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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Capture the Complete Clinical Picture With Precision

Clinical validation could upend your current risk adjustment policies. The rise of risk adjustment-based managed care programs in the past 15 years within Medicare, Medicaid, and Affordable Care Act (ACA) plans has led to remarkably good news: There has been a significant improvement in the accuracy of the diagnosis codes abstracted from medical documentation among […]

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AAPC Knowledge Center

TAVR Approved Clinical Study

Transcatheter Aortic Valve Replacement
Transcatheter aortic valve replacement (TAVR – also known as TAVI or transcatheter aortic valve implantation) is a new technology for use in treating aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve.
CMS issued a Medicare National Coverage Determination on May 1, 2012 which allows coverage of TAVR under Coverage with Evidence Development (CED) with certain conditions.  The complete determination is available on our website.  As part of CED, we are identifying below the Medicare approved registry and Medicare approved clinical trials which have been reviewed and determined to meet the requirements of coverage.
Clinical Study Approvals
Study Title: REPRISE IV: Repositionable Percutaneous Replacement of Stenotic Aortic Valve through Implantation of LOTUS Edge Valve System in IntermediatE Surgical Risk Subjects
Sponsor: Boston Scientific
Clinicaltrials.gov number: NCT03618095
Investigational Device Exemption (IDE) Number: G160209
CMS Approval Date: 10/16/2018
Study Title: Transcatheter Aortic Valve Replacement (TAVR) With Medtronic TAVR System in Patients With Severe Bicuspid Aortic Valve Stenosis and at Low Predicted Risk of Mortality With Surgical Aortic Valve Replacement (SAVR)
Sponsor: Medtronic Cardiovascular
Clinicaltrials.gov number: NCT03635424
Investigational Device Exemption (IDE) Number: G160022
CMS Approval Date: 10/10/2018
Study Title: A Prospective, Single-arm, Controlled, Multicenter Study to Establish the Safety and Effectiveness of the CENTERA THV System in Intermediate Risk Patients Who Have Symptomatic, Severe, Calcific, Aortic Stenosis Requiring Aortic Valve Replacement
Sponsor: Edwards Lifesciences
Clinicaltrials.gov number: NCT03517436
Investigational Device Exemption (IDE) Number: G180045
CMS Approval Date: 07/05/2018
Study Title: Strategies to Prevent Transcatheter Heart Valve Dysfunction in Low Risk Transcatheter Aortic Valve Replacement
Sponsor: Medstar Health Research Institute
Clinicaltrials.gov number: NCT03557242
Investigational Device Exemption (IDE) Number: G150207
CMS Approval Date: 06/28/2018
Study Title: Transfemoral Replacement of Aortic Valve with HLT MeriDIAN Valve Early Feasibility Trial (RADIANT)
Sponsor: HLT Inc.
Clinicaltrials.gov number: NCT02799823
Investigational Device Exemption (IDE) Number: G160091
CMS Approval Date: 06/29/2017
Study Title: Evaluation of Transcatheter Aortic Valve Replacement Compared to SurveilLance for Patients With AsYmptomatic Severe Aortic Stenosis
Sponsor: Edwards Lifesciences
Clinicaltrials.gov number: NCT03042104
Investigational Device Exemption (IDE) Number: G160259
CMS Approval Date: 06/05/2017
Study Title: Edwards SAPIEN 3 TVH PARTNER 3 Aortic Valve-in-Valve Trial
Sponsor: Edwards Lifesciences
Clinicaltrials.gov number: NCT03003299
Investigational Device Exemption (IDE) Number: G150278
CMS Approval Date: 01/17/2017
Study Title: Transcatheter Aortic Valve Replacement to UNload the Left ventricle in patients with ADvanced heart failure: a randomized trial (TAVR UNLOAD)
Sponsor: Cardiovascular Research Foundation
ClinicalTrials.gov Number: NCT02661451
Investigational Device Exemption (IDE) Number: G150252
CMS Approval Date: 09/06/2016
Study Title: JenaValve AS EFS study
Sponsor: JenaValve Technology, Inc.
ClinicalTrials.gov Number: NCT02732691
Investigational Device Exemption (IDE) Number: G150035
CMS Approval Date: 07/20/2016
Study Title: JenaValve AR EFS study
Sponsor: JenaValve Technology, Inc.
ClinicalTrials.gov Number: NCT02732704
Investigational Device Exemption (IDE) Number: G150035
CMS Approval Date: 07/12/2016
Study Title: Low Risk TAVR
Sponsor: MedStar Cardiovascular Research Institute
ClinicalTrials.gov Number: NCT02628899
Investigational Device Exemption (IDE) Number: G150207
CMS Approval Date: 07/01/2016
Study Title: Medtronic CoreValve Evolut R US Clinical Study: Evolut 34R Addendum
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT02746809
Investigational Device Exemption (IDE) Number: G140059
CMS Approval Date: 06/06/2016
Study Title: Medtronic Transcatheter Aortic Valve Replacement (TAVR) 2.0 US Clinical Study
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT02738853
Investigational Device Exemption (IDE) Number: G160039
CMS Approval Date: 05/31/2016
Study Title: SAPIEN 3 THV PARTNER 3 Trial
Sponsor: Edwards Lifesciences
ClinicalTrials.gov Number : NCT02675114
Investigational Device Exemption (IDE) Number: G150278
CMS Approval Date: 03/17/2016
Study Title: Medtronic Transcatheter Aortic Valve Replacement (TAVR) with the Medtronic Transcatheter Aortic Valve Replacement System (TAVR) in patients at Low Risk for Surgical Aortic Valve Replacement (SAVR)
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT02701283
Investigational Device Exemption (IDE) Number: G160022
CMS Approval Date: 03/17/2016
Study Title:  REPRISE III: REpositionable Percutaneous Replacement of Stenotic Aortic Valve through Implantation of Lotus™ Valve System – Randomized Clinical Evaluation
Sponsor:  Boston Scientific Corporation
ClinicalTrials.gov Number : NCT02202434
Investigational Device Exemption (IDE) Number:  G140090
CMS Approval Date: 09/13/2014
Study Title:  The Medtronic CoreValve™ Evolut R™ Clinical Study
Sponsor:  Medtronic
ClinicalTrials.gov Number: NCT02207569  
Investigational Device Exemption (IDE) Number: G140059
CMS Approval Date: 07/24/2014
Study Title: TranScatheter Aortic Valve RepLacement System a US Pivotal Trial (SALUS)
Sponsor:  Direct Flow Medical, Inc.
ClinicalTrials.gov Number: NCT02163850
Investigational Device Exemption (IDE) Number: G120160
CMS Approval Date: 06/05/2014
Study Title: Portico Re-sheathable Transcatheter Aortic Valve System US IDE Trial (PORTICO) Interventional Trial
Sponsor: St. Jude Medical
ClinicalTrials.gov Number: NCT02000115
Investigational Device Exemption (IDE) Number: G120263
CMS Approval Date: 03/25/2014
Study Title: SALUS Trial: The Direct Flow Medical Transcatherter Aortic Valve Replacement System US Feasibility Trial
Sponsor: Direct Flow Medical
ClinicalTrials.gov Number: NCT01932099
Investigational Device Exemption (IDE) Number: G120160
CMS Approval Date: 09/25/2013
Study Title: Alternative Access Approaches for Transcatheter Aortic Valve Replace (TAVR) in Inoperable Patients with Aortic Stenosis
Sponsor: The Society of Thoracic Surgeons and The American College of Cardiology Foundation
ClinicalTrials.gov Number: NCT01787084
Investigational Device Exemption (IDE) Number: G120291
CMS Approval Date: 02/07/2013
Study Title:  Medtronic CoreValve Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI)
Sponsor: Medtronic
ClinicalTrials.gov Number:  NCT01586910
Investigational Device Exemption (IDE) Number:  G120169
CMS Approval Date:  09/05/2012
Study Title: Medtronic CoreValve Expanded Use Study
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT01675440
Investigational Device Exemption (IDE) Number: G100012
CMS Approval Date: 09/11/2012
Study Title:  PARTNER II Trial (Placement of AoRTic TraNscathetER Valves Trial II)
Sponsor: Edwards Lifesciences
ClinicalTrials.gov Number:  NCT01314313
Investigational Device Exemption (IDE) Number:  G090216
CMS Approval Date: 05/01/2012
Study Title: Medtronic CoreValve U.S. Pivotal Trial
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT01240902
Investigational Device Exemption (IDE) Number:  G100012
CMS Approval Date: 05/01/2012
Study Title:  Medtronic CoreValve Continued Access Study
Sponsor: Medtronic
ClinicalTrials.gov Number: NCT01531374
Investigational Device Exemption (IDE) Number:  G100012
CMS Approval Date: 05/01/2012


Coding Ahead

Clinical Guidelines for Ultrasound in Pregnancy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location; and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

Policy/Criteria:

It is the policy of health plans affiliated with Centene Corporation that the following
ultrasounds during pregnancy are considered medically necessary when the following conditions are met,

I. Standard first trimester ultrasound (76801)
II. Standard second or third trimester ultrasound (76805)
III.Detailed anatomic ultrasound (76811)
IV. Transvaginal ultrasound (76817)
V. Not medically necessary conditions

I. One standard first trimester ultrasound (76801) is allowed per pregnancy.

Subsequent standard first trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.

II. One standard second or third trimester ultrasound (76805) is allowed per pregnancy.

Subsequent standard second or third trimester ultrasounds are considered not medically necessary as a limited or follow-up ultrasound assessment (76815 or 76816) should be sufficient to provide a re-examination of suspected concerns.

III.One detailed anatomic ultrasound (76811) is allowed per pregnancy when performed to evaluate for suspected anomaly based on history, laboratory abnormalities, or clinical evaluation; or when there are suspicious results from a limited or standard ultrasound.

Further indications include the possibility of fetal growth restriction and multifetal gestation. This ultrasound must be billed with an appropriate high risk diagnosis code. See below,

A second detailed anatomic ultrasound is considered medically necessary if a new maternal fetal medicine specialist group is taking over care, a second opinion is required, or the patient has been transferred to a tertiary care center in anticipation of delivery of an anomalous fetus requiring specialized neonatal care.

Further anatomic ultrasounds are considered not medically necessary as there is inadequate evidence of the clinical utility of multiple detailed fetal anatomic examinations.

IV. Transvaginal ultrasounds (TVU) are considered medically necessary when conducted in the first trimester for the same indications as a standard first trimester ultrasound, and later in pregnancy to assess cervical length, location of the placenta in women with placenta previa, or after an inconclusive transabdominal ultrasound. Cervical length screening is conducted for women with a history of preterm labor or to monitor a shortened cervix based on below information,

Up to 12 transvaginal ultrasounds are allowed per pregnancy.

Berghella approach to TVU measurement of cervical length for screening singleton gestations

Past pregnancy history

1. Prior preterm birth, 14 to 27 weeks
2. Prior preterm birth 28 to 36 weeks
3. No prior preterm birth

TVU cervical length screening 

1. Start at 14 weeks and end at 24 weeks
2. Start at 16 weeks and end at 24 weeks
3. One exam between 18 and 24 weeks

Frequency 

1. Every 2 weeks as long as cervix is at least 30 mm* 
2. Every 2 weeks as long as cervix is at least 30 mm*
3. Once

Maximum # of TVU

1. 6
2. 5
3. 1

* Increase frequency to weekly in women with TVU cervical length of 25 to 29 mm. If <25 mm before 24 weeks, consider cerclage.

V. 3D and 4D ultrasounds are considered investigational and are therefore not medically necessary. Studies lack sufficient evidence that they alter management over twodimensional ultrasound in a fashion that improves outcomes.

The following additional procedures are considered not medically necessary:
  • Ultrasounds performed solely to determine the sex of the fetus or to provide parents with photographs of the fetus;
  • Scans for growth evaluation performed less than 2 weeks apart;
  • Ultrasound to confirm pregnancy in the absence of other indications;
  • A follow-up ultrasound in the first trimester in the absence of pain or bleeding.

Classifications of fetal ultrasounds include:

I. Standard First Trimester Ultrasound – 76801:

A standard first trimester ultrasound is performed before 14 weeks and 0 days of gestation. It can be performed transabdominally, transvaginally, or transperineally. When performed transvaginally, CPT 76817 should be used. It includes an evaluation of the presence, size, location, and number of gestational sac(s); and an evaluation of the gestational sac(s).

Indications for a first trimester ultrasound include the following:

  •  To confirm an intrauterine pregnancy
  •  To evaluate a suspected ectopic pregnancy
  •  To evaluate vaginal bleeding
  •  To evaluate pelvic pain
  •  To estimate gestational age
  •  To diagnose and evaluate multiple gestations
  •  To confirm cardiac activity
  •  As adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine device
  •  To assess for certain fetal anomalies, such as anencephaly, in high risk patients
  •  To evaluate maternal pelvic or adnexal masses or uterine abnormalities
  •  To screen for fetal aneuploidy (nuchal translucency) when a part of aneuploidy screening
  •  To evaluate suspected hydatidiform mole

II. Standard Second or Third Trimester Ultrasound – 76805:

A standard ultrasound in the second or third trimester involves an evaluation of fetal presentation and number, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and an anatomic survey.

Indications for a standard second or third trimester ultrasound include the following:

  •  Screening for fetal anomalies
  •  Evaluation of fetal anatomy
  •  Estimation of gestational age
  •  Evaluation of fetal growth
  •  Evaluation of vaginal bleeding
  •  Evaluation of cervical insufficiency
  •  Evaluation of abdominal and pelvic pain
  •  Determination of fetal presentation
  •  Evaluation of suspected multiple gestation
  •  Adjunct to amniocentesis or other procedure
  •  Evaluation of discrepancy between uterine size and clinical dates
  •  Evaluation of pelvic mass
  •  Examination of suspected hydatidiform mole
  •  Adjunct to cervical cerclage placement
  •  Evaluation of suspected ectopic pregnancy
  •  Evaluation of suspected fetal death
  •  Evaluation of suspected uterine abnormality
  •  Evaluation of fetal well-being
  •  Evaluation of suspected amniotic fluid abnormalities
  •  Evaluation of suspected placental abruption
  •  Adjunct to external cephalic version
  •  Evaluation of prelabor rupture of membranes or premature labor
  •  Evaluation for abnormal biochemical markers
  •  Follow-up evaluation of a fetal anomaly
  •  Follow-up evaluation of placental location for suspected placenta previa
  •  Evaluation with a history of previous congenital anomaly
  •  Evaluation of fetal condition in late registrants for prenatal care
  •  Assessment for findings that may increase the risk of aneuploidy

III.Detailed Anatomic Ultrasound – 76811:

A detailed anatomic ultrasound is performed when there is an increased risk of an anomaly based on the history, laboratory abnormalities, or the results of the limited or standard ultrasound.

IV. Other Ultrasounds – 76817:

A transvaginal ultrasound of a pregnant uterus can be performed in the first trimester of pregnancy and later in a pregnancy to evaluate cervical length and the position of the placenta relative to the internal cervical os. When this exam is done in the first trimester, the same indications for a standard first trimester ultrasound, 76801.

High risk diagnosis code for Ultrasound:

B06.00 – B06.9 Rubella [German measles]
B50.0 – B54 Malaria
B97.6 Parvovirus as the cause of diseases classified elsewhere
E66.01 Morbid (severe) obesity due to excess calories [severe obesity with a BMI of 35 or >]
O09.511 – O09.519 Supervision of elderly primigravida
O09.521 – O09.529 Supervision of elderly multigravida
O09.811 – O09.819 Supervision of pregnancy resulting from assisted reproductive technology
O24.011 – O24.019, Diabetes mellitus in pregnancy
O24.111 – O24.119, Diabetes mellitus in pregnancy
O24.311 – O24.319, Diabetes mellitus in pregnancy
O24.811 – O24.819, Diabetes mellitus in pregnancy
O24.911 – O24.919 Diabetes mellitus in pregnancy
O30.001 – O30.099 Twin pregnancy
O30.101 – O30.199 Triplet pregnancy
O30.201 – O30.299 Quadruplet pregnancy
O30.801 – O30.899 Other specified multiple gestation
O31.10x+ – O31.23x+ Continuing pregnancy after spontaneous abortion / intrauterine death of one fetus or more
O33.6xx+ Maternal care for disproportion due to hydrocephalic fetus
O33.7xx+ Maternal care for disproportion due to other fetal deformities
O35.0xx+ Maternal care for (suspected) central nervous system malformation in fetus
O35.1xx+ Maternal care for (suspected) chromosomal abnormality in fetus
O35.2xx+ Maternal care for (suspected) hereditary disease in fetus
O35.3xx+ Maternal care for (suspected) damage to fetus from viral disease in mother
O35.4xx+ Maternal care for (suspected) damage to fetus from alcohol
O35.5xx+ Maternal care for (suspected) damage to fetus by drugs
O35.6xx+ Maternal care for (suspected) damage to fetus by radiation
O35.8xx+ Maternal care for other (suspected) fetal abnormality and damage
O35.9xx+ Maternal care for (suspected) fetal abnormality and damage, unspecified
O36.011+ – O36.099+ Maternal care for rhesus isoimmunization
O36.111+ – O36.199+ Maternal care for other isoimmunization
O36.511+ – O36.599+ Maternal care for other known or suspected poor fetal growth
O40.1xx+ – O40.9xx+ Polyhydramnios
O41.00x+ – O41.03x+ Oligohydramnios
O69.81x+ – O69.89x+ Labor and delivery complicated by other cord complications
O71.9 Obstetric trauma, unspecified
O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery
O98.311 – O98.319 Other maternal infectious and parasitic diseases complicating pregnancy
O98.411 – O98.419 Other maternal infectious and parasitic diseases complicating pregnancy
O98.511 – O98.519 Other maternal infectious and parasitic diseases complicating pregnancy
O98.611 – O98.619 Other maternal infectious and parasitic diseases complicating pregnancy
O98.711 – O98.719 Other maternal infectious and parasitic diseases complicating pregnancy
O98.811 – O98.819 Other maternal infectious and parasitic diseases complicating pregnancy
O99.320 – O99.323 Drug use complicating pregnancy
O99.411 – O99.419 Diseases of the circulatory system complicating pregnancy
Q04.8 Other specified congenital malformations of brain [choroid plexuscyst]
Q30.1 Agenesis and underdevelopment of nose [absent or hypoplastic nasalbone]
Q62.0 Congenital hydronephrosis [fetal pyelectasis]
Q71.811 – Q71.819 Congenital shortening of upper limb [humerus]
Q72.811 – Q72.819 Congenital shortening of lower limb [femur]
Q92.0 – Q92.9 Other trisomies and partial trisomies of the autosomes, not elsewhere classified [fetuses with soft sonographic markers of aneuploidy]
R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
R93.8 Abnormal findings on diagnostic imaging of other specified body structures
Z68.35 – Z68.45 Body mass index (BMI) 35.0 – 70 or greater, adult


Coding Ahead

Achieving Clinical Documentation Improvement

Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can maximize the integrity of the medical record?” Although the goal of CDI is always the same—to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receives—the means to achieve that goal are often specific […]

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AAPC Knowledge Center

Clinical Examples

The clinical examples that are provided in this supplement are limited to Office or Other Outpatient Services, Hospital Inpatient Services, Consultation and Critical Care services. These clinical examples do not encompass the entire scope of medical practice. Inclusion or exclusion of any particular specialty group does not infer any judgment of importance or lack thereof; nor does it limit the applicability of the example to any particular specialty.

Office / Outpatient Services

New patient

99201 Clinical Examples
99202 Clinical Examples
99203 Clinical Examples
99204 Clinical Examples
99205 Clinical Examples

Established patient

99211 Clinical Examples
99212 Clinical Examples
99213 Clinical Examples
99214 Clinical Examples
99215 Clinical Examples

Consults

99241 Clinical Examples
99242 Clinical Examples
99243 Clinical Examples
99244 Clinical Examples
99245 Clinical Examples

Hospital Inpatient Services

Initial Hospital Care

99221 Clinical Examples
99222 Clinical Examples
99223 Clinical Examples

Subsequent Hospital Care

99231 Clinical Examples
99232 Clinical Examples
99233 Clinical Examples

Consults

99251 Clinical Examples
99252 Clinical Examples
99253 Clinical Examples
99254 Clinical Examples
99255 Clinical Examples


Emergency Department Services

New or Established patient 


Critical Care Services



Coding Ahead

Clinical Examples for 99251


Initial hospital consultation for a 27-year-old female with fractured incisor post-intubation. (Oral & Maxillofacial Surgery)

Initial hospital consultation for an orthopaedic patient on IV antibiotics who has developed an apparent candida infection of the oral cavity .(Oral & Maxillofacial Surgery)

Initial inpatient consultation for a 30-year-old female complaining of vaginal itching, post orthopaedic surgery. (Obstetrics & Gynecology)

Initial inpatient consultation for a 36-year-old male on orthopaedic service with complaint of localized dental pain. (Oral & Maxillofacial Surgery)


Coding Ahead

Clinical Examples for 99252


Initial hospital consultation for a 45-year-old male, previously abstinent alcoholic, who relapsed and was admitted for management of gastritis, The patient readily accepts the need for further treatment. (Addiction Medicine)

Initial hospital consultation for a 35-year-old dialysis patient with episodic oral ulcerations. (Oral & Maxillofacial Surgery)

Initial preoperative consultation for a 43-year-old women with cholecystitis and well-controlled hypertension. (Cardiology)

Initial inpatient consultation for recommendation of antibiotic prophylaxis for a patient with a synthetic heart valve who will undergo urologic surgery. (Internal Medicine)

Initial inpatient consultation for possible drug induced skin eruption in 50-year-old male. (Dermatology)

Preoperative inpatient consultation for evaluation of hypertension in a60-year-old male will undergo a cholecystectomy. Patient had a normal annual check-up in your office four months ago. (Internal Medicine)

Initial inpatient consultation for 66-year-old patient with wrist and hand pain and finger numbness, secondary to carpal tunnel syndrome.(Orthopaedic Surgery/Plastic Surgery)

Initial inpatient consultation for a 66-year-old male smoker referred for pain management immediately status post-biliary tract surgery done via sub-costal incision. (Anesthesiology/Pain Medicine)    


Coding Ahead

Clinical Examples for 99253


Initial hospital consultation for 50-year-old female with incapacitating knee pain due to generalized rheumatoid arthritis. (Orthopeadic Surgery)

Initial hospital consultation for a 60-year-old male with avascular  necrosis of the left femoral heel with increasing pain. (Orthopaedic Surgery)

Initial hospital consultation for a 45-year-old female with compound mandibular fracture and concurrent head, abdominal, and/or orthopaedic injuries. (Oral & Maxillofacial)

Initial hospital consultation for a 22-year-old female, paraplegic, to evaluation wrist and hand pain. (Orthopaedic Surgery)

Initial hospital consultation for a 40-year-old male with 10-day history of incapacitating unilateral sciatica, unable to walk now, not improved by bed rest. (Neurosurgery)

Initial hospital consultation, requested by pediatrician, for treatment recommendations for a patient admitted with persistent inability to walk following soft tissue injury to ankle. (Physiatry)

Initial hospital consultation for a 27-year-old previously healthy male who vomited during IV sedation and may have aspirated gastric contents. (Anesthesiology)

Initial hospital consultation for a 33-year-old female, post-abdominal surgery, who now has a fever. (Internal Medicine)

Initial inpatient consultation for a 57-year-old male, post lower endoscopy, for evaluation of abdominal pain and fever. (General Surgery)

Initial inpatient consultation for rehabilitation of a 73-year-old female one week after management of a hip fracture. (Physical Medicine & Rehabilitation)

Initial inpatient consultation for diagnosis/management of fever following abdominal surgery. (Internal Medicine)

Initial inpatient consultation for a 35-year-old female with a fever and pulmonary infiltrate following cesarean section. (Pulmonary Medicine)

Initial inpatient consultation for a 42-year-old non-diabetic patient, postoperative cholecystectomy, now with an acute urinary tract infection. (Nephrology)

Initial inpatient consultation for 53-year-old female with moderate uncomplicated pancreatitis. (Gastroenterology)

Initial inpatient consultation for 45-year-old patient with chronic neck pain with radicular pain of the left arm. (Orthopaedic Surgery)

Initial inpatient consultation for 8-year-old patient with new onset of seizures who has a normal examination and previous history. (Neurology)


Coding Ahead

Clinical Examples for 99254


Initial in patient consultation for a 15-year-old patient with painless swelling of proximal humerus with lytic lesion by X-ray. (Orthopaedic Surgery)

Initial hospital consultation for evaluation of a 29-year-old female with a diffusely positive medical review of systems and history of multiple surgeries. (Psychiatry)

Initial hospital consultation for a 70-year-old diabetic female with gangrene of the foot. (Orthopaedic Surgery)

Initial inpatient consultation for a 47-year-old female with progressive pulmonary infiltrate, hypoxemia, and diminished urine output. (Anesthesiology)

Initial hospital consultation for a 13-month-old with spasmodic cough, respiratory distress, and fever. (Allergy & Immunology)

Initial consultation for a patient with failed total hip replacement with loosening and pain upon walking. (Orthopaedic Surgery)

Initial hospital consultation for a 62-year-old female with metastatic breast cancer to the femoral neck and thoracic vertebra. (Orthopaedic Surgery)

Initial hospital consultation for a 39-year-old female with nephrolithiasis requiring extensive opioid analgesics, whose vital signs are now elevated, She initially denied any drug use but today gives history of multiple substance abuse, including opioids and prior treatment for a personality disorder. (Psychiatry)

Initial hospital consultation for a 70-year-old female without previous psychiatric history, who is now experiencing nocturnal confusion and visual halluncinations following hip replacement surgery. (Psychiatry)

Initial inpatient consultation for evaluation of a 63-year-old in the ICU with diabetes and chronic renal failure who develops acute respiratory distress syndrome 36 hours after a mitral value replacement. (Anesthesiology)

Initial inpatient consultation for a 66-year-old female with enlarged supraclavicular lymph nodes, found on biopsy to be malignant. (Hematology/Oncology)

Initial inpatient consultation for a 43-year-old female for evaluation of sudden painful visual loss, optic neuritis, and episodic paresthesia. (Ophthalmology)

Initial inpatient consultation for evaluation of a 71-year-old male with hyponatremia (serum sodium 114) who was admitted to the hospital with pneumonia. (Nephrology)

Initial inpatient consultation for a 72-year-old male with emergency admission for possible bowel obstruction. (Internal Medicine/General Surgery)

Initial inpatient consultation for a 35-year-old female with fever, swollen joints, and rash of one-week duration. (Rheumatology)


Coding Ahead