Overview
Goals & Objectives
Teaching Matrix

Instructional Strategies
Description of Strategies

Tools
PowerPoint
Trigger Scenarios
Case Exercises
Documentation Basics
Coding Tips
Pocket Coding Guide
Additional Resources

Readings
Recommended Readings
Further Readings

Assessment
Description of Strategies
Quiz

The cases below are designed to be useable in multiple ways, to best suit the needs of the learner(s) and resources available. Possibilities include:

• Case scenario is presented by a faculty member to a group of learners. The faculty member facilitates discussion among the learners, raising key questions at appropriate points in the discussion.
• Case scenario and key questions are given in written form to a group of learners. They are charged with discussing the issues, coming to consensus on answers, and presenting them (in written or spoken form) to faculty.
• Case scenario and key questions accessed by individual learner(s) on-line. Answers are e-mailed to faculty for approval and feedback to learner(s).
• Case scenario and key questions accessed by individual learner(s) on-line. Learners compare their own answers with answers provided on-line, for self-assessment.
• Case scenario and key questions accessed by multiple learners on-line. They are charged to work as a group electronically, to generate answers and submit to faculty for approval.

Case Scenarios

Scenario 1

A healthy 45 year old male is denied life insurance because the company’s review of his medical record shows a history of MI. He has never had a heart attack or heart trouble. How can this happen?

Solution On careful review of the history, it is noted that the patient presented to an emergency department3 years ago with chest pain. He was evaluated with cardiac enzymes and serial EKG, all of which were negative. He was discharged with the presumptive diagnosis of GERD, started on an H2 blocker, and symptoms resolved. Investigation of the billing reveals that during the ED evaluation, the provider indicated a diagnosis of “rule out MI” as justification for the cardiac studies. Since there is no ICD-9 indicator for “rule out”, this was coded as myocardial infarction.

Scenario 2

A PA working in orthopedics is known within the practice as knowledgeable in the areas of coding and billing. His revenue is consistently better than his peers, and he is being heavily recruited by 2 competing practices to come work for them. Why?

Solution Providers who are knowledgeable and aware of the principles of coding tend to be more complete in their coding, undercode less, and have fewer denials. Therefore their revenue is better, both for themselves and the practice.

Scenario 3

A 75-year-old woman with multiple medical problems is seen for a routine check-up with her primary provider. A month later, she receives a bill indicating Medicare has denied payment for the visit or the tests associated with it. She is distraught, as she cannot afford to pay the bill. How did this happen?

Solution The provider, seeing this visit as an annual check-up for the patient, coded it as a well visit. Medicare does not provide benefits for health maintenance/well care, with the exception of certain approved screening tests (such as mammography). The diagnosis of “general medical exam” (v70.0) does not justify the tests that were ordered for monitoring of the patient’s multiple medical problems. Since the majority of the visit was in reality devoted to monitoring of chronic diseases, the provider would have been correct in coding a 99214 (or 99215, depending upon the degree of services rendered), with the patient’s diagnoses of diabetes, congestive heart failure, hyperlipidemia, etc. The visit would then have been a covered service, as would all of the linked lab tests and studies.

Diagnosis Coding

Scenario 1

A 50 year old patient with multiple sclerosis has gradually progressed to a level of disability that makes her unable to care for herself. Her family tries to find placement for her in a nursing facility, only to find she is repeatedly refused because the facilities are unwilling to take schizophrenics. What is going on?

Solution MS does at times cause mental confusion. The patient in question had delusions at one point in her course. A provider not entirely familiar with her case coded the diagnosis of schizophrenia as the cause of her delusions, though that diagnosis had never formally been made.

Scenario 2

A healthy 29-year-old is seen for an annual exam and Pap smear. During the visit she notes she’s had urinary frequency and some dysuria for the past 2 days. The provider orders a urinalysis, which is normal. Two months later, the patient complains because she’s received a bill for the urinalysis—payment was denied by her insurance company. Why do you suspect this happened? What diagnosis code(s) would you use for this encounter?

Solution The provider coded the visit purely as a well visit, since no disease was found. Urinalysis is not a recommended routine screening test in a non-pregnant healthy young woman, so it was not covered by the insurance What diagnosis code(s) would you use for this encounter? V70.0 general medical exam or v72.3 gynecological exam (depending upon the scope of the exam), and 788.1 dysuria and/or 788.41 urinary frequency The urinary symptoms would justify the urinalysis, even though the result was negative

Scenario 3

A 72 year old male is seen for a routine check of his multiple problems. His history includes diabetes (with nephropathy), hypertension, prostate cancer, and emphysema. He was recently treated for an acute case of olecranon bursitis. He sees his urologist regularly. At the visit you check his glucose (289) and blood pressure (115/79); examine his heart, lungs, feet, and elbow; increase his gliburide; and discuss diet and exercise. What diagnosis code(s) would you use for this encounter? Which diagnosis would you list first?

Solution What diagnosis code(s) would you use for this encounter? 250.42 diabetes type 2 with renal manifestations, uncontrolled 401.1 hypertension, essential benign 492.8 emphysema 726.33 olecranon bursitis Since there was no care specific to the diagnosis of prostate cancer, and it is not likely to have affected the care that was delivered, that diagnosis should not be coded for this encounter. Which diagnosis would you list first? Given that the diabetes is poorly controlled, and the other problems are doing well, the most effort in the visit was probably devoted to the diabetes, and this should be listed first.

Procedure Coding

Scenario 1

Four patients are seen in sigmoidoscopy clinic one morning. The first has one polyp which is snared and removed for pathology. The third has some atypical-looking areas which are sampled for pathology. The other two are completely normal. How should these procedures be coded?

Solution Patient 1 - 45338 - sigmoidoscopy with removal of lesion by snare Patient 2 - 45330 - sigmoidoscopy without collection of specimens Patient 3 - 45331 - sigmoidoscopy with biopsy Patient 4 - 45330 - sigmoidoscopy without collection of specimens

Scenario 2

A patient with multiple skin lesions requests removal of several that are bothersome to her. These include: several skin tags around her neck a 4 mm raised pigmented nevus on her shoulder, which is irritated by her bra strap and bleeds on occasion several 8-10 mm waxy seborrheic keratoses on her chest and back You see her initially, discuss the possible approaches for each of these, and plan a return visit for procedures. At the return visit you remove 8 skin tags and the nevus by shaving them off, and treat 5 SK’s with liquid nitrogen.

Solution How would you code this second visit? 11200 removal of skin tags, up to 15 11300 shave of epidermal lesion, 0.5 cm or less 17000 destruction benign or premalignant lesion, first lesion 17003 x7 destruction benign or premalignant lesion, second through Would you charge for evaluation and management services? An E&M charge is appropriate for the first visit. At that time, history was taken, exam performed, and medical decisions made. The second visit was planned specifically to complete the procedures, and that is all that was done, so no E&M is justified for that encounter For the shave biopsy, you used local infiltration of lidocaine and epinephrine for anesthesia. The wound required electrocautery to control bleeding. Should you code for these? The CPT description of 11300 indicates “This includes local anesthesia, chemical or electrocauterization of the wound.” To charge for these separately would be unbundling. What payment issues should you discuss with the patient? Removal of skin tags is often considered a cosmetic procedure, and therefore not paid for by many insurance policies. Shave biopsy of a nevus that has been bleeding, on the other hand, would generally be covered, including pathologic analysis to rule out malignancy. Coverage for cryotherapy of seborrheic keratoses varies; patients may wish to check with their insurance company before undertaking this.