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MCCG222– Advanced CPT and HCPCS Level II Coding

Week 6 Physician Query Assessment


This Assessment is worth 15% of your overall grade.

Deadline

Due by the end of Week 6 at 11:59 pm, ET.

Completing this Assessment will help you to meet the following:

Course Outcome

  • Evaluate the accuracy and completeness of documentation to generate physician queries relative to correct CPT code assignments.

Directions

Accurate and complete documentation, as well as appropriate code assignment, is critical to the continuity of patient care. As part of your job as a certified coder, you must review documentation. When documentation is incomplete, it is your responsibility to query the physician.

For this Assessment, you will be presented with documentation for four cases below. Review the documentation for each case and complete the following in the Physician Query Assessment Template, which is provided in Blackboard:

  1. Assign ICD-10-CM, HCPCS Level II, and CPT codes where applicable.
  2. Determine whether the documentation for the surgical procedure is complete or incomplete.
  3. If the documentation is incomplete, assign a compliant physician query. If the documentation is complete, list N/A.

Case 1:

55-year-old female here today for diagnostic colonoscopy.  Patient has been experiencing rectal bleeding intermittently for the last month. 

Pre-operative diagnosis:  Rectal Bleeding

Post-operative diagnosis:  Colon polyp

Anesthesia:  Propofol 120 mg

Procedure Performed:  Diagnostic colonoscopy with polyp removal

A physical exam was performed. Informed consent was obtained from the patient

after explaining all of the risks (perforation, bleeding, infection and adverse effects to the medication), benefits and alternatives to the procedure which the patient appeared to understand and so stated. The patient was connected to the monitoring devices and placed in the left lateral position. Continuous oxygen was provided with a nasal cannula and IV medicine administered through an indwelling cannula. After adequate conscious sedation was achieved, a digital exam was performed, and the colon scope introduced into the rectum and advanced under direct visualization to the terminal ileum.  A polyp was identified descending colon and removed.    The scope was then withdrawn. 

Electronically Signed By:  John Smith, MD 6/2/2021 8:00am

Case Scenario 2:

35-year-old female with chronic back pain here for steroid injection. 

Pre-operative diagnosis:  Cervical spondylosis

Post-operative diagnosis:  Cervical spondylosis

Anesthesia: Local

Patient laid in left, lateral position with right side up.  Her right shoulder was pulled down and neck was prepped and draped.  We injected ropivacaine 1 mg locally.  We advanced a 2.5-inch, 25-gauge curved diamond point needle in the middle of the trapezoid at cervical spine.  We injected Omnipaque Low Osmolar 100 mg to confirm placement and then at three paravertebral facet joints of cervical spine, we injected ropivacaine 1mg and 1 mg of dexamethasone acetate at each level.

Patient felt immediate relief. 

Electronically Signed By:  Aslinia Bowl, MD 6/7/21 3:15pm

Case Scenario 3: 

8-year-old male patient brought here today by mother complaining of leg pain after falling while riding the bicycle outside at home.  Patient’s lower right leg is sore to the touch and appears red.  After closer evaluation, patient has a laceration that involves epidermis and dermis.  

Lidocaine 1% was applied, and laceration repair was made.       

Patient to follow up with primary care physician. 

Electronically Signed By:  Ellie Fowler, MD 6/3/2021 6:00pm

Case Scenario 4:

45-year-old female here with a history of menorrhagia, dysmenorrhea presenting today for a total vaginal hysterectomy.

Anesthesia:  General

Patient was prepped and draped.  Bladder was emptied as part of the prep, and weighted speculum was placed in the vagina.  The cervix was grasped with a single tooth tenaculum.  The cervix was circumferentially incised with a scalpel.  The posterior vaginal wall was grasped with forceps and incised with mayo scissors and the posterior cul-de-sac was entered.   The uterosacral ligaments were clamped, transected and sutured.  At this point I dissected the bladder from cervix using metzenbaum scissors.  The anterior peritoneal fold was visualized and cut with metzenbaum scissors and the anterior cul-de-sac was entered. 

The cardinal ligaments were clamped, cut and suture ligated.  The uterine arteries were then clamped, transected and suture ligated.  The broad ligament was clamped, transected and suture ligated.   The utero-ovarian ligaments were then clamped and transected, and the uterus was amputated.  The uterus and cervix were handed off to pathology.  The utero-ovarian ligaments were then doubly suture ligated.  All pedicles were inspected and found to be hemostatic.  The angles of the cuff were then transfixed to the ipsilateral uterosacral ligaments.  The vaginal cuff was bleeding actively and was rendered hemostatic with a running locking 0 vicryl stitch then closed with a series of figure of eight stiches of 0 vicryl.  The cuff was noted to be hemostatic.  At this point a foley catheter was placed into the bladder and drained clear urine.   The procedure was terminated.

Electronically Signed By:  Pablo Duble, MD 6/5/21 9:35am

MCCG222 – Physician Query Assessment Grading Rubric
CriteriaExceeds ExpectationsMeets ExpectationsNeeds ImprovementPoints
Code Assignment (30 points)27 – 30 points   All ICD-10-CM, HCPCS Level II, and CPT codes are correctly identified.21 – 26 points   No more than two ICD-10-CM, HCPCS Level II, or CPT codes are incorrectly identified.  0 – 20 points   Three or more ICD-10-CM, HCPCS Level II, or CPT codes are incorrectly identified.     
Documentation Complete/ Incomplete (30 points) 27 – 30 points   Documentation complete or incomplete is correctly identified for four cases.    21 – 26 points   Documentation complete or incomplete is correctly identified for three cases.    0 – 20 points   Documentation complete or incomplete is correctly identified for two or fewer cases.     
Compliant Physician Query Assignment (40 points)36 – 40 points   If applicable, a physician query is assigned, or N/A is listed correctly for four cases.    28 – 35 points   If applicable, a physician query is assigned, or N/A is listed correctly for three cases.    0 – 27 points   If applicable, a physician query is assigned, or N/A is listed correctly for two or fewer cases.     
Instructor Comments:   Total Points: 

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