THE EXTRA STEP, PHYSICIAN-BASED CODING PRACTICE, 2010 EDITION
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By Carol Buck, MS, CPC-I, CPC, CPC-H, CCS-P, Program Director (Retired), Medical Secretarial Programs, Northwest Technical College, East Grand Forks, MN
Description
Designed to help you perfect your coding skills and position yourself for career advancement, this easy-to-use resource presents realistic
patient cases specific to outpatient physician settings to give you the extra practice you need to remain competitive in the medical
coding marketplace and prepare for the CPC and CCS-P certification exams.
Contents
Chapter 1: Evaluation and Management
Case 1: Discharge Summary, Chest Pain
Case 2: Progress Note, Renal
Case 3: Progress Note, Hypotension
Case 4: Discharge Summary, Cardiac Catheterization
Case 5: Nephrology Consultation,
Hypertension
Case 6: Nephrology Consultation, Hypotension
Case 7: Discharge Summary, Acute and Chronic Renal Failure
Case 8: Discharge Summary, Hypotension
Case 9: Progress Note, Hemoptysis
Case 10: Neurosurgery Consultation, Neck Injury
Case 11: Neurosurgery Consultation, Neck Pain
Case 12: Neurosurgery Consultation, Leg Pain
Case 13: Consultation,
Intracerebral Hematoma
Case 14: Rehabilitation Consultation, Back Pain and SOB
Case 15: Urology Consultation, Oliguria
Case 16: Thoracic Medicine/Critical Care Progress Note, Lung Cancer
Case 17: Clinic Visit, Diarrhea
Case 18: Cardiology
Consultation, Chest Pain and SOB
Case 19: Clinic Visit, Abdominal Pain
Chapter 2: Anesthesiology
Case 1: Perforated Appendicitis
Case 2: Right Inguinal Herniorrhaphy
Case 3: Laparoscopic Cholecystectomy
Case
4: Left Breast Biopsy
Case 5: Amputation
Case 6: Intracerebral Hematoma
Case 7: Colostomy and Cholecystectomy
Case 8: Modified Radical Mastectomy
Case 9: Incision And Drainage Of Perirectal Abscess
Case 10: Division and
Insert of Flap
Case 11: Intracerebral Hematoma
Chapter 3: Cardiology
Case 1: Catheter Placement
Case 2: Chart Note, Therapeutic Apheresis
Case 3: Catheterization
Case 4: Coronary
Artery Bypass Graft
Case 5: Intubation
Case 6: Dressing Change and Oversewing of Tracheostomy
Case 7: Thoracentesis
Case 8: Endarterectomy
Case 9: Angiogram
Case 10: Intraaortic Balloon Pumping
Chapter
4: Integumentary
Case 1: Excision, Cheek Lesion
Case 2: Right Breast Wide Excision
Case 3: Thenar Flap
Coverage
Case 4: Division and Insert of Flap
Case 5: Laceration Repair
Case 6: Massive Debridement
Case
7: Minimal Debridement
Case 8: Amputation
Case 9: Nevus Excision
Chapter 5:
Emergency Medicine
Case 1: Forearm Abrasion and Swelling
Case 2: Vomiting
Case 3: Gastroesophageal Reflux
Disease
Case 4: Headache
Case 5: Intracranial Injury
Case 6: Sore Throat, Earache, and Sore Chest
Case 7:
Thigh Redness
Case 8: Patellar Dislocation
Case 9: Leg Laceration
Case 10: Abdominal Pain and Diarrhea
Case
11: Scrotal Bleeding
Case 12: Dyspnea and Tachycardia
Chapter 6: Medicine
Case 1: Echocardiogram
Case 2: Stress Test
Case 3: Cardiac Catheterization
Case 4: Cardiac Catheterization
Case 5: Right Heart Catheterization
Case 6: Bilateral Laser Doppler
Case 7: Saphenous Vein Mapping
Case
8: Venous Ultrasound
Case 9: Extremities Ultrasound
Case 10: Renal Dialysis Progress Note
Chapter
7: Gastroenterology
Case 1: Orogastric Tube Placement
Case 2: Splenectomy and Colectomy
Case 3: Gastrojejunostomy
Placement
Case 4: Cystotomy
Case 5: Small Bowel Anastomosis
Case 6: Pyloroplasty
Chapter 8: Nephrology
Case 1: Progress Note, Dialysis
Case 2: Progress Note, Peritoneal Dialysis
Case 3: Progress Note, Cycler PD
Case 4: Renal Tumor Excision
Case 5: Renal Mass
Case 6: Renal Tumor
Case
7: Dialysis Catheter Replacement
Chapter 9: Neurology and Ophthalmology
Case
1: Intracerebral Hematoma
Case 2: Release Of Ulnar Nerve and Cubital Tunnel
Case 3: Parietal Burr Holes
Case 4:
Diskectomy
Case 5: Carpal Tunnel
Case 6: Repair of Pseudomeningocele
Case 7: Laminectomy with Foraminotomy
Case
8: Laminotomy, Diskectomy, and Foraminotomy
Case 9: Halo Crown and Vest
Case 10: Intracapsular Cataract
Chapter 10: Obstetrics and Gynecology
Case 1: Abdominal Hysterectomy
Case 2: Dilation and Curettage
Case 3: Cesarean Section
Case 4: Labial Excision
Case 5: Dilation and Curettage
Case 6: Cervical Cerclage Preoperative
Examination
Case 7: Suction D&C
Case 8: Cesarean with Tubal Ligation
Case 9: Cesarean Section
Case 10:
OB Ultrasound
Case 11: Laparoscopic Drainage of Cyst
Chapter 11: Orthopedics
Case 1: Arthroplasty and Spur Excision
Case 2: Meniscectomy, Knee
Case 3: Plical Excision
Case 4: Medial Meniscectomy,
Knee
Case 5: Steroid Injection
Case 6: Open Reduction Internal Fixation
Case 7: Fascial Sling Arthroplasty
Case
8: Excision Bone Tumor
Case 9: Carpal Tunnel Release
Case 10: Debridement of Chondromalacia
Case 11: Excision of
Mass, Bursa
Case 12: Excision Of Mass, Finger
Case 13: Arthroplasty, Hip
Chapter
12: Otorhinolaryngology
Case 1: Tympanostomy
Case 2: Direct Laryngoscopy
Case 3: Myringotomy with Tympanostomy
Case 4: Adenoidectomy
Case 5: Tonsillectomy and Adenoidectomy
Case 6: Esophagoscopy with Dilation
Case 7: Cervical
Node Excision
Case 8: Septoplasty
Case 9: Mandibular Angle Fracture
Case 10: Brachial Cleft Fistula Repair
Case 11: Incus and Stapes Mobilization
Case 12: Ethmoidectomy, Sphenoidotomy, and Septoplasty
Case 13: Tarsorrhaphy
Chapter 13: Pathology
Case 1: L3-L4 Disc
Case 2: Uterus, Bilateral Tubes, and
Ovaries
Case 3: Placenta
Case 4: Cervical Disc
Case 5: Cervical Disc
Case 6: Endometrial Curettage
Case
7: Cerebral Hematoma
Case 8: Necrotic Fascia
Case 9: Myxoma
Case 10: Soleus Muscle
Chapter
14: Pediatrics, Neonatology, and Adolescent Medicine
Case 1: Well-Child Check
Case 2: NICU Progress Note, Prematurity
with Respiratory Difficulty
Case 3: Progress Note, Ventilator Assist
Case 4: NICU Progress Note, Ventilator Assist
Case 5: Circumcision
Case 6: Newborn Report
Chapter 15: Diagnostic Radiology
Case 1: CT of Brain
Case 2: X-Ray, Chest
Case 3: Cranial CT
Case 4: X-Ray, Chest
Case 5: CT of
Abdomen and Pelvis
Case 6: Gallbladder Ultrasound
Case 7: Ultrasound, Kidneys
Case 8: Catheter Placement
Case
9: Stress Test
Case 10: Ventilation-Perfusion Lung Scan
Case 11: Head Ultrasound
Case 12: Abdominal X-Ray, UVC Catheter
Placement
Case 13: Neonatal Cystourethrogram
Chapter 16: Intervention Radiology and
Radiation Oncology
Case 1: CT-Guided Liver Biopsy
Case 2: CT-Guided Lung Mass Biopsy
Case 3: Lumbar Puncture
Case 4: Ultrasound-Guided Paracentesis
Case 5: Catheter Placement
Case 6: Cardiac Angiogram
Case 7: Aortogram
Case 8: Tube Placement
Case 9: Fistulogram
Case 10: Extremity Angiogram
Case 11: Abdominal Aortogram
Case
12: Inpatient Consultation, Radiology Oncology
Case 13: Treatment Planning Note, Radiation Oncology
Case 14: Simulation
Note, Radiation Oncology
Chapter 17: Urology
Case 1: Native Kidney Biopsy
Case
2: Cystoscopy
Case 3: Catheterization
Case 4: Cystoscopy and Retrograde Pyelogram
Case 5: Kidney Biopsy
Case
6: Native Kidney Biopsy
Case 7: Ureteral Stent Change
Case 8: Multiple Bladder Biopsies
Case 9: Fulguration and
Penile Lesion Biopsy
Case 10: Hydrocele Repair
Chapter 18: General Surgery
Case 1: Perforated Appendicitis
Case 2: Right Inguinal Herniorrhaphy
Case 3: Laparoscopic Cholecystectomy
Case
4: Stab Wound
Case 5: Left Breast Biopsy
Case 6: Amputation
Case 7: Umbilical Herniorrhaphy
Case 8: Colostomy
and Cholecystectomy
Case 9: Modified Radical Mastectomy
Case 10: Incision and Drainage of Perirectal Abscess
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