The Practice Step: Physician-Based Coding Cases, 2012 Edition

1. Evaluation and Management

Case 1-1: Discharge Summary, Chest Pain

Case 1-2: Progress Note, Acute and Chronic Renal Failure

Case 1-3: Progress Note, Hypotension

Case 1-4: Discharge Summary, Cardiac Catheterization

Case 1-5: Nephrology Consultation, Hypertension

Case 1-6: Nephrology Consultation, Chronic Renal Failure

Case 1-7: Discharge Summary, End-Stage Renal Disease

Case 1-8: Discharge Summary, Hydronephrosis

Case 1-9: Progress Note, Hemoptysis

Case 1-10: Neurosurgery Consultation, Neck Injury

Case 1-11: Neurosurgery Consultation, Neck Pain

Case 1-12: Neurosurgery Consultation, Leg Pain

Case 1-13: Consultation, Intracerebral Hematoma

Case 1-14: Rehabilitation Consultation, Back Pain and SOB

Case 1-15: Urology Consultation, Oliguria

Case 1-16: Thoracic Medicine/Critical Care Progress Note, Lung Cancer

Case 1-17: Clinic Visit, Diarrhea

Case 1-18: Cardiology Consultation, Chest Pain and SOB

Case 1-19: Clinic Visit, Abdominal Pain

2. Anesthesiology

Case 2-1: Perforated Appendicitis

Case 2-2: Right Inguinal Herniorrhaphy

Case 2-3: Laparoscopic Cholecystectomy

Case 2-4: Left Breast Biopsy

Case 2-5: Amputation

Case 2-6: Umbilical Herniorrhaphy

Case 2-7: Takedown Colostomy and Cholecystectomy

Case 2-8: Modified Radical Mastectomy

Case 2-9: Incision and Drainage Of Perirectal Abscess

Case 2-10: Division and Insetting of Flap

Case 2-11: Intracerebral Hematoma

3. Cardiology

Case 3-1: Catheter Placement

Case 3-2: Chart Note, Therapeutic Apheresis

Case 3-3: Catheterization

Case 3-4: Coronary Artery Bypass Graft

Case 3-5: Intubation

Case 3-6: Dressing Change and Oversewing of Tracheostomy

Case 3-7: Thoracentesis

Case 3-8: Endarterectomy

Case 3-9: Angiogram

Case 3-10: Intra-aortic Balloon Pumping

4. Integumentary

Case 4-1: Excision, Cheek Lesion

Case 4-2: Right Breast Wide Excision

Case 4-3: Thenar Flap Coverage

Case 4-4: Division and Insert of Flap

Case 4-5: Laceration Repair

Case 4-6: Massive Debridement

Case 4-7: Minimal Debridement

Case 4-8: Amputation

Case 4-9: Nevus Excision

5. Emergency Medicine

Case 5-1: Forearm Abrasion and Swelling

Case 5-2: Vomiting

Case 5-3: Gastroesophageal Reflux Disease

Case 5-4: Headache

Case 5-5: Closed Head Injury

Case 5-6: Sore Throat, Earache, and Sore Chest

Case 5-7: Thigh Redness

Case 5-8: Patellar Dislocation

Case 5-9: Leg Laceration

Case 5-10: Abdominal Pain and Diarrhea

Case 5-11: Scrotal Bleeding

Case 5-12: Dyspnea and Tachycardia

6. Medicine

Case 6-1: Echocardiogram

Case 6-2: Stress Test

Case 6-3: Cardiac Catheterization

Case 6-4: Cardiac Catheterization

Case 6-5: Right Heart Catheterization

Case 6-6: Bilateral Laser-Doppler

Case 6-7: Saphenous Vein Mapping

Case 6-8: Venous Ultrasound

Case 6-9: Extremities Ultrasound

Case 6-10: Renal Dialysis Progress Note

7. Gastroenterology

Case 7-1: Orogastric Tube Placement

Case 7-2: Splenectomy and Colectomy

Case 7-3: Gastrojejunostomy Placement

Case 7-4: Cystotomy

Case 7-5: Small Bowel Anastomosis

Case 7-6: Pyloroplasty

8. Nephrology

Case 8-1: Progress Note, Dialysis

Case 8-2: Progress Note, Peritoneal Dialysis

Case 8-3: Progress Note, Cycler PD

Case 8-4: Renal Tumor Excision

Case 8-5: Renal Mass

Case 8-6: Renal Tumor

Case 8-7: Dialysis Catheter Replacement

9. Neurology and Ophthalmology

Case 9-1: Intracerebral Hematoma

Case 9-2: Release of Ulnar Nerve and Cubital Tunnel

Case 9-3: Parietal Burr Holes

Case 9-4: Discectomy

Case 9-5: Carpal Tunnel

Case 9-6: Repair of Pseudomeningocele

Case 9-7: Laminectomy with Foraminotomy

Case 9-8: Laminotomy, Discectomy, and Foraminotomy

Case 9-9: Halo Crown and Vest

Case 9-10: Extracapsular Cataract

10. Obstetrics and Gynecology

Case 10-1: Abdominal Hysterectomy

Case 10-2: Dilation and Curettage

Case 10-3: Cesarean Section

Case 10-4: Labial Excision

Case 10-5: Dilation and Curettage

Case 10-6: Cervical Cerclage Preoperative Examination

Case 10-7: Suction Diltion and Curettage

Case 10-8: Cesarean with Tubal Ligation

Case 10-9: Cesarean Section

Case 10-10: OB Ultrasound

Case 10-11: Laparoscopic Drainage of Cyst

11. Orthopedics

Case 11-1: Arthroplasty and Spur Excision

Case 11-2: Meniscectomy, Knee

Case 11-3: Plical Excision

Case 11-4: Medial Meniscectomy, Knee

Case 11-5: Steroid Injection

Case 11-6: Open Reduction Internal Fixation

Case 11-7: Fascial Sling Arthroplasty

Case 11-8: Excision Bone Tumor

Case 11-9: Carpal Tunnel Release

Case 11-10: Debridement of Chondromalacia

Case 11-11: Excision of Mass, Bursa

Case 11-12: Excision of Mass, Finger

Case 11-13: Arthroplasty, Hip

12. Otorhinolaryngology

Case 12-1: Tympanostomy

Case 12-2: Direct Laryngoscopy

Case 12-3: Myringotomy with Tympanostomy

Case 12-4: Adenoidectomy

Case 12-5: Tonsillectomy and Adenoidectomy

Case 12-6: Esophagoscopy with Dilation

Case 12-7: Cervical Node Excision

Case 12-8: Septoplasty

Case 12-9: Mandibular Angle Fracture

Case 12-10: Brachial Cleft Fistula Repair

Case 12-11: Incus and Stapes Mobilization

Case 12-12: Ethmoidectomy, Sphenoidotomy, and Septoplasty

Case 12-13: Tarsorrhaphy

13. Pathology

Case 13-1: L3-4 Disc

Case 13-2: Uterus, Bilateral Tubes, and Ovaries

Case 13-3: Placenta

Case 13-4: Cervical Disc

Case 13-5: Cervical Disc

Case 13-6: Endometrial Curettage

Case 13-7: Cerebral Hematoma

Case 13-8: Necrotic Fascia

Case 13-9: Myxoma

Case 13-10: Soleus Muscle

14. Pediatrics, Neonatology, and Adolescent Medicine

Case 14-1: Well-Child Check

Case 14-2: NICU Progress Note, Prematurity with Respiratory Difficulty

Case 14-3: Progress Note, Ventilator Assist

Case 14-4: NICU Progress Note, Ventilator Assist

Case 14-5: Circumcision

Case 14-6: Newborn Report

15. Diagnostic Radiology

Case 15-1: CT of Brain

Case 15-2: X-Ray, Chest

Case 15-3: Cranial CT

Case 15-4: X-Ray, Chest

Case 15-5: CT of Abdomen and Pelvis

Case 15-6: Gallbladder Ultrasound

Case 15-7: Ultrasound, Kidneys

Case 15-8: Catheter Placement

Case 15-9: Stress Test

Case 15-10: Ventilation-Perfusion Lung Scan

Case 15-11: Head Ultrasound

Case 15-12: Abdominal X-Ray, UVC Catheter Placement

Case 15-13: Neonatal Cystourethrogram

16. Intervention Radiology and Radiation Oncology

Case 16-1: CT-Guided Liver Biopsy

Case 16-2: CT-Guided Lung Mass Biopsy

Case 16-3: Lumbar Puncture

Case 16-4: Ultrasound-Guided Paracentesis

Case 16-5: Catheter Placement

Case 16-6: Carotid Angiogram

Case 16-7: Aortogram

Case 16-8: Tube Placement

Case 16-9: Fistulogram

Case 16-10: Extremity Angiogram

Case 16-11: Abdominal Aortogram

Case 16-12: Inpatient Consultation, Radiology Oncology

Case 16-13: Treatment Planning Note, Radiation Oncology

Case 16-14: Simulation Note, Radiation Oncology

17. Urology

Case 17-1: Native Kidney Biopsy

Case 17-2: Cystoscopy

Case 17-3: Catheterization

Case 17-4: Cystoscopy and Retrograde Pyelogram

Case 17-5: Kidney Biopsy

Case 17-6: Native Kidney Biopsy

Case 17-7: Ureteral Stent Change

Case 17-8: Multiple Bladder Biopsies

Case 17-9: Fulguration and Penile Lesion Biopsy

Case 17-10: Hydrocele Repair

18. General Surgery

Case 18-1: Perforated Appendicitis

Case 18-2: Right Inguinal Herniorrhaphy

Case 18-3: Laparoscopic Cholecystectomy

Case 18-4: Stab Wound

Case 18-5: Left Breast Biopsy

Case 18-6: Amputation

Case 18-7: Umbilical Herniorrhaphy

Case 18-8: Colostomy and Cholecystectomy

Case 18-9: Modified Radical Mastectomy

Case 18-10: Incision and Drainage of Perirectal Abscess

Case 18-11: Peritoneal Dialysis Catheter Placement

Appendix A: Coding Answers to Patient Cases