can you please code these from the career step medical billing and coding part II-coding practicum so I can check my answers? The em code worksheet multiple choice is in the same format for all the ones who have it.

The answers can be in the format such as:

evaluation and management 1

1 codes

2 codes

3 codes

4 codes

Em code worksheet answer

5 codes

6 codes

7 codes

8 codes

OFI 12:52 PM Management 1 Evaluation and Management 2 Patient Type: Evaluation and What is the patient type? Management 3 Evaluation and New Patient Management 4 Established Patient Evaluation and Consultation Management 5 O Emergency Department Evaluation and Management 6 Evaluation and Next Management 7 Evaluation and Management 8 Evaluation and Management 9 Evaluation and Management 10 Evaluation and Management 11 Evaluation and Management 12 5. E/M Code(s): Evaluation and Management 13 6. Primary CPT Code: Evaluation and Management 14 7. Secondary CPT Code(s): Evaluation and 8. HCPCS Code(s): Management 15 Outpatient (Book] Anesthesia Outpatient ( Book) Submit Pathology Outpatient (Book) Psychiatric Coding Practicum > Outpatient (Book] - Evaluation and Management x Prev | Next Outpatient (Book] - GO General Surgery Page: 11 of 313 | Go to page Outpatient [Book) - Copyright 2019 Career Step, LLC. All Rights Reserved. | CSTS | Go to Top of page. O D Career Step - training . ca -\\ C X Search or X HICC FTCC PMICE with Applied PCS with Assessment \\) GOOGLElu NEVILLE TO`BEE ASSESSMENT Test 1 . 0 Coding Practicum = Outpatient [ Back ] - Evaluation and Management* * Prev I NEXT* Page : 12 Of 313. I Go to page\\ - PMICE 12.01 1.0 $ Program Orientation Your score on this page will be recorded . Computer Fundamentals This will be the first time you submit this page . Good luck ! Health Information Management Evaluation and Management 2 Healthcare Delivery SYSTEMIS Code the Following Report Reimbursement Methodologies Read the following report and enter the proper code ('s ) in the blank 's ) provided . Remember to code for* ICD - 10 - CM , CFTC, and HOPES codes . If a specific category of code is not applicable please leave the box* ` Medical Terminology* blank .` Anatomy and Physiology* Coding Hint : There is one diagnosis code associated with this report . There is also one E'Ml code ; pay* ` Pathophysiology* attention to level of complexity and patient status , new or Established .\\ $ Pharmacology ` Introduction to Coding Record $ 1CO - 70 Coding * Legal and Compliance* Primary Care Clinic Note* ledical F [PTIHCFCS Coding - Black The patient is a 3 2 - year-old African- American male , Established patient , with a past* [PTIHCFCS Coding - Black` medical history of recurrent genital herpes . No fevers or chills . NO GI or respiratory Symptoms . The patient claims that when he was on a prophylactic dose of Valacyclovir ` Advanced [[O - 10 Coding he was doing fine . He moved to_` '_ [PLACE] last _ [DATE] and since then he has had* Coding Practicum* more than 10 recurrences of genital herpes .` ` Introduction PHYSICAL EXAMINATION : Temperature 95 . 7 , pulse rate 5.1 , respirations 15 , blood pressure 1 1/4/72, and weight 156 pounds . HEENT , NECK : Supple neck . NO NO or cervical Outpatient Coding Practicum Overview lymphadenopathy . LUNGS : Clear to auscultation bilaterally . No crackles or wheeze .* HEART : Regular rate and rhythm . No 53 or murmur . ABDOMEN : Soft. Positive bowel Outpatient ( Book ) - Sounds . EXTREMITIES : No edema , cyanosis , or clubbing . NEUROLOGIC : The patient is Evaluation and Management alert and oriented* 3 . No focal or neurological deficits .\\ Evaluation and ASSESSMENT I PLAN Management !` 1 . Recurrent genital herpes . WE will start the patient on Valacyclovir 1000 my P. O . \\Evaluation and " Management 2 9. J . Will follow the patient in 2 to 3 months ." Evaluation and* Management =] Evaluation and Management 4 I . FILL IN THE BLANK .` Evaluation and Enter the proper code ('s ) in the blank ( s ) provided . If a specific category of code is not* Management } applicable , please leave the box blank . When entering multiple codes in the same box . Evaluation and separate them with a comma and a space (i.e . $71 . 9 , [To] . Management { 1 . Primary ICO - TO -CM Code :\\ Evaluation and Management*!" 2. Secondary ICO - TO - CM Code ( s ) :` Evaluation and Management ` 3 . 2 Code 's ! !\\ Evaluation and 4 . External Cause of Morbidity Codels*\\ Management* } Evaluation and Elm Cade Worksheet} Management ! 0! Evaluation and 5 . EMM Code ( 5 ) : Management 17 5 . Primary CPT Code :` Evaluation and* Management 1 2) 7 . Secondary CPT Code ( s ) :\\ Evaluation and Management 13) B . HCFCS Code ( 5 ) :` Evaluation and Management 1 4 Evaluation and Management 15 Submit* Outpatient ( Book )- Anesthesia\\ Outpatient ( BOOK ) - Coding Practicum = Outpatient ( Block ) _ Evaluation and Management* * Prey I Next* Pathology Page : 12 Of 3.13. I Go to page\\ Outpatient ( Book )` Psychiatric\\ Outpatient ( Book )| General Surgery Outpatient [ BLOIDK ) - Copyright 207:51 Career Step , LLC. All Rights Reserved . I HAVE I Go to Top Ofpage . !'- - ` THATS`\\M` Career Step - training . ca -\\ C X Search or X \\[ 2] HICC FTCC PMICE with Applied PCS with Assessment \\^`LELU NEWTHE```` This will be the first time you submit this page . Good luck ! ASSESSMENT Test 1 . 0 Evaluation and Management 3 - PMICE 12.01 1 .0 $ Program Orientation* Code the Following Report Computer Fundamentals Read the following report and enter the proper code ( s ) in the blank 's ) provided . Remember to code for Health Information ICO - TO - CM , CFTC , and HEPCS codes . If a specific category of cade is not applicable please leave the box` Management blank .` Healthcare DELIVERY! Coding Hint : There are two diagnosis codes associated with this report . There is also one Ei'm code .` SYSTEMIS Reimbursement Methodologies |1 Record ` Medical Terminology" Anatomy and Physiology* ENT Clinic Note Medical! $ Pathophysiology $ Pharmacology* This is a 5.0- year-old gentleman who was SEEN in the Primary Care Clinic last week and noted to have a lesion in the posterior tonsilar pillar .* A neck IT was ordered and the* ` Introduction to Coding patient was sent to ENT for consultation . The patient has no complaints secondary to this $ 1CO - 70 Coding lesion .` * Legal and Compliance* PAST MEDICAL HISTORY' is significant for cataracts , hypertension , central occlusion of CFTIHCFCS Coding - Black retinal artery , and history of multiple [VAS .` His medications include Cephalexin , Coumadin , vitamin E, and guaifenesin [PTIHCFCS Coding - Black; ALLERGIES : HE HAS NO KNOWN DRUG ALLERGIES .` ` Advanced [[O - 10 Coding SOCIAL HISTORY : Significant for smoking with a dependence on cigarettes and Coding Practicum* occasional alcohol use .* ` Introduction REVIEW OF SYSTEMS : Negative for dysphagia , adynophagia , otalgia , hemopty 515 , Outpatient Coding hematEmesis , weight loss , chills , fevers , or any other complaints . Practicum Overview PHYSICAL EXAMINATION : Reveals an obese white male in no acute distress . HEENT ! Outpatient ( Book ) - Normacephalic , atraumatic . Pupils are equally round and reactive to light. Extraocular Evaluation and Management* muscles are intact . EARS : Auricles and external auditary canals are within normal limits . NOSE : Without deformities or Epistaxis . ORAL CAVITY: THE patient is partially edEntulous* Evaluation and Management ! Oral cavity is without lesions . Tongue protrudes midline . Floor of mouth is soft . Base of tongue is soft to palpation . There appears to be a papilloma of the left posterior tonsilar* Evaluation and Management* = pillar of approximately 4 - 5 mm . This lesion does not have any ulceration , no bleeding . and it does not look consistent with a carcinoma . NECK is without adenopathy or masses \\Evaluation and ` Management } CT scan was reviewed , which shows a 1 . 3. I'm right neck made without evidence of ring Evaluation and Enhancement or suspicious for malignancy' . The rest of the scan Shows a small* Management 4 asymmetry on the area of Waldeyer's ring ; however , no ring Enhancement or Suspicious* Evaluation and masses are present .* Management } ASSESSMENT : Left oropharyngeal papilloma . Evaluation and Management { PLAN : Our plan is to follow the patient in a month . Evaluation and Management*!" Evaluation and Management` I . FILL IN THE BLANK . Evaluation and Enter the proper code ('s ) in the blank ('s ) provided . If a specific category of code is not* Management* } applicable , please leave the box blank . When entering multiple codes in the same box , Evaluation and separate them with a comma and a space (i.E . $71. 9 , 110) . Management !0! 1 . Primary ICO - 10 - CM Code :\\ Evaluation and Management 17 2 . Secondary ICO - 10 - CM Code ( 5 ) :` Evaluation and* Management 1 2 3 . 2 Code ( 5 ) .\\ Evaluation and Management 13) 4 . External Cause of Morbidity Codeis * :\\ Evaluation and ESM Code Worksheet Management 1 4 Evaluation and 5 . EIM Code ( 5 ) . Management 15 Outpatient ( Go` K ) - 5 . Primary CPT Code :` Anesthesia\\ 7 . Secondary [CPT Code/ s ) : Outpatient ( BOOK ) - Pathology 8 . HCFCS Code ( 5 ) .` Outpatient ( Book )` Psychiatric\\ Outpatient ( Book )| General Surgery \\Submit* Outpatient [ ELCIDK ) - {` Copyright 20:15 Career Step . LLC. All Rights Reserved . !\\ HIE I Go to Top of page .\\ Career Step - training . ca -\\ C X Search or X HICC FTCC PMICE with Applied PCS with Assessment ASSESSMENT Test 1 . 0 Coding Practicum = Outpatient [ Back ] - Evaluation and Management* * Prev I Next* Page : 14 OF 313. I Go to page\\ - PMICE 12.01 1.0 $ Program Orientation Your score on this page will be recorded . Computer Fundamentals This will be the first time you submit this page . Good luck ! Health Information Management Evaluation and Management 4 Healthcare Delivery SYSTEMIS Code the Following Report Reimbursement Methodologies Read the following report and enter the proper code ('s ) in the blank 's ) provided . Remember to code for* ` Medical Terminology* ICD - 10 - CM , CFTC , and HCFCS codes . If a specific category of cade is not applicable please leave the box blank .` Anatomy and Physiology* $ Pathophysiology* Code this report as if you work for the ER physician .* Coding Hint : There are two diagnosis codes associated with this report . There is also one ErM code ; pay* $ Pharmacology attention to level of complexity .` ` Introduction to Coding $ 1CO - 70 Coding al Record * Legal and Compliance* OPTIHCFCS Coding - Block Emergency Department Note I lealpal [PTIHCFCS Coding - Black` SUBJECTIVE : The patient comes in this morning at 3 a . m . complaining of a severe headache . HE states he has had problems with headaches in the past . He has been* ` Advanced [[O - 10 Coding* taking ibuprofen at home but states that it does not help . HE is also nauseated with this ." Coding Practicum* HE denies any visual changes . No focal weakness or numbness . No syncope . HE states he ` Introduction has been Evaluated at several other hospitals for this and has had a CAT scan , which he* Outpatient Coding Says was negative .\\ Practicum Overview HE states he has been told at_ [ PLACE ] that he has chronic tension headaches . He is Outpatient ( Book ) - Frustrated because he has tried the anti - inflammatories but they do not work and he* Evaluation and Management wonders what Else we can do for him ." Evaluation and OBJECTIVE : VITAL SIGNS : Stable . HEENT : Pupils are equally round and reactive to light Management ! and accommodation . Extraocular movements are intact . CROPHARYNX Without erythema Evaluation and or exudate . No cervical adenopathy . CHEST : Clear to auscultation bilaterally . HEART : Management* { Regular rate and rhythm . ABDOMEN : Soft , nontender , nondistended . NEUROLOGIC Evaluation and EXAM : Cranial nerves II -*Il were intact . No focal weakness or numbness . Normal reflexes Management } in patella and biceps bilaterally . BACK EXAM : He is tender at the occipital insertion of the* ` Evaluation and paraspinous muscles and along the superior insertion of the trapezius muscles . HE* * Management 4 describes & throbbing in his temples bilaterally .` Evaluation and* ASSESSMENT / PLAN : Chronic tension headaches . WE gave him 30 ing of Toradol I'M and Management* } 25 my of Phenergan I'M for nausea . He stated this helped somewhat . We then* Evaluation and discharged him and told him to come back if he developed any severe or unremitting* Management { nausea or vomiting , any focal weakness or numbness , or visual changes . He can* Evaluation and Continue taking ibuprofen as prescribed .` Management*!" Evaluation and Management ` Evaluation and Management* } I . FILL IN THE BLANK .` Enter the proper code ('s ) in the blank ('s ) provided . If a specific category of code is not* Evaluation and Management !0! applicable , please leave the box blank . When entering multiple codes in the same box , separate them with a comma and a space ( i.e. El1. 9, 110) .` Evaluation and Management 17 1 . Primary ICO - 70 - CM Code :\\ Evaluation and* Management 1 2 2 . Secondary ICO - 10 - CM Code ( s ) : Evaluation and 3 . 2 Code ( 5) !` Management 13) Evaluation and 4 . External Cause of Morbidity Codels *\\ Management 1 4 Evaluation and EIM Code Worksheet } Management 15 5 . EPM Code ( s ):\\ Outpatient ( Go` K ) - Anesthesia\\ 5 . Primary CPT Code :` Outpatient ( BOOK ) - Pathology 7 . Secondary CPT Code ( s ) :` Outpatient ( Book )` & . HCFCS Code ( 5 ) !` Psychiatric\\ Outpatient ( Book )| General Surgery Outpatient [ BLOIDK ) - Submit\\ { Copyright 20:15 Career Step , LLC. All Rights Reserved . I | HIE I Go to Top of page .\\ Career Step - training . ca -\\ C X Search or X HICC FTCC PMICE with Applied PCS with Assessment ASSESSMENT Test 1 . 0 Coding Practicum = Outpatient [ Back ] - Evaluation and Management* * Prev I NEXT* Page : 15 Of 313. I Go to page\\ - PMICE 12.01 1.0 $ Program Orientation Your score on this page will be recorded . Computer Fundamentals This will be the first time you submit this page . Good luck ! Health Information Management Evaluation and Management 5 Healthcare Delivery SYSTEMIS Code the Following Report Reimbursement Methodologies Read the following report and enter the proper code ('s ) in the blank 's ) provided . Remember to code for* ICO - 10 - CM , CFTC, and HOPES codes . If a specific category of cade is not applicable please leave the box* ` Medical Terminology* blank .` Anatomy and Physiology* Coding Hint : There are three diagnosis codes and one I code associated with this report . There is also one ` Pathophysiology* EIMl code ; pay attention to level of complexity and patient status , new or established .* $ Pharmacology ` Introduction to Coding Record $ 1CO - 70 Coding * Legal and Compliance* Progress Note ledical F [PTIHCFCS Coding - Black The patient is a 40- year- old white male , new to this office , with Spruce disease , Vitamin [PTIHCFCS Coding - Black` BIZ deficiency , folate deficiency anemia , and autoimmune hemolytic anemia . He came* into the clinic and was referred to Or._ [ NAME] . We First spoke over the telephone and ` Advanced [[O - 10 Coding discussed the plan . Basically , he is producing REC's but they are clotting together . HE has Coding Practicum* been on prednisone for 20 years on 20 my q.J . Chronically . Last _ [ DATE] . HE was* hospitalized and then discharged on 50 mng 4. J . Of prednisone because of autoimmune* ` Introduction hemolysis .* Outpatient Coding Practicum Overview PHYSICAL EXAMINATION : Vital signs : Blood pressure 124/63 , weight 21.8 pounds , temperature 97. 9 , pulse 103 , respiratory rate 20. Heart : Regular rate and rhythm without Outpatient ( Book ) - murmur , gallop , or rub . Lungs : Clear to auscultation bilaterally . Abdomen : Bowel sounds Evaluation and Management positive , soft , nontender , nondistended .\\ Evaluation and LABORATORY DATA:_\\ _[DATE] : Creatinine O.B ._ `._ [DATE] : PSA O. J ._ _ [ DATE] : WEC 8. 2 . Management ! hemoglobin 7.6 , hematocrit 22. 4 , platelets 3:3:4 , Serum sodium 135 , potassium 4 . 2 . Evaluation and chloride 105 , bicarbonate 25 , GUIN 10 , creatinine 0. 9 . glucose 94 . Albumin 3. 7 , bilirubin* Management* { total 1 . 2 , bilirubin direct O . 2 . alkaline phosphatase 52 , AST 24 , ALT ZE. Today , hemoglobin Evaluation and 9.3 , hematocrit 27. 7 , MEV 109. 2.` Management =] MEDICATIONS : He is on numerous medications . Evaluation and Management 4 ASSESSMENT AND PLAN *Evaluation and 7 . Continue prednisone 20 mng t. i. d . for his autoimmune hemolytic anemia . * Management* } 2. Idiopathatic sprue disease to follow-up\\ Evaluation and 3. Follow up in 2 week's here and check a CEC with reticulocyte count* Management { 4 . Check cholesterol fasting for the next visit because the patient was requesting* Evaluation and that .\\ Management !` 5. Call Or._ [NAME] next WEEK , Schedule for a hematology appointment. Evaluation and Management ` Evaluation and Management } Evaluation and I. FILL IN THE BLANK .` Management !0! Enter the proper code ('s ) in the blank ('s ) provided . If a specific category of code is not* applicable , please leave the box blank . When entering multiple codes in the same box , Evaluation and Management 17 separate them with a comma and a space ( i.e . E/1. 9, [To] .` Evaluation and* 1 . Primary ICO - TO- CM Code :\\ Management 1 2) Evaluation and 2 . Secondary ICD - 10 - CM Code ( s ) : Management 13) 3 . 2 Code ( 5 ) :\\ Evaluation and Management 1 4 4 . External Cause of Morbidity Codeis * \\ Evaluation and Management 15 I'M Code Worksheet ?` Outpatient ( Go` K ) - Anesthesia\\ 5 . EMM Code ( s ) :` Outpatient ( BOOK ) - 5 . Primary CPT Code :` Pathology Outpatient ( Book )` 7 . Secondary CPT Code ( s ) :\\ Psychiatric\\ 8 . HCFCS Code / 5 ) .\\ Outpatient ( Book )| General Surgery Outpatient [ ELCIDK ) - { Copyright 20:15 Career Step , LLC. All Rights Reserved . !` | HIE I Go to Top of page .\\ Career Step - training . ca - C X Search or X \\[ 2] HICC FTCC PMICE with Applied PCS with Assessment Evaluation and Management 6 ASSESSMENT Test 1 . 0 - PMICE 12. 01 1.0 Code the Following Report* $ Program Orientation Read the following report and enter the proper code ('s ) in the blank 's ) provided . Remember to code for* Computer Fundamentals ICO - 10 - CM , CPTIE, and HCFCS codes . If a specific category of cade is not applicable please leave the box blank .` Health Information Management Healthcare DELIVERY! |1 Record SYSTEMIS Reimbursement Inpatient Consultation Methodologies ledical F ` Medical Terminology" REASON FOR CONSULTATION : Melena ." Anatomy and Physiology* REVIEW OF RECORDS : The patient is a pleasant $4- year-old gentleman with a history of $ Pathophysiology* chronic obstructive pulmonary disease and lung carcinoma ( needle biopsy had Shown it* $ Pharmacology* was consistent with small -cell carcinoma , and he has undergone radiation treatment ) . He* ` Introduction to Coding is from_ [ PLACE] and presented with two Episodes of black tarry stools and dizziness* and symptoms of presyncopE . He also had mild lower abdominal pain that was diffuse $ 1CO - 70 Coding He denied any nausea , vomiting , or early satiety .\\ * Legal and Compliance* HE takes aspirin 325 Ing once a day . He denied taking nonsteroidals or other herbal CFTIHCFCS Coding - Block medications .` [PTIHCFCS Coding - Black HE denies other constitutional symptoms like chest pain , Shortness of breath , or palpitations . No symptoms of FIND or orthopnea . He denies any cough or sputum ` Advanced [[O - 10 Coding production . His appetite had been fair . HE denied genitourinary Symptoms . Coding Practicum* Patient's FEV'T is O. & and he has also a history of obstructive sleep apnea and uses BIPAP ` Introduction at night .\\ Outpatient Coding PAST MEDICAL HISTORY : Chronic obstructive pulmonary disease , quite severe , and he is Practicum Overview on three liters of oxygen BiPAP machine at night ; Squamous cell carcinoma lung status* Outpatient ( Book ) - post radiation treatment ; history of benign prostatic hypertrophy .` Evaluation and Management* CURRENT MEDICATIONS : Terazosin 5 my 9. 1 . 5., aspirin 325, my q.d. Combivent inhaler 2 puffs q. id., triamcinolone 2 puffs 4. 1 . J. , BiPAP machine at night .` Evaluation and Management ! ALLERGIES : NO KNOWN MEDICAL ALLERGIES Evaluation and FAMILY HISTORY : His mother died at the age of_ [ AGE ] Of old age and his dad died in Management* { _ [ DATE ] at the age of 52 of an acute myocardial infarction . Patient has two brothers* Evaluation and who are deceased and one of them had stomach cancer and the other colon cancer and Management } one of his sisters also has a history of colon cancer . He has another older sister who is* Evaluation and alive and well . He has three children who are alive and well .` Management 4 Evaluation and SOCIAL HISTORY : The patient has a 100 - pack - year history of smoking . He quit about* Management 5 three years ago . He lives in_ [ PLACE] with his wife . He is currently' on disability* secondary to severe lung disease . He was a welder by profession .\\ ` Evaluation and " Management by REVIEW OF SYSTEMS : Positive for dizziness , presyncopal symptoms , and melena ." Evaluation and Management*!" PHYSICAL EXAMINATION* Evaluation and GENERAL : He appeared to be a well - developed , well - nourished male who was afebrile* Management ` alert and oriented to time , person , and place . VITAL SIGNS today showed a temperature* Evaluation and Of $7 , pulse BB , respirations 20 , blood pressure 12 2/98 . HEENT : Normocephalic .\\ Management* } atraumatic . Pupils were Equally reacting to light . External ocular muscles were intact .` Evaluation and There was no scleral icterus or conjunctival injection . Tympanic membranes were normal . Management ! ` Throat was moist . NECK : Supple . No lymph adenopathy . No thyromegaly .* CARDIOVASCULAR SYSTEM: Rate was almost regular . There are no murmurs . NO JVO . NO` Evaluation and Management 17 carotid fruits . RESPIRATORY SYSTEM : Clear to auscultation bilaterally . There are no Tales* No rhonchi . ABDOMEN : Obese , soft . Liver edge was not palpable . There is no* Evaluation and* Management 1 2) 5plenomegaly . EXTREMITIES : NO clubbing , cyanosis , or pedal Edema .` Evaluation and ASSESSMENT Management 13) 7 . Melena . Differential diagnosis would include upper GI bleed , gastritis , peptic Ulcer Evaluation and Management 1 4 disease , internal hemorrhoids , external hemorrhoids , and possible metastatic lesions .` Evaluation and 2. Chronic obstructive pulmonary disease . Oxygen dependent . Management 15 3 . Benign prostatic hypertrophy .` Outpatient ( Go` K ) - 4 . History of Squamous cell carcinoma lung* Anesthesia\\ RECOMMENDATIONS : He was started on proton - pump inhibitor and will have an* Outpatient ( BOOK ) - Pathology Emergent upper endoscopy secondary to his poor lung function . WE will also order a CT scan of the abdomen . For now , we will continue to watch his hemoglobin and hematocrit* Outpatient ( Book )` Psychiatric\\ and discontinue aspirin and other NSAIDS . Continue on proton - pump inhibitor . Outpatient ( Book )| General Surgery Outpatient [ BLOIDK ) - { Copyright 2015 Career Step . LLC. All Rights Reserved . I HAVE I Go to Top Ofpage . !) Career Step - training . ca - C X Search or X \\[ 2] HICC FTCC PMICE with Applied PCS with Assessment PAST MEDICAL HISTORY : Chronic obstructive pulmonary disease , quite Severe , and he is ASSESSMENT Test 1 . 0 on three liters of oxygen BiPAP machine at night ; Squamous cell carcinoma lung Status - PMICE 12. 01 1.0 post radiation treatment ; history of benign prostatic hypertrophy* .* $ Program Orientation CURRENT MEDICATIONS : Terazosin 5 my 9. 1 . 5 . aspirin 325, 19 9. d.. [ombivent inhaler 2 puffs q . id., triamcinolone 2 puffs q. 1 . J ., BiPAP machine at night .` Computer Fundamentals Health Information ALLERGIES : NO KNOWN MEDICAL ALLERGIES* Management FAMILY HISTORY : His mother died at the age of_ [ AGE ] Of old age and his dad died in Healthcare DELIVERY! _ [ DATE ] at the age of 52 of an acute myocardial infarction . Patient has two brothers* SYSTEMS who are deceased and one of them had stomach cancer and the other colon cancer and Reimbursement one of his sisters also has a history of colon cancer . He has another older sister who is* Methodologies alive and well . He has three children who are alive and well .* ` Medical Terminology* SOCIAL HISTORY : The patient has a 100 - pack - year history of smoking . He quit about* Anatomy and Physiology three years ago . He lives in_ [ PLACE] with his wife . He is currently on disability* ` Pathophysiology* secondary to severe lung disease . He was a welder by profession .* $ Pharmacology* REVIEW OF SYSTEMS : Positive for dizziness , presyncopal symptoms , and melena . ` Introduction to Coding PHYSICAL EXAMINATION $ 1CO - 70 Coding GENERAL : He appeared to be a well - developed , well- nourished male who was afebrile . * Legal and Compliance* alert and oriented to time , person , and place . VITAL SIGNS today showed a temperature* CFTIHCFCS Coding - Black Of 97 , pulse BB , respirations 20 , blood pressure 122 /58 . HEENT : Normacephalic ,\\ atraumatic . Pupils were Equally reacting to light . External ocular muscles were intact .\\ [PTIHCFCS Coding - Black There was no scleral icterus or conjunctival injection . Tympanic membranes were normal . Throat was moist . NECK : Supple . No lymph adenopathy . No thyromegaly .` CARDIOVASCULAR SYSTEM : Rate was almost regular . There are no murmurs . NO NO . NO ` Advanced [[O - 10 Coding carotid fruits . RESPIRATORY SYSTEM : Clear to auscultation bilaterally . There are no rales* Coding Practicum* No rhonchi . ABDOMEN : Obese , soft . Liver edge was not palpable . There is no* ` Introduction splenomegaly . EXTREMITIES : NO clubbing , cyanosis , or pedal Edema .` Outpatient Coding ASSESSMENT Practicum Overview 7 . Melena . Differential diagnosis would include upper GI bleed , gastritis , peptic Ulcer Outpatient ( Book ) - Evaluation and disease , internal hemorrhoids , External hemorrhoids , and possible metastatic* Management* lesions .` Evaluation and 2 . Chronic obstructive pulmonary disease . Oxygen dependent . Management ! 3 . Benign prostatic hypertrophy . T 4 . History of squamous cell carcinoma lung* Evaluation and Management* = RECOMMENDATIONS : He was started on proton - pump inhibitor and will have an* Evaluation and Emergent Upper Endoscopy secondary to his poor lung function . WE will also order a CT Management } Scan of the abdomen . For now , we will continue to watch his hemoglobin and hematocrit* Evaluation and and discontinue aspirin and other NSAIDS . Continue on proton-pump inhibitor . Management 4 Evaluation and Management 5 ` Evaluation and " Management by I . FILL IN THE BLANK .` Enter the proper code ('s ) in the blank ( s ) provided . If a specific category of code is not Evaluation and Management*!" applicable please leave the box blank . When entering multiple codes in the same box separate them with a comma and a space (i.e . El1. 9 , 1To1 . Evaluation and Management ` 1 . Primary ICD - TO - CM Cade :\\ Evaluation and Management* } 2. Secondary ICO - 10 - CM Code ( s ) :` Evaluation and 3 . 2 Code ( s ) :` Management ! ` 4 . External Cause of Morbidity Codeis *\\ Evaluation and Management 17 I'M Code Worksheet} Evaluation and* Management 1 2 5 . EIM Code ( 5 ) :\\ Evaluation and Management 13) 5 . Primary CPT Code :* Evaluation and Management 1 4 7 . Secondary CPT Code / s ) : Evaluation and B . HOPES Code ( 5 ) . Management 15 Outpatient ( Book )` Anesthesia\\ Outpatient ( BOOK ) - Submit Pathology Outpatient ( Book) - Psychiatric\\ Coding Practicum = Outpatient ( Block ) - Evaluation and Management* * Prey | Next* Outpatient ( Book )| Page : 1 8 Of 3.13 / 60 to page \\\\ General Surgery Outpatient [Look ) - {` Copyright 201.5 Career Step . LLC. All Rights Reserved . I LE | 50 to Top Ofpage , !'12:53 PM Outpatient (Book] - Evaluation and Management s Prev | Next GO PMCB (2.0) 1.0 Page: 17 of 313 | Go to page Program Orientation Your score on this page will be recorded. Computer Fundamentals This will be the first time you submit this page. Good luck! Health Information Management Evaluation and Management 7 Healthcare Delivery Systems Code the Following Report Reimbursement Methodologies Read the following report and enter the proper code(s) in the blank(s) provided. Remember to code for Medical Terminology ICD-10-CM, CPT@, and HCPCS codes. If a specific category of code is not applicable please leave the box blank. Anatomy and Physiology Coding Hint: There are three diagnosis codes associated with this report. There is also one E/M code; pay 4 Pathophysiology attention to level of complexity. Pharmacology Introduction to Coding ICD-10 Coding Medical Record Legal and Compliance Consultation CPT/HCPCS Coding - Block HISTORY OF PRESENT ILLNESS: This patient was referred by Dr. __ [NAME] for a CPT/HCPCS Coding - Block consultation concerning visual field blockage from drooping eyelids. As he puts it, he 2 actually has redundant superfluous eyelid skin hanging over his lashline, which has Advanced ICD-10 Coding caused some levator dehiscence and ptosis of his eyelid in addition to overhanging skin. Coding Practicum Both sides are bad, but the right side is worse than the left. Introduction PAST MEDICAL HISTORY: He states that he is otherwise in good physical condition for a 77-year-old man. He does drive and states he does have considerable problems with his Outpatient Coding Practicum Overview visual field at night, when his pupils are dilated, and he has been told by other clinicians that he would benefit from this surgery. Outpatient (Book) - Evaluation and PAST SURGICAL HISTORY: He has had multiple other surgeries in the past, multiple Management hernia repairs, on multiple occasions. Evaluation and Management 1 ALLERGIES: NO KNOWN MEDICAL ALLERGIES. Evaluation and MEDICATIONS: He does not take any medications. Management 2 Evaluation and SOCIAL HISTORY: Nonsmoker, nondrinker. Management 3 REVIEW OF SYSTEMS: All systems were reviewed and found to be negative, other than Evaluation and that related to his visual field problems with the dermatochalasia and the ptosis of Management 4 bilateral lids. Evaluation and PHYSICAL EXAM Management 5 Evaluation and GENERAL: He is 5 feet 11-1/2 inches and 150 pounds. WDWN, regular pulse, R.R., afebrile. Management 6 HEENT: Head atraumatic, normocephalic. No acute distress. Cranial nerves II-XII intact. Evaluation and NEUROLOGIC: Normal affect and mood. Alert and oriented x 3. EYES: Pupils are equally Management 7 round and reactive to light. Extraocular movements are intact. This patient has Evaluation and considerable ptosis or dermatochalasia of the right and the left upper lid, being worse on Management 8 the right, with the redundant skin extending over the lashline causing visual field obstruction. It appears he has at least 2 mm levator aponeurosis dehiscence causing Evaluation and Management 9 some ptosis of his eyelids. EARS/NOSE/MOUTH/OROPHARYNX: Without abnormality. NECK: Supple, full range of motion. No adenopathy. No thyroid gross abnormality. Evaluation and Management 10 LUNGS: Clear to auscultation A&P. Normal respiratory effect. HEART: RRR, without murmur. CV: No gross edema, or significant varicosities. ABDOMEN: Soft, nontender, Evaluation and nondistended. No hepatosplenomegaly or masses. Normal bowel sounds. EXTREMITIES: Management 11 Within normal limits. MUSCULOSKELETAL: Generally unremarkable. Normal gait. No Evaluation and asymmetry. Normal range of motion. LYMPHATIC: No adenopathy, neck and axilla. SKIN: Management 12 No visual or palpable gross irregularities on areas examined. Evaluation and Management 13 ASSESSMENT/PLAN: The patient would benefit from two separate surgeries. The first being excision of superfluous excess skin weighing down the upper eyelids, and then Evaluation and Management 14 tightening of the levator aponeurosis for correction of ptosis of the eyelid. He will require both of these procedures, which should be done under a general anesthetic but can be Evaluation and Management 15 performed as an outpatient procedure. Approximately 15 minutes were spent explaining the risks and benefits of the proposed surgical procedure to the patient. All his Outpatient (Book] numerous questions were answered, including time needed for recuperation, his Anesthesia postoperative care, his limitations relative to driving a car and any permanent disability. Outpatient (Book) - He is in agreement with the proposed procedures and at the patient's request we will go Pathology ahead and proceed with these surgeries upon authorization from the insurance Outpatient (Book) - company Psychiatric Outpatient (Book] - General Surgery Outpatient [Book) - FILL TALTHE BLA Copyright 2019 Career Step, LLC. All Rights Reserved. I CSTS | Go to Top of page. D( - ) Career Step - training . ca - C X Search or X \\[ 2] HICC THE FTCC PMICE with Applied PCS with Assessment THAT THE BILAL THE & T ERT . TIL ALLILL S TITUL TIL IS UILIILI WHILE IN YOU'L PETTY STILLIT LET ILIILIUNIT BUT HI` 77 - year- old man . HE does drive and states he does have considerable problems with his ASSESSMENT Test 1 . 0 visual field at night , when his pupils are dilated , and he has been told by other clinicians - PMICE 12. 01 1.0 that he would benefit from this surgery .\\ $ Program Orientation PAST SURGICAL HISTORY : He has had multiple other surgeries in the past , multiple* hernia repairs , on multiple occasions .` Computer Fundamentals Health Information ALLERGIES : NO KNOWN MEDICAL ALLERGIES . Management MEDICATIONS : He does not take any medications . Healthcare DELIVERY! SYSTEMS SOCIAL HISTORY : Nonsmoker , nondrinker .* Reimbursement REVIEW OF SYSTEMS : All systems were reviewed and found to be negative , other than* Methodologies that related to his visual field problems with the dermatochalasia and the ptosis of* ` Medical Terminology* bilateral lids . Anatomy and Physiology PHYSICAL EXAM ` Pathophysiology* GENERAL : He is 5 feet 1 1 - 1 / 2 inches and 150 pounds . WOWN , regular pulse , R. R., afebrile* $ Pharmacology* HEENT : Head atraumatic , normacephalic . No acute distress . Cranial nerves II -* IT intact . ` Introduction to Coding NEUROLOGIC : Normal affect and mood . Alert and oriented* 3 . EYES : Pupils are equally round and reactive to light . Extraocular movements are intact . This patient has\\ $ 1CO - 70 Coding considerable ptosis or dermatochalasia of the right and the left upper lid , being worse on * Legal and Compliance* the right , with the redundant skin extending over the lastline causing visual field* EFTIHCFCS Coding - Black obstruction . It appears he has at least 2 mm levator aponeurosis dehiscence Causing Some ptosis of his Eyelids . EARSINOSE , MOUTH / ORO PHARYNX : Without abnormality* [PTIHCFCS Coding - Black NECK : Supple , Full range of motion . No adenopathy . No thyroid gross abnormality .* LUNGS : Clear to auscultation ARF . Normal respiratory effect . HEART: ARR, Without* murmur . [ Y : No gross edema , or significant varicosities . ABDOMEN : Soft , nontender , ` Advanced [[O - 10 Coding nondistended . No hepatosplenomegaly or masses . Normal bowel sounds . EXTREMITIES* Coding Practicum* Within normal limits . MUSCULOSKELETAL : Generally unremarkable . Normal gait . NO\\ ` Introduction asymmetry . Normal range of motion . LYMPHATIC : NO adenopathy , neck and axilla . SKIN :` Outpatient Coding NO visual or palpable gross irregularities on areas examined . Practicum Overview ASSESSMENT / PLAN : The patient would benefit from two Separate surgeries . The first Outpatient ( Book ) - being excision of superfluous excess skin weighing down the upper eyelids , and then* Evaluation and tightening of the levator aponeurosis for correction of ptosis of the eyelid . He will require* Management* both of these procedures , Which should be done under a general anesthetic but can be* Evaluation and performed as an outpatient procedure . Approximately 15 minutes were Spent Explaining Management ! the risks and benefits of the proposed surgical procedure to the patient . All his* Evaluation and numerous questions were answered , including time needed for recuperation , his* Management*{ postoperative care , his limitations relative to driving a car and any permanent disability . Evaluation and HE is in agreement with the proposed procedures and at the patient's request we will go Management } ahead and proceed with thesE Surgeries Upon authorization from the insurance* Evaluation and company . Management 4 Evaluation and Management Evaluation and Management { I . FILL IN THE BLANK .` Enter the proper code ('s ) in the blank ( s ) provided . If a specific category of code is not* `Evaluation and* - Management !` applicable , please leave the box blank . When entering multiple codes in the same box . separate them with a comma and a space ( i.e . El1. 9 , 1To1 .` Evaluation and Management` 1 . Primary ICO - 10 - CM Code :\\ Evaluation and Management* } 2 . Secondary ICO - 10 - CM Code ( s ) :` Evaluation and 3 . 2 Code ( s ) : Management !0! 4 . External Cause of Morbidity Codels * \\ Evaluation and Management 17 EI'M Cade Worksheet } Evaluation and* Management 1 2 5 . EIM Code ( s ) :\\ Evaluation and Management 13) 5 . Primary [PT Code :` Evaluation and Management 1 4 7 . Secondary CPT Code / s ) : Evaluation and B . HOPES Code ( 5 ) !` Management 15 Outpatient ( Book )- Anesthesia\\ Outpatient ( BOOK ) - \\Submit Pathology Outpatient ( Book) - Psychiatric\\ Coding Practicum = Outpatient ( Book ) _ Evaluation and Management* * Prey I Next* Outpatient ( Book )| Page : 17 Of 3.13 | Go to page\\\\ General Surgery Outpatient [ BOOK ) - {` Copyright 207.5 Career Step , LLC. All Rights Reserved . I HAVE I Go to Top Of page , !'12:54 PM Management 14 Evaluation and 5. E/M Code(s): Management 15 Outpatient (Book] 6. Primary CPT Code: Anesthesia 7. Secondary CPT Code(s): Outpatient (Book)- Pathology 8. HCPCS Code(s): Outpatient (Book)- Psychiatric Outpatient (Book] - General Surgery Submit Outpatient [Book) - Copyright 2019 Career Step, LLC. All Rights Reserved. | CSTS | Go to Top of page. D O- 9 12:54 PM Psychiatric Outpatient (Book] - 5. E/M Code(s): General Surgery 6. Primary CPT Code: Outpatient [Book) - Copyright 2019 Career Step, LLC. All Rights Reserved. | CSTS | Go to Top of page. D O 012:54 PM Evaluation and Management 12 5. E/M Code(s): Evaluation and Management 13 6. Primary CPT Code: Evaluation and Management 14 7. Secondary CPT Code(s): Evaluation and 8. HCPCS Code(s): Management 15 Outpatient (Book] Anesthesia Outpatient ( Book) Submit Pathology Outpatient (Book) Psychiatric Coding Practicum >> Outpatient (Book) - Evaluation and Management & Prev | Next * Outpatient (Book] - Page: 19 of 313 | Go to page GO General Surgery Outpatient [Book) - Copyright 2019 Career Step, LLC. All Rights Reserved. | CSTS | Go to Top of page. D Career Step - training . ca - C X Search or X \\[ 2] HICC FTCC PMICE with Applied PCS with Assessment \\)[GOOGLEILL NEV`EM```E Evaluation and Management 10 ASSESSMENT Test 1 . 0 - PMICE 12. 01 1.0 Code the Following Report $ Program Orientation Read the following report and enter the proper code ('s ) in the blank 's ) provided . Remember to code for Computer Fundamentals ICO - TO - CM , CPTIE, and HOPES codes . If a specific category of cade is not applicable please leave the box blank .` Health Information Management Coding Hint : There is one diagnosis code associated with this report . There is also one EI'M code* Healthcare DELIVERY! SYSTEMIS 1 Record Reimbursement Methodologies ` Medical Terminology" Consultation Medical { Anatomy and Physiology* HISTORY OF PRESENT ILLNESS : The patient is a 31 - year -old homemaker , new to me , which $ Pathophysiology* 15 SEEN for a consultation regarding a large lesion on her neck . She was referred by her* $ Pharmacology* family practice physician and her dermatologist for a lesion that is So large and* ` Introduction to Coding concerning to both of these physicians they felt it warranted evaluation by a plastic* surgeon . The lesion is a large cystic lesion , about the size of a quarter , that is fixated to $ 1CO - 70 Coding the skin and fascia underneath . She states that there has been some recent active gazing * Legal and Compliance* from the lesion . She states it has been present for approximately 13 years . She states* CFTIHCFCS Coding - Black that is has been very painful and inflamed at times . She also said that it has been* recurring and has gotten larger over time .\\ [PTIHCFCS Coding - Black; REVIEW OF SYSTEMS : The patient has some mild asthma . She also has a large sebaceous skin lesion the size of a quarter on the back of her neck , which is Fixated to the skin and ` Advanced [[O - 10 Coding has pus coming out of it . There is some scarring involved with it. All other systems were* Coding Practicum* reviewed and were found negative .` ` Introduction FAST MEDICAL HISTORY : The patient states she is otherwise healthy with no other major Outpatient Coding medical problems besides the history of asthma .* Practicum Overview PAST SURGICAL HISTORY : Denies any significant past surgical history . Outpatient ( Book ) - Evaluation and ALLERGIES : THE PATIENT HAS NO KNOWN ALLERGIES ! Management* MEDICATIONS : None .* Evaluation and Management ! SOCIAL HISTORY : The patient is a nonsmoker and nondrinker ! Evaluation and PHYSICAL EXAMINATION :` Management*{ Evaluation and CONSTITUTIONAL : General : She is 5'8 and 150 pounds , EP 120 180 , temperature 57 . 8 Management } heart rate &D. WOWN , regu