Case 4.2 Auditing Code Assignment

Audit the following cases to determine whether the correct codes have been reported in the correct order. If a coding mistake has been made,

state the correct code and your reason for assigning it.

B. Physician's notes, 2/24/2029, patient George Kadar, DOB 10/11/1954:

Subjective:This seventy-five-year-old patient complains of voiding difficulties, primarily urinary incontinence. No complaints of urinary retention.

Objective:Rectal examination: enlarged prostate. Patient catheterized for residual urine of 200 cc. Urinalysis is essentially negative.

C.Patient: Gloria S. Diaz:

Subjective:This twenty-five-year-old female patient presents with pain in her left knee both when she moves it and when it is inactive. She

denies previous trauma to this area but has had right-knee pain and arthritis in the past.

Objective:Examination revealed the left knee to be warm and slightly swollen compared to the right knee. Extension is 180 degrees; flexion is

90 degrees. Some tenderness in area.

Assessment:Left-knee pain probably due to chronic arthritis.

Plan:Daypro 600 mg 2-QD 3 1 week; recheck in one week.

The following codes were reported: M25.562, M19.90.

Assessment:Prostatic hypertrophy, benign.

Plan:Refer to urologist for cystoscopy.

The following code was reported: N40.1.