Case Study 1 Coding Application (30 points)

Case Study 1 Coding Application (30 points) Instructions: ï‚· Review the below clinical documentation ï‚· List out the ICD-10-CM and CPT codes. Then provide medical necessity by linking the procedure(s) coded to a diagnostic code. ï‚· Save your file. ï‚· Upload file in the course designated assignment area before the due date and time Clinical Documentation: Patient: Eve Jeffers DOB: 07/14/1962 Date of Service: 04/07/20xx Type of Service: Office visit with x-rays Subjective: Chief Compliant: Fall two days ago, bruise on left chest near pacemaker. Recent chest cold. History of Present Illness: Patient fell on Saturday night as she was walking the dog. States that she felt lightheaded, grabbed an outside chair on the lawn, and then fell, bumping her face and her upper left chest on the chair. She states that she now has a bruise over her left upper chest over the top of her pacemaker. She also states that as she fell she bumped her left pinky toe on the chair, and it is now purple and swollen. The last time this patient was seen in the office was three months ago for a check-up and refill on her prescribed medications. Review of Systems: Constitutional: feeling poorly, no fever, no chills, and not feeling tired Cardiovascular: no chest pain and no palpitations Respiratory: no shortness of breath with cough Gastrointestinal: No abdominal pain, no nausea, no constipation, no diarrhea, no heartburn, no vomiting Genitourinary: no dysuria Musculoskeletal: no arthralgia Neurological: dizziness, but no headache Hematologic/lymphatic: a tendency for easy bruising Past, Family, Social History: Current medications reviewed. No known drug allergies. Family history of diabetes mellitus. Objective: Physical Examination: Constitutional: alert and in no acute distress Neck: normal in appearance, supple; no jugular-venous distention. The thyroid was not enlarged Cardiovascular: edema was present on ankles. Heart rate and rhythm were normal and no acute murmurs. Heart tones are very distant; Difficult to hear due to cough/ congestion Pulmonary: normal respiratory rhythm and effort comma no respiratory distress. Musculoskeletal: normal gait. No apparent limitations in mobility. Neurologic: motor exam was normal. Skin: weathered skin. Psychiatric: a decrease in concentrating ability was observed; but oriented to person, plan, and time. Affect was normal and not pleasant. Assessment and Plan: 1. Acute upper respiratory infection. Cough is likely associated with acute URI. Will need to re-evaluate with a spike in temperature or if breathing gets worse. STAT chest X ray done here in the office, 2 views, there were no signs of pneumonia or heart failure. 2.Bruising. Bruising on chest over pacemaker site, resolving. Still tender to the touch. Chest x-ray confirms that pacemaker leads are intact and pacemaker battery pack is undamaged. 3. Fracture of 5th toe of left foot, initial encounter. Lower limb x-ray done before this visit. The x-ray report and image was viewed. The image confirms fracture of 5th toe of the left foot. Completed fracture care with buddy strapping of toes. SIGNED: D. K. Williams, MD Determine the procedure(s) and diagnosis from the case study by answering the following questions. After you determine the procedure(s) and diagnosis, identify the medical necessity for the procedures with code linkage. 1. List the ICD-10-CM codes for all diagnoses (per above documentation and coding guidelines). 2. List the CPT code(s) for all procedures and services per the above documentation and coding guidelines. 3. Now that you have the procedures and the diagnoses; identify the medical necessity for all procedures. i need help with all three questions

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