Chapter 18 – Medicine – Review Questions – Flashcards

PAD rehabilitative physical exercises are used for what disease/disorder?

Nerve conduction, amplitude, and latency study of the median sensory nerve to the first digit is coded with what CPT code?

A 28 week pregnant 35 year-old established patient with thoracic and low back pain, requests osteopathic manipulative treatment to her back. Osteopathic manipulative therapy is done on one to two body regions for somatic dysfunction. Therapy is performed by high velocity, low amplitude. Muscle spasm is not present. What CPT and diagnoses codes are reported for this encounter?

Patient presented in clinic today for asthma exacerbation. Spirometry was done prior to albuterol. Albuterol 1 mg was given via nebulizer, and then two out of three attempts were obtained for spirometry and showed an obstructive pattern. After nebulizer use, most of her wheezing resolved with slightly increased air movement, but there was still restricted flow. What CPT code is reported for this service?

A 10 year-old, established patient has a high fever and sore throat. The mother contacts the office at closing time and is told to bring the child to the office for treatment. The office remained open until they arrived. The physician performs a problem focused history, expanded problem focused exam, and the medical decision making is of low complexity. What CPT codes are reported for this service?

Today in the office, a 53 year-old receives two allergy injections IM in her left upper arm for ragweed and cat dander. The doctor administers the allergen extract brought in by the patient. What is the CPT code for this service?

A 65 year-old stumbles and trips in her home, landing on her side and injuring her left hip. The ER physician gets the X-ray, back showing an anterior, dislocation of the left hip. Consent is given for sedation for the reduction of the hip. The ER physician administers Ketamine (IV) and a nurse is there to assist in the monitoring of the patient for 15 minutes. Abduction is performed on the right hip and reduction is successful by the ER physician. Upon recovery from sedation, the patient states She feels better. What CPT code(s) are reported by the ER physician?

A 6 year-old patient comes in for a preventive medicine service. Along with the exam, the physician does visual acuity screening using the Rosenbaum Test and a hearing screening test. The patient only responds to tones of different pitches and intensities. What CPT codes are reported for the visual acuity and hearing screening?

Medical Record Documentation #1: Chief Complaints/Concerns 1. Established patient with back pain, requests OMT to back. 2. Depression. Has been feeling more stressed and depressed the last few weeks. Has been treated for depression in the past. Has been having some bad thoughts but no intent or any kind of planning. Procedures Osteopathic manipulation therapy (OMT). Osteopathic manipulative therapy done on one to two body regions for somatic dysfunction. Therapy performed by the following method: high velocity low amplitude. Muscle spasm is not present. Exam VS—T98, RR -20, BP 120/78 Appearance: healthy appearing female, nutrition good, hair disheveled Psychiatric: Speech—quiet, slow; asked pt. several times to speak up Thought processes—reasoning okay, somewhat slow response time, distracted Associations—loose thinking, wanders from one topic to another Abnormal or psychotic thoughts—no suicidal ideation; delusions; or hallucinations Judgment—insight intact regarding current difficult situation Abdomen—soft, non-tender Reflexes-2 +, normal Extremities-1+ edema, normal Pelvic exam—not done Back—no obvious lesions, intact. No redness or swelling No CVAT Assessment/Plan Low back pain (LBP), acute Pain in thoracic spine, acute Depression, Medication prescribed, medications reviewed, side effects reviewed, discussed treatment plan with patient Somatic dysfunction, thoracic, acute Somatic dysfunction, lumbar, acute Encounter for therapeutic drug monitoring, severe Medications ordered, renewed, and stopped this visit: Brand Name: Zoloft Dose: 50 mg Sig Desc: One by mouth daily x 3 Days then 2 POQD Start Date Stop Date 02/29/20xx Follow-up: Status: ordered Follow-up: office visit Timeframe: in 3 days Reason/Comment: recheck What are the CPT and ICD-10-CM codes for this dictation?

Medical Record Documentation #2: Chief Complaints/Concerns: 1. New patient; 2 year-old WCE (well child exam). Mom doesn't have immunization record. States child's last shot was given when he was 5 months old. Past Medical History & Family History—Reviewed. Pediatric Interval Social History Sleep: There are no sleep concerns. Activity Level: There are no activity or exercise concerns. Developmental History—All areas of development are appropriate for, age. Review of Systems Constitutional: No fever, irritability or lethargy; good appetite. HEENT: Sees and hears well; no eye, ear or nasal discharge. Respiratory: No cough, no audible wheeze, respirations normal. Cardiovascular: No color changes. Gastrointestinal: No vomiting, diarrhea or constipation. Bowel elimination history: There are no bowel concerns. Nutrition history: Patient drinks milk from a cup; on demand; of 2% milk daily. Patient drinks juice from a cup on demand; of varied juice daily. Patient drinks water from a cup; on demand; of well water daily. Genitourinary: Normal urine output. Bladder elimination history: there are no bladder concerns Dermatologic: No unusual rashes. Musculoskeletal: Moving all extremities as usual; normal gait. Vital Signs: Height 37.50 in, Weight 35.50 lb Physical Exam General/Constitutional: No apparent distress. Well nourished and well developed. Ears: TM's gray. Landmarks normal. Positive light reflex. Nose/Throat: Nose and throat clear; palate intact; no lesions. Lymphatic: No palpable cervical, supraclavicular or axillary adenopathy. Respiratory: Normal to inspection. Lungs clear to auscultation. Cardiovascular: RRR without murmurs. Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses. Integumentary: No unusual rashes or lesions. Musculoskeletal: Good strength; no deformities. Full ROM all extremities. Extremities: Extremities appear normal. Assessment/Plan Routine Infant/Child Health Visit Immunizations given: DTaP, IPV, MMR, Hib-HepB, Varicella What are the CPT and ICD-10-CM codes for this dictation?