Test Bank - Chapter 01 - Test 1 Q1: T1-1A EMERGENCY AND OUTPATIENT RECORD LOCATION: Outpatient, Clinic PATIENT: Ryan Hoffgrand PHYSICIAN: Paul Sutton, MD This is a 17-year-old male who comes in after he got punched in the right side of his face. Mother is concerned because he is a diabetic and has a couple of lip lacerations, also complained of some transient blurry vision, which has since improved. The patient states that he did get hit on the right cheek area. Immediately following this he had some blurry vision in the right eye, which slowly has improved and is near normal now. He also notes that he had a cut on his right lower lip and upper inside of his right lip as well. No other complaints. Visual acuity is 20/40 both. Note the patient normally wears glasses but did not have them for this examination. PHYSICAL EXAMINATION: Head is normocephalic. PERRLA (pupils equal, round, reactive to light and accommodation). EOMS (extraocular movements) intact. Funduscopic examination is normal. There are no hemorrhages. Good sharp discs bilaterally. The discs appear clear bilaterally. TMs (tympanic membranes) are normal. Nose is without discharge. He has some tenderness and erythema in the right cheek where he was hit, no obvious swelling. Right upper lip: He had a 1- to 1.5-cm (centimeter) laceration. Superficial skin edges are not opposed, not bleeding. The teeth are in good repair. The right lower lip above the vermilion border has an abrasion. He opens and closes the jaw well. No TMJ (temporomandibular joint) tenderness. Neck is soft and supple. ASSESSMENT: 1. Upper inner lip laceration, requiring simple suture repair. 2. Lower lip abrasion. 3. Right cheek contusion. PLAN: Discussed my findings and diagnoses with the mother. I reassured her that the laceration was minor and only required two sutures to close adequately. She was advised to keep the area clean and to make an appointment with the family practitioner for removal of sutures in 7 days. He may rinse with some hydrogen peroxide and water. Watch for signs of infection; follow up if any occur. Continue to check blood sugars as stress can sometimes make these go off. Use some ice on the lip and right cheek. Follow up if any problems. T1-1A: SERVICE CODE(S): _____________________________________________ ICD-10-CM DX CODE(S): ________________________________________ (Fill in the blank) Rationale: Professional Services: 99283 (Evaluation and Management, Emergency Department) ICD-10-CM DX: S01.511A (Laceration, lip), S00.83XA (Contusion, cheek) Optional code that could be 5 bonus points, code: Y04.2XXA (Striking against, other person[s], assault) RATIONALE: The MDM included a multiple number of diagnoses/management options (lower lip laceration, abrasion, and right cheek contusion), no data to review, and low risk (acute uncomplicated injury), which is a low complexity MDM. The low level of MDM support 99283. The Emergency Department report mentions that the laceration required 2 sutures, but the details of the procedure are not documented; therefore, the coder is unable to assign a code for the laceration repair. The diagnosis is as stated in the Assessment section of the report. The lip laceration is reported with S01.511A and the contusion of the lip and cheek with S00.83XA. The 7th character “A” indicates the initial encounter. External cause codes are not optional for outpatient hospital facilities, and as such, Y04.2XXA must be reported. E917.9 (hit by other person) is used instead of Y04.0XXA (fight) because it is not documented that the “punch” was deliberate. The diabetes is not coded because it is not the reason for the encounter nor was it treated or monitored.
Q2: T1-1B CRITICAL CARE SERVICE Dr. Sutton, emergency room physician, called in Dr. Elhart, the cardiologist on call from the local clinic, to provide critical care services to Linda Paulo. Code
Buck's The Next Step: Advanced Medical Coding and Auditing 2025 2026 1e Koesterman Test Bank