OP Coding 2014 Assessment
Name: ________________________
Complete the following questions before submitting your completed assessment:
Please record the length of time in hours and minutes it took for you to complete this
competency evaluation:
Time:
Date Taken:
What coding resource did you utilize to complete the evaluation? For example, ICD-9CM code books, CPT code book, 3M encoder, Ingenix encoder, etc.
ICD-9, CPT & 3M
What reference materials did you use to assist you in completing the competency
evaluation?
Coders desk reference, internet searches.
INSTRUCTIONS FOR
COMPLETION
Please read all instructions carefully
1)
Use the most current edition of the coding books when answering the questions.
2)
Record all codes legibly in the spaces provided.
3)
Be sure your name or initials are on every page of the evaluation.
4)
Email or fax your completed competency evaluation to:
Prospective Payment Specialist
easy@ppscompliance.com or marissa.smith@ppscompliance.com
FAX: 310-563-1813
PPS CODING ASSESSMENT
Be sure to read each question thoroughly. Assign all applicable ICD-9-CM
diagnoses and procedures. E codes and V codes should be assigned when
applicable. Use 2014 Coding Guidelines and assign discharge dispositions and
POA assignments
PART II: OUTPATIENT SURGERY
1. Patient is a 28 year old female admitted to observation from the ER with severe right lower
quadrant pain. An ultrasound performed revealed acute appendicitis. She was taken to the
operative room where a laparoscopic appendectomy was performed. Pathology report stated:
Acute on chronic appendicitis.
Diagnosis:
Procedure:
2. Mr. Smith is a 65 year old male Medicare patient scheduled for colon cancer screening. His past
medical history reveals COPD, hypertension, Diabetes Mellitus, and family history of colon
cancer. Patient was taken to the endoscopy suite where a colonoscopy was performed revealing
mild diverticulosis and internal hemorrhoids.
Diagnosis:
Procedure:
3. Jonah is a 3 year old male with chronic otitis media as well as chronic tonsillitis. He was brought
to the operative room where bilateral myringotomy with tube insertion and tonsillectomy was
performed.
Diagnosis:
Procedure:
4. Joe was playing baseball when he twisted his right arm throwing the ball to home plate. He
suffered severe pain. He presented to the doctor’s office with the complaints of his shoulder
pain with the only known injury was the twisting during the game. Radiology results revealed a
torn rotator cuff. He was scheduled for repair. Joe was taken to the operative room for
arthroscopic repair of the rotator cuff. Upon entering the shoulder it was discovered that he
also had a SLAP lesion which was also repaired.
Diagnosis:
Procedure:
5. Ms. Smith is an 89 year old resident of the local nursing home. While eating steak she began to
choke at which time she felt as if she had something stuck in her throat. She currently has breast
cancer which she is being treated with chemotherapy which has also spread to her bones,
diabetic retinopathy, legal blindness, and AKA of her right leg. She was brought to the
emergency room at which time an EGDY was performed and the foreign body was removed. A
biopsy was also performed at the area of the foreign body for white residue. The pathology
report reported candidal Esophagitis.
Diagnosis:
Procedure:
6. Susie is a 5 year old female that wrecked her pedal bike. Her mother brought her to the
emergency room where xrays were performed showing a LT distal radius fracture. The
orthopedic doctor was called for consultation who provided a closed reduction under conscious
sedation.
Diagnosis:
Procedure:
7. Brandon was the driver of a car whom was hit head on by another car on the interstate. He was
brought to the emergency facility by ambulance. Brandon was found to have a right
pneumothorax, 6 fractured ribs, shaft of the tibia and fibula, as well as a subdural hematoma.
While in the emergency room he developed acute respiratory failure and shock at which time
the patient was intubated and had a PICC line insertion. He was then sent to a higher medical
facility for treatment of his injuries.
Diagnosis:
Procedure:
8. Jodie is a 36 year old female whom was scheduled for endometrial ablation due to
menometorrhagia as well as a tubal ligation she has no children. She has a history of irregular
periods, tobacco abuse, cocaine abuse, as well as alcohol abuse. She presented to the operative
suite where a hysteroscopic endometrial ablation was performed as well as laparoscopic tubal
ligation using Fische clips.
Diagnosis:
Procedure:
9. Patient is a 70 year old male with chronic cough and 30 year history of tobacco abuse. Attempts
of quitting have been unsuccessful and he still continues to smoke ½ a pack a day. Chest xrays
shows a mass in the lower right lobe. He was taken to the operative room where a
bronchoscopy with biopsy of the right lower lobe was performed. Pathology report shows small
cell lung carcinoma.
Diagnosis:
Procedure:
10. Kristi is a 34 year old female whom is 16 weeks pregnant. While at her checkup it was
discovered the fetus did not have a heartbeat with an ultrasound confirming. A missed abortion
was diagnosed and she was taken immediately to the operative suite for a D&E.
Diagnosis:
Procedure:
11. Ralph fell down the steps at his home while going to make breakfast. He had a fracture of his
humeral shaft. He was taken to the operative suite where an open reduction internal fixation of
the fracture was performed.
Diagnosis:
Procedure:
12. Sally has lumbar stenosis of L6-L8. At this time she would like to try conservative treatment
measures. The doctor suggested that she have a lumbar epidural steroid injection performed.
She agreed and presented to the pain management suite where the provider injected the area.
Diagnosis:
Procedure:
13. Tom presented to the orthopedic office with his index and middle fingers curling. The provider
diagnosed him with trigger fingers and scheduled him for trigger finger releases. He presented
to the OR for the trigger finger release of both fingers which went well.
Diagnosis:
Procedure:
14. Patient has severe pain of her bilateral wrists as well as left elbow pain. She was discovered to
have carpal tunnel syndrome and cubital tunnel syndrome. The provider scheduled her for
release. She presented to the operative room where a bilateral endoscopic release was
performed and a left cubital tunnel release.
Diagnosis:
Procedure:
15. Bella was cutting up vegetables for her grandmother’s home made vegetable soup when the
knife slipped and she accidentally cut the inside of her hand. The laceration measured 5 cm in
length. It required a simple laceration repair. While she was here she also had a TDAP injection.
Diagnosis:
Procedure: