, unilateral: one view for the left hip and for the right hip.

M16.52—The diagnosis identifies unilateral post-traumatic osteoarthritis of the left hip.

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1997 Musculoskeletal Exam – Case Studies Page 25-28

Year End Questions - Case Studies Page 43 - 46

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What is the ICD 10 Code(s)?

What is Evaluation and Management Code?

A 43-year-old patient is seen in the office for a follow-up visit of her RF-positive rheumatoid arthritis and primary osteoarthritis of

the left knee. The patient is on sulindac, methotrexate and folic acid. At her last visit, the patient's methotrexate dose was

increased, which has greatly reduced her pain. Her pain is at Level 2 for her knees. The osteoarthritis is stable. The patient

denies any chest pain; her dyspnea and all other systems are negative.

On examination, the patient is alert and oriented. Her weight is 155 lbs., height 5 feet and 6 inches with a temperature of 98°F.

There is no lymphadenopathy. Her lungs are clear. She has a regular heart rate and rhythm with no murmurs or friction rubs. Her

skin shows no lesions or rashes, and her abdomen is soft with no masses or HSM. Intact Sensation in UE.

Musculoskeletal exam: Bony proliferation and slight ulnar deviation in the bilateral wrists, bony proliferation and slightly

decreased flexion in the bilateral second and fifth PIP joints, and bony proliferation of the bilateral knees. All other joints are

unremarkable with FROM.

Diagnoses:

1. Rheumatoid arthritis with rheumatoid factor;

2. Osteoarthritis of the left knee;

3. Long-term nonsteroidal anti-inflammatory drug (NSAID); and

4. Long-term disease-modifying anti-rheumatic drug (DMARD).

Plan: Complete blood count and liver function tests are ordered to monitor drug toxicity. The patient is to continue on her current

medication regimen. The patient is told to schedule a follow-up visit in two months.

Not in Case Study Packet

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CPT: 99214Diagnosis Codes: M05.79, M17.12, Z79.1, Z79.899

Rationale to code this encounter as 99214:

History—The history of present illness was extended. The review of systems was comprehensive, and one of the three past, family and social history were documented. This makes the history level Expanded Problem Focused.

Eight systems were examined. This makes the exam level comprehensive.

Medical decision making—The diagnoses are four established problems stable. Labs were ordered, and the labs were done to monitor toxicity of medication. Prescription Management occurred. This makes the MDM Moderate.

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L40.0 Psoriasis Vulgaris

Plaque psoriasis

R21 Rash NOS

86480 Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon

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History

Exam

Medical Decision Making

The ANA test is a test helping to diagnose a suspected autoimmune discorder or rule out other conditions with similar signs and symptoms.

ANA = Antinuclear antibodies

Titer = the concentration of an antibody, as determined by finding the highest dilution at which it is still able to cause agglutination of the antigen.

CPT 86039

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95908 - as 4 NCSs were performed. Each motor nerve with F-wave study is considered a single NCS

72114 Radiologic examination, spine, lumbosacral; complete including bending views, minimum of 6 views

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25

20611

20611 59

Modifier 59 indicates the second service was a distinct procedure

72146 Magnetic resonance imaging, spinal canal and contents, thoracic; without contrast

**Assume no contrast unless mentioned**

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M32.9 Systemic lupus erythematosus unspecified

SLE NOS

Systemic lupus erythematosus NOS

Systemic lupus erythematosus without organ involvement

unilateral sural sensory nerve,- unilateral peroneal motor nerve recording from extensor digitorum brevis (EDB) with F-wave

- unitateral tibial motor nerve with F-wave?

95908 - three NCSs were performed

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Ulna

Radius

Carpals

Metacarpals

Phalanges

E/M level 99213

No it will NOT be billed “Incident to” because the case study does not indicate the physician is providing “direct” supervision. The NP NPI will be listed as the rendering provider on the claim to Medicare

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Modifier 26

Radiology Services

Professional component: 26 modifier

Technical component: TC modifier

Place of Service 21 indicates the service was performed in an Inpatient Hospital setting

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Report code 95908 in addition to the EMG studies, as four NCSs were performed. For the EMG studies, there were three muscles tested, therefore, report add-on code 95885 for limited EMG studies less than five muscles. If five or more muscles were tested, report code 95886 for complete limb

Extended

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M07.661 enteropathic arthropathies right knee

M07 Notes

“Code also associated enteropathy such as regional enteritis “

Excludes 1 PSA (L40.5X)

K50.00 Crohn’s disease of the small intestine without complications

Modifier 24

Apply ONLY to E/M code

The procedure billed previously may have 10 or 90 day global period

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Written or verbal request for consult documented in medical record

Consult is documented with provider’s opinion

Written report is sent to the requesting physician

No, Modifier 25 can only be added to an Evaluation and Management service

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R68.2 Dry Mouth

Alpha Index: Dry/Mouth R68.2

Tabular: Dry Mouth Unspecified R68.2

Excludes dry mouth due to Sicca Syndrome (Sjogren) (M35.0X)

R70.0 Elevated erythrocyte sedimentation rate (ESR)

M25.541 Pain in joints of right hand

Alpha Index: Pain/Joint/Hand M25.54X

Tabular: Pain in joints of hand right M25.541

72100 Radiologic examination, spine, lumbosacral; 2-3 views

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Modifier 25 would be reported with the Evaluation and Management service

Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration Guidelines

“For same day E/M service, a different diagnosis is not required”

Pg 717

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Advanced Beneficiary Notice required by Medicare when provider determines services may not be covered and the provider plans to collect from the patient for services

Alpha Index: Fibromyalgia M79.7

Tabular:

M79.7 Fibromyalgia

Fibromyositis

Fibrositis

Myofibrositis

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80053 Comprehensive Metabolic Panel

36415 Collection of venous blood by venipuncture

72200 Radiologic examination, sacroiliac joint; less than 3 views

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CPT Index

Hepatitis/Hepatitis Antibody/Panel/Acute vs Obstetric

80074 Acute hepatitis panel

Page 539

20600 F7 Small joint injection 3rd Right finger

20600 F1 Small joint injection 2nd Left finger

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71046 Radiological examination, chest, 2 views,

Old Code maybe on test - 71020

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, Social History (PFSH)

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20611 RT – 1 unit

20611 LT – 1 unit

OR

20611 50 – 1 unit

Under column “Presenting Problem”, you will see One or more chronic illnesses with mild exacerbation, progression or side effect of treatment which indicates Moderate Risk

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Femoral Head

Acetabulum

sheath

DX: M77.11 Right Lateral Epicondylitis

20550 Tendon sheath injection

J1020 Methylpredisolone Acetate (Depomedrol) 20mg

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72202 Radiologic examination, sacroiliac joint; 3 or more views

Place of Service

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76881 US Complete Examination to include real time scan of muscle, bone, tendon, joint and soft tissue within a specific musculoskeletal area

76882 US Limited Examination – specific anatomical structure examined

POS 11 indicates the service was performed at an office

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27096 RT

E/M level 99214

It will be billed “Incident to” because the physician is providing “direct” supervision; the physician’s NPI will be listed as the rendering provider on the claim to Medicare

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Add the GA modifier to the procedure

Three

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Alpha Index:

Back (see condition)

Pain/low back M54.5

OR

Sciatic (see condition)

Sciatica with lumbago M54.4X

Tabular: M54.41 Lumbago with sciatica, Right side

Tibia

Fibula (Not weight bearing)

Tarsals

Metatarsals

Phalanges

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Three

Head

Eyes

Ears, Nose, Mouth, Throat

Remember each would need to be documented

Past history

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Under Management Option – Est problem worsening

Table of Risk – Moderate due to pharmacological management

Add the GC modifier

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85025 Complete CBC, automated and automated differential WBC count.

20526 Carpal Tunnel Injection

76942 Ultrasound Guidance

J3301 x 1 unit Kenalog

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20552 Trigger Point injection because no fluoroscopy was used

J1020 Depomedrol x 1 unit

20611 Aspiration of Baker’s cyst with USG

Alpha index:

Baker’s Cyst – see Cyst, Bakers

Cyst, Bakers M71.2X

M71.21 Synovial cyst of popliteal space (Baker’s) right knee

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1997 because I can count an update of 3 chronic conditions as an extended HPI

72074 Radiologic examination, spine, thoracic, minimum 4 views

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Alpha index:

Scleroderma, sclerodermia/Systemic M34.9

Tabular: M34.9 Systemic sclerosis unspecified – look above to M34 Systemic Sclerosis (scleroderma)

Alpha index: Long-Term/Steroids/Systemic Z79.52

Tabular: Z79.52 Long term (current) use of Systemic Steroids

You would look under the column “Presenting Problem” and view One stable chronic illness to conclude Low Risk

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ROS - Eyes

ROS - Respiratory

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86580 Tuberculosis test, intradermal

20606 AC joint injection (medium joint) with USG

J1020 Methylpredisolone Acetate 20mg

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ROS – Allergic/Immunologic or Eyes

Under General Multi-System Exam 12 elements in at least 2 organ systems or body areas

Under Single Organ System Exam 12 elements identified by a bullet

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ROS - Gastrointestinal

Timing

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20553 Trigger point injections 3 or more muscles

J3301 X 4 four muscles injected with 10mg each= 40 mg total

ROS – Psychiatric OR Constitutional

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Unable to code RA because it has not been confirmed

We may code the symptoms if documented

ENA = Extractable Nuclear Antigen CPT 86235

Detection of antibodies to the extractable nuclear antigens Sm (Smith), RNP, SS-A (Ro), SS-B (La), Scl-70, and Jo-1 in serum. The results will be reported in ENA Units with corresponding interpretations of negative, borderline or positive.

Report each antibody

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CREST

Alpha Index CREST syndrome M34.1

Tabular: CREST syndrome M34.1

OR look at your tabs

Erythrocyte sedimentation rate

ESR

Sed Rate

CPT Sedimentation Rate, Erythrocyte; non automated 85651

VS Automated 85652

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If bone density (DEXA or DXA) is performed under 2 years and patient is not taking steroids.

ABN also would not be needed for first bone density

J3420 Injection, vitamin b-12 cyanocobalamin, up to 1000 mc

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CPT 80305 Drug Test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only

Review Page 546 Drug Testing codes

In the HPI, patient will show complaints in a specific anatomical area or disease process

During the exam, the provider may note abnormal findings

The provider changes the medication or increases the dose

The provider orders additional diagnostic tests

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72148 Magnetic resonance imaging, spinal canal and contents, lumbar, without contrast material

**Assume no contrast unless mentioned**

ROS - Neurological

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J1745 Remicade/Infliximab per 10mg X 50 units

96413 First hour X 1

96415 Additional hours X 2

80048 Basic Metabolic Panel (Calcium Total)

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ROS – Endocrine or Integumentary

DX: M17.11 Unilateral primary osteoarthritis of the knee

J7321 X 1 unit EJ modifier

20611 X 1 unit

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ROS - Integumentary

You must meet 2 out of 3 to achieve the MDM level (Straightforward, Low Complexity, Moderate Complexity, High Complexity)

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95910 - eight NCSs performed + 95886 for complete limb EMG.

No – for a comprehensive level, you can only use organ systems

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ROS - Hematologic

Context

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1997 Evaluation and Management Guidelines because “using only the Musculoskeletal system”

Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border

96413 Chemotherapy administration, intravenous infusion; up to 1 hour

J0129 Orencia, Abatacept per 10mg X 100 units

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DX M81.0 Age-related osteoporosis

J1740 Boniva x 3 mg (dose is always 3mg)

96374 Boniva is administered through an IV push

Select the BEST answer - 59

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Radiology (7000s series)

Iodine and Barium

50 for bilateral

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Alpha Index: Raynaud;s disease (secondary) I73.0

Tabular: I73.00 Raynaud’s syndrome without gangrene

“NOT coded here”

An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together.

Example:

M30 Polyarteritis nodosa

Excludes1 microscopic polyarteritis (M31.7)

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