Congenital Nasolacrimal Duct Obstruction Case

QUESTION 1: (300 WORD MINIMUM) Case 1. Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable: • o ▪ ▪ ▪ ▪ ▪ PATIENT: KILLBURN, JOHN ACCOUNT/EHR #: KILBJO001 DATE: 10/11/21 Attending Physician: Katie M. Robbs, MD The patient is a male, gestational age 41 weeks, 5 days, born by Cesarean section in this facility, 10/10/21, 27:37. This is a subsequent hospital visit. IMPRESSION: Neonate was of a single birth, BWT 2,857 grams without significant OR procedures with a normal newborn diagnosis. 21″ long. Head circumference: 31 cm. Amniotic fluid: clear. Cord: 3 vessels. Head is acrocephalitic, and there is evidence of premature cranial suture fusion. The fingers of the right hand are syndactylic, as well. APGAR SCORE: 1 min. = 7; 5 min. = 8. Heart rate: 100; respiratory effort: good; muscle tone: active; response to catheter in nostril: cough; color: body pink, extremities blue MATERNAL HISTORY: 40 years old, G2P2, blood type B+ , planned C-section due to previous C-section birth three years ago.

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General anesthesia. HIV-tested during pregnancy: neg. ADMINISTRATIONS: Hepatitis B, peds, vaccine (recomb) 5 mcg/0.5 mL, given: 10/12/21 RECOMMENDATIONS: Newborn has acrocephalosyndactyly. Consultation with neonatologist requested. Katie M. Robbs, MD PHJ/mg D: 10/11/21 09:50:16 T: 10/13/21 12:55:01 QUESTION 2: (MATCH ONLY) QUESTION 3: (300 WORD MINIMUM) Review the scenario and assign the appropriate ICD-10-CM and CPT code(s), applying modifiers where appropriate. Diagnosis: Congenital Nasolacrimal duct obstruction Procedure: Nasolacrimal duct probing and irrigation for right eye Procedure Details: The patient was brought into the OR. The operative eye was prepped. A punctal dilator was used to dilate the superior and inferior puncta of the operative eye. A double O Bowman probe was bypassed through one of the puncta and passed into the common canaliculus. The probe was passed into the nasolacrimal sac and down the bony cancal of the nasolacrimal duct. The probe passed into the nasal cavity beneath the inferior turbinate. The probe was removed. A lacrimal cannula attached to a 30cc syringe filled with fluorescein solution was used to cannulate the nasolacrimal duct. An aspirating catheter was placed in the ipsilateral nasal cavity. Fluorescein was irrigated into the nasolacrimal duct. Fluorescein was aspirated from the nasal cavity following the irrigation. The lacrimal cannula and catheter was removed. QUESTION 4: (300 WORD MINIMUM) Review the scenario and determine if the physician query is complaint or non-compliant and explain why. During the removal of an abdominal mass, the surgeon documents, in the description of the operative procedure, a “serosal injury to the stomach was repaired with interrupted sutures.” Physician Query: In the description of the operative procedure a serosal injury to the stomach was noted and repaired with interrupted sutures. Was this serosal injury and repair: A complication of the procedure _____________ Integral to the above procedure _____________ Not clinically significant ____________________ Other ___________ Clinically Undetermined____________ Please document your response in the health record or below accompanied by clinical substantiation. QUESTION 5: (300 WORD MINIMUM) Review the scenario and determine if the physician query is complaint or non-compliant and explain why. 24-year-old female came into the emergency room with high fever, cough, tachycardia and states that they lost their taste and smell 4 days ago. Physician Query: Based off the patient’s symptoms of fever, loss of taste and smell, can you document the diagnosis of COVID? QUESTION 6: (300 WORD MINIMUM) Review the scenario and determine if the physician query is complaint or non-compliant and explain why. 67-year-old male was documented as having acute respiratory failure with no clinical indicators to support the diagnosis. Physician Query: Please provide additional clinical indicators supportive of your documented diagnosis of acute respiratory failure. No respiratory distress was noted through the medical record from the time of the initial progress note. Patient has been on a maximum of 2 L of supplemental oxygen since admission. Lowest oxygen saturation appears to be 96%. – If the condition does not exist, please amend documentation in the next progress note. – Unable to provide additional clarity regarding the diagnosis. – Other (please specify) – Unknown