Audit Report 4.2 Laboratory Workup
A patient with acquired hemolytic anemia reports to the lab for the following blood work:
Ferritin:
Iron:
Hemoglobin:
One of the following codes was incorrectly reported for this case. Indicate the incorrect code
PROFESSIONAL SERVICES Ferritin, 82728; Iron, 83540; Hemoglobin, 83051
ICD-10-CM DX; Anemia, D59.9
INCORRECT CODE:
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Audit the coding for the following reports.Audit Report 4.1 Laboratory WorkupA65-year-old female with ESRD, hypertension, diabetes mellitus type 2 ad atrial fibrillation on Coumadin presents to the lab for the followingComprehensive metabolic panel:Magnesium: Prothrombin time (PT):UA (Automated with microscope)One or more of the following codes are reported incorrectly for this case, Indicate the incorrect code or codesPROFESSIONAL SERVICES: Creatinine. B2565. Urinalysis. 81003. Comprehensive metabolic canal, 80053. Magnesium, 83735. Prothrombin time, 85610.ICD-10-CM DX: Hypertensive kidney disease, I12.0; End-stage renal disease, N18.6; Diabetes,...
One of the following codes was incorrectly reported for this case. Indicate the incorrect code. PROFESSIONAL SERVICES: Ferritin, 82728; Iron, 83540; Hemoglobin, 83051 ICD-10-CM DX: Anemia, D59.9 What is the INCORRECT CODE:
Audit Report 4.6 Transfusion MedicineOne or more of the following codes are reported incorrectly his case. Indicate the incorrect code or codes.Delores, a laboratory technician, preforms splitting of blood products, 1 unit. SERVICE CODES: Irradiation of blood products, 869452. Jessica, a laboratory technician, preforms screening of RBC antibodies, serum techniqueSERVICE CODES: RBC antibody identification, 86870INCORRECT/MISSING CODE(S):
Audit Report 5.1 Operative Report, BiopsyLOCATION: Inpatient, Hospital PATIENT: Arvid ComerSURGEON: Mohamad Almaz, MDATTENDING PHYSICIAN: Mohomad Almaz, MDPREOPERATIVE DIAGNOSIS: Cellulitis of the right hip AISTOPERATIVE DIAGNOSIS: Cellulitisof the right hip OPERATIVE PROCEDURE. Biopsy of the right hip cellulitisANESTHESIA: 1% XylocaineINDICATIONS FOR PROCEDURE: The patient is a 73-year-old Caucasian male who is critically ill. The patient has developed cellulitis of his right tip, and a biopsy was needed for diagnostic purposes for culture.DESCRIPTION OF PROCEDURE The patient was prepped with Betadine volution. One percent...
Audit Report 4.4 ImmunohematologyOne or more of the following codes are reported incorrectly for this case. Indicate the incorrect code or codes86156 Cold agglutinin, titer86277 Growth hormone, human, antibody86480 Tuberculosis, intradermal86592 Syphilis test: quantitativeINCORRECT/MISSING CODE(S):
Audit Report 4.5 Body FluidsOne or more of the following codes are reported inconcty this case. Indicate the incorrect code or codes84160 Protein, serum total82547 Glucose89300 Semen Analysis, Complete85004 Cell Count w/DiffINCORRECT/MISSING CODE(S)
please provide ICD-10-CM codes A 30-year-old woman is admitted directly from her hematologist-oncologist's office after a follow-up visit concerning drastically reduced blood counts as reported on recent laboratory tests. After workup, the attending physician diagnosed acquired aplastic anemia. The physi. cian also refers to her aplastic anemia as "pancytopenia with hypocellular bone marrow." The! patient has been undergoing aggressive cytotoxic chemotherapy for left ovarian carcinoma. No chemotherapy was administered during this visit. The patient was discharged and scheduled to report...
Audit Report 5.4 Operative Report, DebridementLOCATION: Inpatient, Hespital PATIENT: Arnie HolmesPREOPERATIVE DIAGNOSIS: Right heel ulcerPOSTOPERATIVE DIAGNOSIS Right heel ulcer with Staphylococcus aureus infectionSURGEON: Gary Sanchez, MDPROCEDURE PERFORMED: Debridement of right heel ulcer down to the boneINDICATIONS FOR THIS PROCEDURE: Mr. Holmes is a 58-year-old male who has a large heel ulcer, measuring at least 7 cm x 3.5 cm in a curvilinear ovoid shape. This needs to be sharply debrided. There is a lot of necrotic tissue here. We need to...
Audit Report 5.3 Operative Report, Carcinoma Lower LipLOCATION: Inpatient, HospitalPATIENT: Lary MontiffSURGEON: Mark Erickson, MDPREOPERATIVE DIAGNOSES:1. Squamous cell carcinoma, left lower lip 2. Submental and submandibular area massPOSTOPERATIVE DIAGNOSES: SamePROCEDURE PERFORMEDExcision of squamous cell carcinoma in skin of the left lower lip, 3.25 cm 2. Suprahyoid neck dissection 3. Bilateral advancement tap closure of surgical defect, 16 square cmANESTHESIA: Local with IV sedationESTIMATED BLOOD LOSS: Less than 25 ccsINDICATIONS: A 70-year-old male with a mass on the submental and submandibular areas....
Audit Report 5.5 Operative Report Malignant MelanomaLOCATION: Outpatient HospitalPATIENT: Jane LoveSURGEON: Gary Sanchez MDPREOPERATIVE DIAGNOSIS: Large lipoma of the lower abdomen POSTOPERATIVE DIAGNOSIS: Malignant neurona, lower abdomenPROCEDURE PERFORMED: Radical excision of large nest of the abdomen, which measured 9 cm x 12 cmANESTHESIA: General anesthesiaINDICATION: The patient has a mass in the lower back. This is becoming quite bothersome to her. We docussed treatment options of observation versus surgical excision. She wishes to have this excised. We discussed the procedure as...