Question Why was I marked wrong? (Practicode Case ID: OPD7419)

Elund

Networker
Messages
43
Location
Irvine, CA
Best answers
0
The documentation:
EMERGENCY DEPARTMENT

SEX: MALE

AGE: 60

DOS: 1/1/20XX

Code only for the ER physician

Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:


Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. REVIEW OF SYSTEMS:


The patient has had dizziness and a mild headache. He has had generalized weakness. No localized weakness. No chest pain, palpitations, abdominal pain, vomiting or diarrhea. No black stools, bloody stools, fever, sore throat or difficulty breathing. No difficulty with urination, skin rash, enlarged lymph nodes or cough. All systems otherwise negative, except as recorded above. PAST HISTORY: Hypertension. No history of a stroke or heart disease. Risk factors for heart disease-smoking and hypertension . Denies the following risk factors for heart disease - elevated cholesterol. SOCIAL HISTORY: Current smoker. No alcohol use or drug use. ADDITIONAL NOTES: The nursing notes have been reviewed. Weight: 80.7 kg. Height: 66 inches. BMI: 28.7. PHYSICAL EXAM:


Appearance: Alert. IV present X 1. EKG monitor and O2 sat monitor on the patient. Vital Signs: Have been reviewed and appear to be correct. (BP: 165/60. HR: 68. RR: 16. Temp: 96.8. O2 saturation 99%). Eyes: No nystagmus. ENT: Normal ENT inspection. Moist mucous membranes. Neck: Normal inspection. Neck supple. CVS: Normal heart rate and rhythm. Heart sounds normal. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Soft and nontender. No organomegaly. Back: Normal inspection. Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor. Extremities: Extremities exhibit normal ROM. No lower extremity edema. Neuro: Alert. Oriented X 3. Mood/affect normal. Cranial nerves normal (as tested). No motor deficit. No sensory deficit. LABS, X-RAYS, AND EKG


EKG: 12 lead EKG time (16:34). No acute process. No acute ischemia. 12 lead EKG performed. EKG shows non-specific T-wave flattening without other abnormality. ( independently viewed and interpreted contemporaneously by me.)


Rhythm Strip: Normal rhythm strip (good tracing): (independently viewed and interpreted contemporaneously by me). Normal sinus rhythm. Normal PR interval. Normal QRS complexes. Normal STs and T waves. No ectopy.


Christopher Thomas, MD


Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX


CT Head: (DISCUSSION: Noncontrasted CT head shows normal brain ventricles,


sulci, basal cisterns. No evidence of mass, mass effect, hemorrhage,


hematomas no acute infarction.


IMPRESSION: Normal Noncontrasted CT head.


Ronald Kramer, MD


Electronically signed by RONALD KRAMER, MD 1/1/20XX *Prior studies were not available for comparison. The study was interpreted by the radiologist (Kramer). Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0525:YJ:CG00123R: (Final results)


Laboratory Test Value: HOLD TUBE FOR COAG SEE NOTE


0525:YJ:C00440S:Final results


Laboratory Test Value


SODIUM 140


POTASSIUM 3.4


CHRUTHDE 105


CARBON DIOXIDE 20.0


ANION GAP 15


GLUCOSE 54


BLOOD UREA NITROGEN 21


CREATININE 1.80


GLOMERULAR FILTRATION RATE 41


TOTAL PROTEIN 8.0


ALBUMIN 3.8


CALCIUM 9.8


BILIRUBIN TOTAL 0.30


SGOT/AST 10


SGPT/ALT 18


ALKALINE PHOSPHATASE 97


CREATINE KINASE (CK) 122


TROPONIN I 0.03


0525:YJ:H00270S: Final results


Laboratory Test Value


WHITE BLOOD CELL 12.8


RED BLOOD CELL 4.24


HEMOGLOBIN 14.0


HEMATOCRIT 42.2


MEAN CELL VOLUME 99.5


MEAN CELL HGB 32.9


MEAN CELL HGB CONCENTRATION 33.1


RED CELL DISTRIBUTION WIDTH 14.0

PLATELET COUNT 264

MEAN PLATELET VOLUME 10.2

NEUTROPHIL % 78.9

LYMPHOCYTE % 12.8

MONOCYTE % 7.7

EOSINOPHIL % 0.2

BASOPHIL % 0.4

NEUTROPHIL # 10.1

LYMPHOCYTE # 1.6

MONOCYTE # 1.0

EOSINOPHIL # 0.0

BASOPHIL # 0.1

MANUAL DIFF REQUIRED? NO

SMEAR REVIEW ? NO

NP AUTO DIFF NO . Bedside Tests: Glucose: hyperglycemia - 181 (performed pre-hospital). Pulse Oximetry: O2 saturation- 99% room air. PROGRESS AND PROCEDURES:

Course of Care: 60 year-old male presents with frequent falls/likely syncopal events. Patient reports 3 times over the past week having falls after feeling dizzy, "blacking out" briefly. No chest pain, dyspnea at any point. Patient feels generally weak and minimally dizzy at time of presentation.

EKG shows non-specific T-wave flattening without other abnormality.

CT head negative.

Labs show mild renal insufficiency without other significant abnormality.

Given several recent syncopal events, will admit Mr. Smith for further observation/workup.

Discussed patient with Dr. Andrews who will admit Mr. Smith.. Discussed case with hospitalist, (Andrews). Reviewed test results. Agreed upon treatment plan. Health care provider will see patient in hospital. Patient and family counseled in person regarding the patient's stable condition, test results, diagnosis and need for admission. IV fluid administered under direct supervision of physician. Clinical Review ECG interpretation documented. Antiplatelet medications administered. Consultation obtained from admitting physician. Disposition: Placed in observation status in Telemetry. CLINICAL IMPRESSION: Syncope of unknown cause. 12 lead EKG performed. Christopher Thomas, MD

Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.

CASE MANAGEMENT NOTE

SCREENED FOR ADMISSION

PT MET CRITERIA UNDER OBSV WITH CARDIAC/RESPIRATORY FINDINGS OF SYNCOPE, UNKNOWN ETIOLOGY.

PT PRESENTED TO ER WITH

Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. The patient has had dizziness and a mild headache. He has had generalized weakness. BP 165/60, HR 68, RR 16 and T 96.8

RA O2 SAT 99 %. PAIN SCORE 0/10.

HX: DIABETES, HTN and GERD

LABS: WBC 12.8 and MAGNESIUM 1.5

GIVEN ASA and IV FLUIDS 1000 MLS.

PM RN CM Electronically signed by R., Paula RN 1/1/20XX

5/16/20XX 18:23

CASE MANAGEMENT ADDENDUM

POTASSIUM 3.4 L mMOL/L (3.5-5.1) CHRUTHDE 105 mMOL/L (98-107) CARBON DIOXIDE 20.0 L mMOL/L (23.0-32.0) ANION GAP 15 H mmol/L (4-12) GLUCOSE 54 L mg/dL (70-110) BLOOD UREA NITROGEN 21 H mg/dL (7-18) CREATININE 1.80 H mg/dL (0.6-1.3) GLOMERULAR FILTRATION RATE 41 L (60-130) PM RN CM Electronically signed by R., Paula RN 1/1/20XX

Why aren't the hypertension and smoking reported?
 
My thinking is don't code past history. Facilities have there own rules on what to code. I think it is basic for lessons though. I was told recently to think of MEAT-stands for monitored, evaluated, assessed/affected, or treated. If the diagnosis isn't mentioned in these terms, in HPI, MDM, or carried along with a diagnostic statement don't code it as a current condition. If there was mention of patient taking meds for hypertension then you would.
As for the smoking again just keep it basic unless you coded F17.210 which would be wrong based on no mention of what is being smoked it wouldn't be coded.
Hope that helps.
 
But the social history says that the patient is a current smoker.

Also, there were other Practicode cases in which I was supposed to code nicotine dependence (cigarettes) when the case didn't specify what substance was being smoked, or even that there was a dependence.
 
But the social history says that the patient is a current smoker.

Also, there were other Practicode cases in which I was supposed to code nicotine dependence (cigarettes) when the case didn't specify what substance was being smoked, or even that there was a dependence.

By any chance did any of those other cases have diagnosis codes that had a "Use Additional Code" note for nicotine dependence?

For example, the C34 category of codes has the following note:

Use additional code to identify:


exposure to environmental tobacco smoke (Z77.22) (Z77.22)


exposure to tobacco smoke in the perinatal period (P96.81) (P96.81)


history of tobacco dependence (Z87.891) (Z87.891)


occupational exposure to environmental tobacco smoke (Z57.31) (Z57.31)


tobacco dependence (F17.-) (F17-F17.299)


tobacco use (Z72.0) (Z72.0)
 
The only diagnosis code was R55, syncope and collapse.

In almost all the previous cases, whenever hypertension and smoking were reported in the current problems list (even if not in the diagnoses), I was expected to code them.

But, I will pay more attention to the "code also" notes from now on. (I think Codify sometimes doesn't show them though, at least on the free version.)

 
I just tried another case (OPD7278) and looked carefully this time at the "code also" notes, in both Codify and the code books. Apparently I was expected to code Z95.1 (presence of aortocoronary bypass graft) and Z95.5 (presence of coronary angioplasty implant and graft), despite neither of these being in the assessment or in the "code also" notes of any of the other diagnoses. (The other codes were I25.10, I34.1, R00.1, and Z79.02.) I'm confused.

The documentation:
OFFICE - ESTABLISHED

CARDIOLOGY

Sex: M

AGE: 70

Date: 01/01/20XX

CHIEF COMPLAINT: He is here for a medication check and six-month check.

PROBLEM LIST

1. Male patient with left heart catheterization (01/01/XX) showing widely patent LIMA to LAD, SVG to OM1 and widely patent RCA stent.

2. History of exercise induced 6-cycle polymorphic ventricular tachycardia per Holter monitor followed by EP study that showed no inducible ventricular tachycardia.

3. Two vessel CABG (01/XX).

4. Right coronary artery stents (20XX).

7. Hyperlipidemia.

ALLERGIES: ACE inhibitors

MEDICATIONS

Plavix 75 mg q.d

Metoprolol ER 125 mg (100 mg in a.m. and 25 mg q h.s.)

Crestor 40 mg q.d.

Omega 3 1000 mg b.i.d.

INTERVAL HISTORY

For reasons unknown, medication changes requested last office visit were not completed. He remains bradycardic, but has had no lightheadedness, dizziness, chest pain or shortness of breath. He reports average home blood pressure is 125/80. Overall, he feels well.

EKG previous results:

1. Sinus bradycardia at 59 b.p.m. with nonspecific T-wave abnormalities.

2. This is no different from previous EKG.

3. Showed significant mitral valve prolapse and thus prompted after load reduction in medication.

PHYSICAL EXAMINATION

VITAL SIGNS: Weight 188 lbs, BP 122/66 in the left arm, pulse 65 and regular,

oxygen saturation 95% on room air.

CONSTITUTIONAL: In no acute distress

HEENY: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.

RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No

adventitious sounds. Chest has normal contour.

CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1 and S2 normal. Systolic murmur, Grade 2/6 heard best at apex. S4 gallop. No diastolic murmur, clicks. Abdominal aorta not palpable.

GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.

SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.

NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.

ASSESSMENT

1. Well-preserved left ventricular function with mitral prolapse

2. Bradycardia.

3. Coronary artery disease with no recent chest pain.

4. Plavix daily

PLAN

1. He is to hold evening metoprolol and add Losartan 25 mg a day.

2. Office visit in six weeks.

Robert Jones, MD

Electronically signed by ROBERT JONES, MD 1/1/20XX
 
Top