Case Scenarios assigning ICD-10-CM (why) and CPT (what) codes. This is most rea

Case Scenarios assigning ICD-10-CM (why) and CPT (what) codes. This is most realistic because everything billed in healthcare requires identifying the reason the patient was seen (ICD-10-CM) and what services were provided (CPT).
For CPT codes, the focus will only be on the E/M services for office and other outpatient services. You will need to determine if the patient qualifies as a new or established patient so you know what CPT E/M codes to choose from.
Make sure you have a good understanding on the following before you complete this assignment.
Coding rules on what to identify as the first-listed condition based on confirmed or not confirmed diseases or conditions. Know how to identify terms that describe a disease/condition, body part, and laterality.
Coding rules on what to code based on signs and symptoms that are part of a confirmed disease/condition. Identify and apply the CPT guideline using time or medical decision making for new or established patients.
Identify the different levels of the three elements in medical decision making when assigning E/M codes.
Coding Cases Instructions
Step 1: Click on the following hyperlink: MA180 Superbill. You are going to refer to this while you answer the coding cases below. You will notice there are sections of E/M codes based on new and established patients. In addition, you will see ICD-10-CM codes listed.
Step 2: You are going to refer to this superbill to determine the ICD-10-CM and CPT codes for your cases below. You are welcome to use the ICD-10-CM index, tabular. and coding guidelines in the table of contents.
Step 3: Submit your answers (CPT and ICD-10-CM codes for each of the coding cases) to the Assignment drop box folder. Note that you must assign the complete code for credit. Any characters missing in the code will be considered incomplete and marked wrong. The Coding Cases are worth four-points each (total of 16 possible points)
Coding Cases Scenarios #1 Case Scenario:
An established patient was seen by their primary care provider for left ear pain after swimming at the local swimming pool. The provider documented: Patient was seen for left ear pain. After examination patient has otitis media in the left ear. Prescribed antibiotics and patient to follow up in one week or sooner if symptoms do not improve. Upon review of the record, the coder determined the provider documented low complexity of problems, low complexity of data, and moderate risk due to drug management. Time spent was 33 minutes. What is the ICD-10-CM Code for this office visit?
What is the E/M CPT code for this office visit?
#2 Case Scenario:
A new patient was seen by Dr. Ortho for congenital scoliosis. Dr. Ortho documented: This 23 year-old patient presents to the office for congenital scoliosis. Upon examination it is my suggestion that the patient undergo surgery to correct this problem. I have explained the risks and the patient agrees to the surgery. Patient is to call the office to schedule the surgery. Upon review of the record, the coder determined the provider documented high complexity of problems, moderate complexity of data, and high risk due to decision of elective surgery. Time spent was 48 minutes. What is the ICD-10-CM Code for this office visit?
What is the E/M CPT code for this office visit?
#3 Case Scenario: An established patient was seen in the office for an urgent matter as the family requested the patient be seen because of their major depression. The provider documented: Patient was seen at the request of family for single episode of major depression. Increased the patient’s antidepressant medication and patient to follow up in one week. If patient shows signs of harming themselves, the family is to call 911 immediately. I spent a total of 40 minutes with the patient. 21 minutes spent counseling and coordinating care with the patient and family. Upon review of the record, the coder determined the provider documented low complexity of problems, low complexity of data, and moderate risk due to drug prescribing. Time spent was 44 minutes. What is the ICD-10-CM Code for this office visit?
What is the E/M CPT code for this office visit?
#4 Case Scenario:
An established patient was seen in the office for abdominal pain. After examining the patient, the provider documented: Patient presents with abdominal pain. Patient may have possible gastritis. Instructed patient to try over the counter medication for three days and if symptoms do not improve or the patient sees blood in stool, they are to return immediately. Upon review of the record, the coder determined the provider documented low complexity of problems, moderate complexity of data, and moderate risk due to drug prescribing. Time spent was 32 minutes. What is the ICD-10-CM Code for this office visit?
What is the E/M CPT code for this office visit?