Medical Coding test

This is an “open book” test with regard to CPT and ICD-10 coding books.

Question number 1-
Please identify the words in the following statement that match at least 4 of the HPI (history of present illness)
elements identified below:
Patient was admitted yesterday with severe asthma exacerbation. She had been trying to
maintain with her inhaler but continued to worsen over the last 24 hours before admit. She
has had 5 breathing treatments and been on 4Lpm O2 for the last 12 hours and now has a
stable 90% sats. ORA she decreases to 78-70%. She has been around her boyfriend’s cat a
lot lately and feels this may have triggered this attack.
Quality ____________________ Modifying Factors ___________________
Context ___________________ Timing ___________________
Duration __________________ Severity __________________________

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Question number 2-
Please identify the Level of Medical Decision Making (MDM) in the following statement:
1. Chest pain- new since last visit
2. DOE (dyspnea on exertion) – worsening
I have discussed this with him, and we will screen for ischemia with stress myocardial
perfusion imaging. If Abnl test, then this may represent a high probability for CAD and angio
should be considered. If test is low risk, then may follow syndrome clinically, and seek other
causes of chest pain. The patient was instructed to avoid strenuous physical activity until
complete stress test results are known.
F/U OV the week after these studies to consolidate eval and recommend further investigations
as indicated.
Low __________ Moderate _________ High___________

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Question number 3-

Please select the level of History (HX) documented in the following statement:
Patient comes in today complaining of 4 days history of cough and congestion. No Fever,
Chest pain or dyspnea. Cough is mildly productive. He has been using Sudafed and Nyquil
with some relief.
Past Medical History-Seasonal allergies
Past Surgical History-tonsillectomy
Past Family History- Asthma—Father and Brother
Smoking status: Smokeless tobacco: Alcohol Use:2 drink(s) per week
Allergies-Cephalexin/Penicillin’s- Rash
Review of systems: Positive for malaise/fatigue. Positive for cough and sputum production
(scant, clear). Negative for shortness of breath and wheezing. All remaining 10 point ROS and
are negative.
HPI- # of Elements__________ PFSH- # reviewed_______ ROS- # of systems ________
History Level __________________
Question number 4-
Please select the level of Exam Both 95 and 97 guidelines documented in the following statement:
Constitutional: He is oriented to person, place, and time. He appears well-developed and
well- nourished.
Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear:
Tympanic membrane normal. Nose: No mucosal edema or rhinorrhea.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal. Eyes:
EOM are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm and No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal.
Lymphadenopathy:He has no cervical adenopathy.
Neurological: He is alert and oriented to person, place, and time. Skin: Skin is warm and dry.
No rash noted. Psychiatric: He has a normal mood and affect. His behavior is normal.
Judgment and thought content normal.
95 Guidelines Detailed________ Comprehensive___________

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97 Guidelines Exp Prob Focused__________ Detailed _________ Comp ______
Question number 5-
Please choose the most accurate way of documenting a Review of System (ROS) in a comprehensive history
__________ ROS complete
__________ 14 point review of system performed
__________ Positive for Shortness of Breath, Negative for Chest Pain. All other systems reviewed and are


_________ ROS is not needed for a comprehensive history

Question number 6-
Please select the level of service documented in the following visit note:
CC: Brought by ambulance – evaluate for non- responsiveness
44 yo man BIBA from Rockies game after being found slouched over on the ground. Pt reports
having too much alcohol to drink today and recalls going over to sit against a wall. He then
closed his eyes and was found by a bystander. no witnessed szr activity. emesis x 1 (NBNB)
in route. pt has no complaints at present. Pt denies fall/trauma.
Vital signs reviewed, Patient afebrile, Pulse normal,Blood pressure normal, Respiratory rate
normal, Patient appears non toxic, pain free. Patient alert and oriented to person, place and
time. HEAD: atraumatic, normocephalic. EYES: Pupils equally round and reactive to light,
Sclera normal. ENT: Nose exam normal, dried blood left nare, no active bleeding. NECK:
Neck exam included findings of normal range of motion, Trachea midline. RESPIRATORY
CHEST: no respiratory distress, Breath sounds clear. CARDIOVASCULAR: Regular rate
and rhythm, Heart sounds normal, normal S1, normal S2. ABDOMEN: nontender, Bowel
sounds normal. BACK: normal inspection, range of motion normal.
UPPER EXTREMITY: inspection normal, Range of motion normal Bilaterally
LOWER EXTREMITY: bilaterally Range of motion normal, no edema.
NEURO: Speech normal. SKIN: warm, dry no abrasions PSYCHIATRIC: intoxicated.
(Continued on next page)

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ASSESSMENT/PLAN: Acute alcohol intoxication- Breath EtOH 114 on arrival. No evidence
of significant trauma by exam or history. Will obvs until sober then d/c. Pt refused EKG.
Disposition: D/C Home.
INSTRUCTION: Follow up with your primary care doctor in 1 week. Return to the emergency
department for worsening symptoms, including worsening headache, numbness, weakness,
tremors, seizure, or any other concerns.
A. 99221
B. 99222
C. 99223
D. None of the above

Question number 7-
Please select the level of service documented in the following statement:
Patient is a 42yr female who presents today with complex migraines since she was a teenager.
Now on relpax. No current migraine today but does need refills of relpax. Patient also on
Prozac and needs a refill of that. Today she is quite depressed and tearful.
ROS-Per HPI-All other systems reviewed and negative.
Vitals – BP 122/60 Temp- 97.4 Height 5′ 10″ Weight 178 lbs
Patient is tearful and upset about a recent breakup with her boyfriend. We discussed in detail
treatment options for her including increased dosage of Prozac, adding Welbutrin, yoga, and
structured counseling. I asked the patient to follow up with my office in a month, unless her
symptoms increase or worsen. I spent 35 minutes in face to face time with the patient 25
minutes of which were spent in counseling and coordination of care.
If New Patient 99202_______ 99203 _________ 99204 _________
If Established Patient 99213 ______ 99214 ________ 99215 ________

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Question number 8-
For a Level 4 new patient, please choose the proper documentation requirements
_______ Detailed History and Comprehensive Exam and Moderate Medical Decision Making
_______ Comprehensive History and Comprehensive Exam and High Medical Decision Making
_______ Comprehensive History and Comprehensive Exam and Moderate Medical Decision Making
________Comprehensive History or Comprehensive Exam and Moderate Medical Decision Making

Question number 9-
Please select the correct level of service based on the documentation below:
I spent 40 minutes in face to face time with the patient and family. 50 % or more was spent in counseling and
coordination of care. We discussed alternative therapies, options for medications, referrals for second opinions,
etc. Risks, benefits and considerations were discussed with patient and family. They will let us know what they

If Established Patient 99214 ________ 99215 _________
If New Patient 99203_________ 99204 _________

Question number 10-
Please circle the correct definition of Critical Care:
A. High-complexity decision-making to assess, manipulate and support vital system function(s) to treat
single or multiple organ system failure and/or to prevent further life-threatening deterioration
B. Direct personal management and Frequent personal assessment
C. Record demonstrate the patient has acute impairment of one or more vital organ systems and has a high
probability of imminent or life-threatening deterioration
D. The interventions of a nature that failure to initiate these interventions on an urgent basis would likely
result in sudden clinically significant or life-threatening deterioration in the patient’s condition
E. All of the Above

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Question number 11-
Please circle the examples of a correctly documented Chief Compliant:
A. Follow up on DM meds
B. Left Knee Pain
C. Follow up
D. Annual Exam

Question number 12-
Please circle the correct time documentation for a 99214 if you are doing time based coding:
A. 30 minutes was spent with the patient today in my office discussing proper dosage of new
B. The patient was in my office for two hours receiving hydration and counseling regarding
food poisoning side effects
C. 25 minutes was spent in face to face time with the patient. 50% or more was spent in
counseling and coordination of care concerning dosage of new medications and possible
side effects.
D. I spent 25 minutes with the patient and 20 minutes were in counseling.

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Coding Quiz Operative Report 1:
PROCEDURE: Lumbar laminectomy, bilateral L4-5.
SURGEON: Ima Neurosurgeon, MD.
ASSISTANT: Hesmy Assistant, PA-C.
INDICATIONS: The patient is a pleasant 85-year-old woman with symptoms of
neurogenic claudication. Her symptoms were refractory to conservative
care. Her imaging studies revealed severe stenosis at L4-L5, relatively
modest stenosis at ____ level. Given these findings, after a careful
explanation of risks, benefits, likely outcome, the patient and family
agreed to proceed with surgery.
NARRATIVE: The patient was brought to the operating room. After suitable
induction of general anesthetic, the patient was carefully positioned
prone on the operative table. All pressure points were padded as

confirmed by me and the anesthesia team. Using surface landmarks and a C-
arm, the incision was planned. The patient was prepped and draped in the

usual sterile fashion. After infiltration of local anesthetic, incision
was made with a #10 blade. Hemostasis was obtained with Bovie
cauterization. The incision was carried down to the level of the lumbar
dorsal fascia. Ligamentous muscular attachments were elevated at the L4-5
region. X-ray once again confirmed our position.
Leksell rongeur was then used to remove the spinous processes and portion
of the lamina.
The operative microscope was brought into the field. High speed drill was
then used to thin the lamina. A curet was used to then separate the
lamina from the ligamentum flavum. With that complete, the remainder of
the bone was removed.
With careful dissection, I was able to then dissect the ligamentum flavum
from the dura. There is perhaps a small fenestration was made in the
dura. This was closed with interrupted 4-0 Nurolon. The facet joints were
undercut laterally on both sides. The remainder of the ligament was also
Once I was satisfied that the decompression was adequate, the seal was
placed over the area where the suture had been placed. The Duragen was
also placed prior to placement of the Tisseel sealant.
The wound was closed with multiple layers of Vicryl followed by a running
locking Prolene.
The patient tolerated the procedure well.
Sponge and instrument counts were correct at the end of the case.
Of note, at the end of the case, the neural monitoring unit had placed
its leads. There were no untoward findings with the neuromonitoring.

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The patient tolerated the procedure well, was turned over to anesthesia
for awakening.
DICTATED BY: Ima Neurosurgeon, MD

ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________


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Coding Quiz Operative Report 2:
PREOPERATIVE DIAGNOSIS: Left subtrochanteric femur fracture.
PROCEDURE: Intramedullary nailing of left subtrochanteric femur fracture.
SURGEON: Shesa Doctor, MD.
ASSISTANT: Hesher Helper, MD. Please note, Mr. Helper was medically
necessary for this patient to help position the patient, to help hold
retractors during the procedure, to help reduce the fracture and to
assist with wound closure.
ANESTHESIA: General endotracheal anesthesia.
DISPOSITION: The patient was successfully awakened and extubated in the
operating room and returned to the postanesthesia care unit in stable
BRIEF PREOPERATIVE NOTE: The patient is a 63-year-old gentleman who was
riding his bicycle when he had a terrible accident, landing directly onto
his left hip. He sustained a comminuted complex proximal femur fracture
which was also complicated by the fact that he was on anticoagulants and
his INR was 3.38. Upon presentation to the hospital. Overnight, he was
given vitamin K and prior to surgery given FFP to get him to a more
normalized INR. The risks and benefits of this procedure were explained
to the patient. The patient asked appropriate questions. After all
appropriate questions were answered, informed consent was obtained and
placed on the chart. At this time, the patient did agree to proceed to
the operating room for the above listed operative procedure.
BRIEF OPERATIVE NOTE: The patient was brought to the operating room,
first in his hospital bed general anesthesia was administered. Next, the
patient was transferred to the fracture table where the endotracheal tube
was in placed under the general anesthetic at that time. The left lower
extremity was placed into a well padded longitudinal traction and the
right lower extremity was placed into a well padded, well leg holder.
Next, image intensifier was brought into the field to ensure that we
could get adequate closed reduction. After significant traction,
adduction and internal rotation of the leg, we were able to get an
adequate reduction. Next, the left lower extremity was prepped and draped
in the usual orthopedic sterile fashion. Next, a 3.2 mm guidewire for the
trochanteric fixation nail was then passed in an intramedullary position.
Next, the opening awl was passed without complication. Next, a ball
tipped guidewire was passed into the canal and measured to the distal
femur 460, but we placed a 420 mm trochanteric fixation nail with a 130
degree helical blade setting. Next, the nail was passed without
complication. Next, the outrigger was placed for placement of the helical
blade. Guide pin was passed for the helical blade in a center-center
position into the femoral neck and head measured a 105 mm. The outer
lateral cortex was drilled without complication, then the triple reamer

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was passed. Next, the 105 mm helical blade was passed without
complication and locked into position. Next, the outrigger was removed.
Orthogonal x-rays showed near anatomic alignment of the proximal femur.
Next, attention was then paid distally to the distal femur for perfect
circles and one 5.0, 52 mm locking bolt was then placed without
complication. Again, orthogonal x-rays showed near anatomic alignment of
the proximal femur, no evidence of hardware failure. At this time, all
wounds were thoroughly irrigated with bacitracin-laden normal saline.
Next, the deep layer was closed with a #1 Vicryl in an interrupted
fashion. The wound was infiltrated with 30 mL of 0.5% Marcaine without
epinephrine. The deep subcuticular layer was closed with an 0 Vicryl,
skin reapproximated with 2-0 Vicryl and then skin staples. Next, sterile
dressings were applied.
Next, the patient was taken out of traction and returned to the hospital
bed. General endotracheal anesthesia was terminated. The patient
tolerated the procedure without complication, was successfully awakened
and extubated in the operating room, returned to the postanesthesia care
unit in stable condition.
DICTATED BY: Shesa Doctor, MD
ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________


Coding Quiz Operative Report 3:

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SURGEON: Fixer Upper, MD.
1. Symptomatic asymmetrical mammary hypertrophy.
2. Cervicalgia.
3. Thoracic pain.
OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.
INDICATIONS FOR SURGERY: The patient is a 66-year-old female who requests
reduction mammoplasty for symptoms related to large and heavy breasts.
The patient has nod only severe tilt of the shoulder with the right
breast larger and lower, but has bra strap grooves. The size is
consistent with a 38 G to H size. She has rounded forward anterior
displaced shoulders, large pendulous ptotic asymmetrical breasts, bra
strap grooves and nonfocal, tightness and tenderness in the trapezius,
interscapular and paraspinal musculature. The patient requests reduction
mammoplasty in an attempt to improve symptoms from large and heavy
PROCEDURE: Markings made preoperatively for a medial pedicle vertical
type reduction mammoplasty accounting for the dyssymmetry. The patient
taken to the operating room, placed on the operating table in the supine
position. All bony prominences were well padded. PAS stockings were in
place and functioning. General anesthesia was induced bilateral upper
extremities were abducted to under 80 degrees on arm boards. Prepping and
draping was performed in a sterile fashion.
Of note, the patient has severe compromised skin envelope with striate
and severe ptosis. Stab incision was made in the area of intended
vertical excision and using a blunt infiltration cannula on each side 500
mL of 0.03% lidocaine with adrenalin 1:1 million was infiltrated on each
side. The operation was performed similarly on each side. First,
attention was directed to the right side after adequate epinephrine
effect, a 45 mm areola was incised. De-epithelization of the medial
pedicle was performed. Incision was made in the upper keyhole in vertical
area, keeping the lower extent of excision 4 cm up from the inframammary
fold. Composite resection was performed after isolating the pedicle by
sharp dissection and adequate at least 2 cm vertical pillars were

Coding Quiz Operative Report 3:

preserved and further resection laterally was performed removing on the
right side 716 grams. Meticulous hemostasis obtained with
electrocauterization. Irrigation was performed with saline. The vertical
pillars repaired with #1 Vicryl sutures. The vertical closure for 8 cm
was performed using gathering 4-0 Monocryl deep dermal sutures, running

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subcuticular 3-0 V-Loc suture. The nipple areolar complex was sutured to
surrounding flaps using interrupted simple 4-0 Monocryl for the deep
dermis, running subcuticular 4-0 Monocryl for the skin. Because of severe
skin envelope laxity, the patient’s body habitus, was necessary to

perform dog ear excision of skin and subcutaneous tissue in the neo-
inframammary fold for contouring purposes. Closure in this area, after

hemostasis obtained with electrocauterization was accomplished using
interrupted 3-0 Vicryl to deep dermis, running subcuticular 3-0 V-Loc
Monocryl for the skin. Next, attention was directed to the left side
where resection of 757 grams was performed, hemostasis obtained with
electrocauterization, closure and dog ear excision was performed in a
similar fashion. The patient’s areola to neo-inframammary fold was 8 cm
on each side with symmetrical mounds created. Specimen was sent to
pathology. After completion of bilateral reductions, the wounds were
dressed with Dermabond and Tegaderm. General anesthesia was then
terminated. The patient went to the recovery room in stable condition.
There were no complications. Sponge and instrument counts correct.
Estimated blood loss was minimal. The patient was discharged with
instructions to resume usual diet and medications with the exception of
holding aspirin and Advil/ibuprofen. The patient will ambulate q.i.d. She
will drink plenty of fluids. She will avoid pressure on her chest. She
will be seen tomorrow in follow up. She will begin Lovenox at 0800 on
07/15/2014. The patient will call for problems, questions or concerns.
Final pathology is pending at the time of dictation.
DICTATED BY: Fixer Upper, MD
ICD-10 Code(s): ____________________________________________________

CPT Code(s): _____________________________________________________

Case Study 1:
Please select the level of History (HX) documented in the following statement:
• HPI: The patient is an 87-year-old white female who lives in a skilled nursing facility. She tells
me that her phone was ringing and she tried to reach over to get the phone but fell out of bed and
ended up on the floor. She reports yelling for help. She was brought to the emergency room with
a facial fracture. She was also found to have a small right frontal intracerebral hemorrhage. She
is being admitted for observation and treatment. She also has a Colles fracture.
• ROS: Constitutional: Denies fevers. Neurologic: She denies a headache. Eyes: She denies any
vision problems. Thinks she has had some cataract surgery. Notes no vision problems right now.
ENT: Denies recent cyanosis or respiratory infection or chronic headache problems.

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Cardiovascular: Denies heart problems or chest pains. Respiratory: Denies shortness of breath or
breathing problems. Gastrointestinal: Denies nausea or diarrhea. Musculoskeletal: Has chronic
back pain mentioned above. Skin: Denies any rashes. Psychiatric: Acknowledges a history of
low-grade depression but has not been problematic recently.
• Patient has a past medical history positive for parkinsons, frequent UTIs and chronic low back
pain. She does not smoke and rarely drinks alcohol. Both parents are dead.
List the HPI elements:
List the ROS:
List the level of history this documentation supports:
For an inpatient admission, would this documentation support a 99221, 99222, or 99223? Please
explain your reasoning.

ICD-10 Code(s): ____________________________________________________


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