THE EXTRA STEP, PHYSICIAN-BASED CODING PRACTICE, 2009 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? certification exam. A companion CD allows you to perform coding functions just as you will
in practice and receive performance evaluations and rationales based on your responses.
Contents
1. Evaluation and Management
Case 1-1: Discharge Summary, Chest Pain
Case 1-2: Progress Note, Renal
Case 1-3: Progress Note, Hypotension
Case 1-4: Discharge Summary, Cardiac Catheterization
Case 1-5: Nephrology Consultation,
Hypertension
Case 1-6: Nephrology Consultation, Hypotension
Case 1-7: Discharge Summary, Acute and Chronic Renal Failure
Case 1-8: Discharge Summary, Hypotension
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: Intracerebral Hematoma
Case 2-7: Colostomy and Cholecystectomy
Case 2-8: Modified Radical Mastectomy
Case 2-9: Incision And Drainage
Of Perirectal Abscess
Case 2-10: Division and Insert 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: Intraaortic 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: Intracranial 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 7-1: Echocardiogram
Case 7-2: Stress Test
Case 7-3: Cardiac Catheterization
Case 7-4: Cardiac Catheterization
Case 7-5: Right
Heart Catheterization
Case 7-6: Bilateral Laser Doppler
Case 7-7: Saphenous Vein Mapping
Case 7-8: Venous Ultrasound
Case 7-9: Extremities Ultrasound
Case 7-10: Renal Dialysis Progress Note
7. Gastroenterology
Case 8-1: Orogastric Tube Placement
Case 8-2: Splenectomy and Colectomy
Case 8-3: Gastrojejunostomy Placement
Case 8-4: Cystotomy
Case 8-5: Small Bowel Anastomosis
Case 8-6: 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: Diskectomy
Case 9-5: Carpal Tunnel
Case 9-6: Repair of Pseudomeningocele
Case 9-7: Laminectomy with Foraminotomy
Case 9-8: Laminotomy, Diskectomy, and Foraminotomy
Case 9-9: Halo Crown and Vest
Case 9-10: Intracapsular 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 D&C
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-L4 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: Cardiac 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
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