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Top 20 ICD-9 Codes
Conversion List – Internal Medicine
Flash Card Samples
Asthma
Orthopedics Initial and Subsequent
Diabetes Mellitus Type 2
Chart Review Examples
Case 1: Pediatrics
Case 2: Internal Medicine
Case 3: Orthopedics
Case 4: Endocrinology
Case 5: Cardiology
Case 6: Urology
Case 7: Dermatology
Case 8: Dermatology
Case 9: Pediatrics
Case 10: Pediatrics
Chart Review Results “Report Card”
IT Vendor Questionnaire
Payor Questionnaire
Testing Considerations
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Top 20 ICD-9 Codes
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Conversion List – Internal Medicine
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FLASH CARD EXAMPLES:
Asthma Flash Card indicating new documentation elements for ICD-10-CM
(3 elements of documentation – Severity, Duration, Tobacco use or exposure)
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Orthopedic Flash Card for Initial Visit
(6 elements of documentation – Displacement, type of fracture, location, laterality, type of encounter, open/closed)
Orthopedic Flash Card for Subsequent Visit
(Documentation Elements – all of the above for “initial” plus “degree of healing” for subsequent encounters)
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Diabetes Mellitus Type 2 Flash Cards showing ICD-10-CM new documentation elements –
Flash Card One
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Diabetes Mellitus Type 2 Flash Card showing ICD-10-CM new documentation elements –
Flash Card Two
(27 documentation elements for DM II to indicate co-morbidity/underlying disease)
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CHART REVIEW EXAMPLES
CASE One (Pediatrics)
This 3 year old female new patient presents for Well Child Check prior to entering preschool.
She is learning English, but is fluent in her native language. The mother and aunty have no concerns for her behavior or development. She has been well.
No sleep problems, Safe home environment, Municipal chlorinated water supply.
No bladder, bowel concerns, No dental concerns. Drinks whole milk daily and assorted juices.
Activity levels no concerns.
Safety uses car toddler seat, the home has smoke detectors. No carbon monoxide detector at home. No firearms at home. There are no pets in the home. Education - will attend preschool.
Does not have a learning disability.
Allergies: no known allergies.
ROS: All other systems are negative- see HPI.
Constitutional: no acute distress, well nourished. Well developed. Head/Face: facial features are symmetric. The skull is atraumatic. Eyes/Ears: PERRLA, ears Rt/Lt normal. Neck/thyroid: inspection reveals symmetry. No thyromegaly or nodules detected. Respiratory: Lungs clear to auscultation. No cough. Cardiac: RRR w/o murmur. Abdomen: no distention, bowel sounds present, no bruits, Soft nontender.
Assessment/Plan: Routine child exam with 15 cavities- should be seen by dentist.
Signed MD
V20.2 Well child check
521.00 Cavities
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CASE TWO (Internal Medicine)
34 year old female presents to the office with one eye red, itchy, pain and blurry. She has DM
II and was last seen one year ago. Problem started last week and has worsened. No fever, cough or runny nose, no one with similar problem. She is out of medication for the DM. Drank coffee and ate bread this morning. Metformin made her vomit and feel dizzy. Voids plenty, feels thirsty and hungry.
Non fasting Blood sugar 258.
Vision 20/20 both eyes.
PE: Constitutional: Pleasant female, present with husband, in no acute distress.
EENT: Conjunctival injection without discharge, EOMI, PERRLA, no auricular adenopathy palpable.
Neck/Thyroid: no cervical adenopathy.
Respiratory: clear to auscultation bilaterally.
Cardiovascular: Regular rhythm s1s2.
Assessment/Plan
Conjunctivitis- Rx, Tobramycin drops four times a day for one week.
DMII uncontrolled - restart Metformin one a day- start lower dose as she related nausea with prior dose. Arrange for lab work then follow up for continued DM care.
Signed MD
372.30 Conjunctivitis
250.02 DM, uncontrolled
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CASE THREE (Orthopedics)
Preoperative diagnosis: Rt ankle fracture
Postoperative diagnosis: same
Procedure: Open reduction and internal fixation right ankle fracture
Implant used: Synthes 4.0 mm canulated screws
Indication for procedure: The patient fell and sustained a rt ankle fracture. Confirmed by both x-rays and CT scan. Explained the risks and complications- patient and family understood and wished to proceed.
Patient was brought to the operating room, given general anesthetic w/o any complications. He was given preoperative antibiotics per usual routine. Rt lower extremity prepped and draped.
Under x-ray guidance, a pointed reduction clamp was placed from the anteriolateral corner of the distal tibia to the medial side and reduced the fracture. Screw set was placed, the fx was anatomically reduced and the ankle joint was anatomic. Wounds irrigated, Closure was done, and compression dressing was placed. Pt was extubated and brought to recovery. No complications noted.
Sponge and needle counts were equal at the end of the case.
Signed MD
824.6 Fracture ankle- trimalleolar
E888.9 Patient fell
E849.9 No information as to where injury happened
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CASE FOUR (Endocrinology)
Subjective: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin, it does seem to hurt there. She has put on 20 pounds since our last visit and continues to smoke.
Objective: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat mildly inflamed with moderate postnasal drainage. No significant adenopathy. Lungs are clear. Heart regular rate and rhythm. Abdomen: soft obese and nontender. Multiple lipomas are palpated.
Assessment:
1. Diabetes mellitus, type 1
2. Diabetic neuropathy.
3. Acute sinusitis.
Plan: at this time I have recommended the addition of some Keflex for her acute sinusitis. I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required.
Signed MD
250.61 DM type 1 with Neuropathy unspecified
357.2 Neuropathy manifestation
461.9 Acute sinusitis
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CASE FIVE (Cardiology)
Preoperative Diagnosis: Coronary artery disease.
Postoperative diagnosis: Coronary artery disease with placement of a drug-eluting stent in the right coronary artery.
Indications: This is a 74 year old male with 75% right coronary artery stenosis, here for stent placement.
Procedure: The patient had a sheath in the right radial artery. He was started on Angiomax and given Plavix 300 mg loading dose. We placed a wire down the right coronary artery and pre-dilated it with a 2.5 x 15 mm balloon. Then we placed a 3.5 x 20 mm drug-eluting stent and dilated it to 20 atm for a final size of 3.19 mm. The artery was widely patent at that point. There was no dissection noted.
Patient tolerated the procedure well. At the end of the procedure, the Angiomax was turned off.
He was returned to the telemetry floor in good condition.
Signed MD
414.01 Coronary Artery Disease
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CASE SIX: (Urology)
Cystoscopy performed- timeout performed, correct patient, correct procedure. Correct side/site
Informed consent was obtained. The patient chose to have no Valium. The patient was placed in the modified frog leg position and the genitalia was prepped in a sterile fashion. Straight cath was performed and the PVR was minimal. 10cc of viscous Lidocaine was introduced into the bladder. Flexible cystoscopy was performed using an 18 French ACMI cystoscope. Rigid cystoscopy was performed.
Findings: Mucosal normal
Ureteral orifices: normal
Urethra: normal
Assessment/Plan: Microscopic hematuria
Kidney stone
Orders: Cipro 500 mg PO
Her hematuria has now been worked up and it is negative except for the calculi (stones).
These are all quite small and should pass. I would like her to do a 24 hr urinalysis. I will see her in 3 mos.
Signed MD
599.72
592.0
Hematuria
Urinary calculus
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CASE SEVEN (Dermatology)
A patient presents to the dermatologist for follow up on the suspicious lesions on her left arm.
Last week, the physician felt these lesion presented as highly suspicious and obtained consent to perform punch biopsy. After prepping the area, the physician injected the site with
Lidocaine 1 percent and d .05 percent Epi. A 3 mm punch biopsy of the lesion of the left arm were taken. The site was closed with a simple one layer closure. The patient returned today for suture removal and to discuss the pathology results.
Signed MD
173.6
D49.2
Skin cancer upper limb including shoulder
Neoplasm, unspecified behavior arm.
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If malignant (confirmed by pathology):
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CASE EIGHT (Dermatology)
A patient has a squamous cell carcinoma on the tip of the nose. After prepping the patient and site, the physician removed the tumor in the first stage and divides it into seven blocks for examination. Seeing positive margins, he removed a second stage, which he divides into seven blocks. The physician again identifies positive margins. He performs a third stage and divides the specimen into three blocks proving to be clear of skin cancer.
Signed MD
173.32 Squamous cell CA tip of nose
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CASE NINE (Pediatrics)
Chief Complaint(s): Asthma
History of Present Illness
This is a Female, age 12 Years old, who presents for wheezing which started 2 day(s) ago. It is constant in duration. It occurs persistently. It is worse. Pt complains of lower back pain. Hx. of Hospitalized for 2 days in the past for her asthma. Family hx – father smokes in the home.
Physical Exam
Vital Signs
Time T P R BP SpO2%
By Comments
2:45 PM 98.6 75 20 150/90 96 Nurse
Wt lb Wt oz Ht In BMI
230.00 74.0 29.53
Measured
Time Pulse Ox Rest
L/min
Pulse Ox Amb Timing
Delivery Method
FiO2 %
2:45 PM 96
General/Constitutional: CONSTITUTIONAL: No apparent distress. Well-nourished well developed..
HEENT: : Normocephalic. Atraumatic ,Tympanic membranes and canals normal.
Eyes: EYES: PERRL, EOM intact.
Nose / Throat: Mucous membranes normal. Tongue and throat appear normal. No mucosal lesions
Neck / Thyroid: Supple, without adenopathy or enlarged thyroid.
Lymphatic: No palpable cervical, supraclavicular or axillary adenopathy.
Respiratory: POSITIVE for : Tachypenia, crackles and wheezing.
Cardiovascular: Regular rate and rhythm. No murmurs.
Extremities: EXTREMITIES: No cyanosis, clubbing or edema.
Assessment / Plan
1. Asthma exacerbation, persistent
Plan
Plan Comments : Rx Prednisone as directed for 5 days.
Return Visit: Follow up sooner prn any problems or concerns. Go to ER if symptoms persist or worsen
493.92 Asthma, unspecified as to Extrinsic or Intrinsic with (acute) exacerbation
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CASE TEN (Pediatrics)
HPI
2 year old here for routine follow up. No concerns at this time. Feeding and UOP normal with no excessive crying. Sleeps throughout the night.
PFSH: No changes from previous visit
Exam
Vital Signs
Time
2:45 PM
Wt lbs/ oz
18.07
T P
98.6
R BP SpO2%
100 99
Time
2:45 PM
Pulse Ox Rest
L/min
Pulse Ox Amb Timing
Delivery Method
FiO2 %
96 NVD
General: CONSTITUTIONAL: No apparent distress. Well nourished, well developed..
HEENT: Normocephalic. Atraumatic, Tympanic membranes and canals normal.
Eyes: PERRL, EOM intact. .
Respiratory: No cough or wheezing.
Cardiovascular: Regular rate and rhythm. No murmurs.
Spine/Extremities: No cyanosis, clubbing or edema, normal ROM
GU/GI: WNL
Skin: No rash, no bruises, color normal
Neuro: Appropriate affect for age
Assessment / Plan
1. Normal healthy Baby, ordered immunizations V20.2 (Well Child Check)
2. 2 nd
Hib V03.81
3. MMR
4. IPV
V06.4
V04.0
5. Hep B
6. Dtap
V05.3
V06.1
Return Visit: Follow up prn for any problems or concerns.
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CHART REVIEW RESULTS “REPORT CARD”
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IT VENDOR QUESTIONNAIRE
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IT VENDOR QUESTIONNAIRE (CONTINUED)
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PAYOR QUESTIONNAIRE
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ADDITIONAL “TESTING” CONSIDERATIONS
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Pre-authorizations?
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Eligibility?
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“Canned” scenarios or practice-specific?
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ICD-9 and ICD-10?
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New Payment Policies?
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Test in stages or by specialty?
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Negative (failed) scenarios and Electronic Remittance Advice?
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End to end testing?
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Who schedules?
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