CPC Exam Dumps : Certified Professional Coder (CPC) Exam

View MR 004397

MR 004397

Operative Report

Preoperative Diagnosis: Calculi of the gallbladder

Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis

Procedure: Cholecystectomy

Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.

Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.

What CPT® coding is reported for this case?

This 27-year-old male has morbid obesity with a BMI of 45 due to a high calorie diet. He has decided to have an open Roux-en-Y gastric bypass. The patient is brought to the operating room and placed in supine position. A midline abdominal incision is made. The stomach is mobilized, and the proximal stomach is divided and stapled creating a small proximal pouch in continuity with the esophagus. A short limb of the proximal bowel of 155 cm is divided. It is brought up and anastomosed to the gastric pouch. The other end of the divided bowel is connected back into the distal small bowel to the short limb's gastric anastomosis to restore intestinal continuity. The abdominal incision is closed.

What are the procedure and diagnosis codes for this encounter?

View MR 099407

MR 099407

Emergency Department Visit

Chief Complaint: VOMITING.

This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).

REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.

PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.

Medications: See Nurses Notes.

Allergies: PCN.

SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.

ADDITIONAL NOTES: The nursing notes have been reviewed.

PHYSICAL EXAM

Appearance: Lethargic. Patient in mild distress.

Vital Signs: Have been reviewed-tachycardic.

Eyes: Pupils equal, round and reactive to light.

ENT: Dry mucous membranes present.

Neck: Normal inspection. Neck supple.

CVS: Tachycardia. Heart sounds normal. Pulses normal.

E D. Course: Insulin IV drip per protocol, at 10 units/hr.

Zofran 8 mg 01:33 Jul 13 2008 IVP.

Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.

Total critical care time: 45 min.

Disposition: Admitted to Intensive Care Unit. Condition: stable.

Admit decision based on need for monitoring and IV hydration and medications.

CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.

What E/M code is reported for this encounter?