Abstracting Documentation for Beginning Coders Case Studies

1. Decide which coding system you would use for each diagnosis and procedure/service that you have abstracted or found in your documentation.

2. Use the proper code book as you look up the code for each diagnosis or procedure/service and find the guidelines and instructions you will need to follow.

3. Use the coding steps provided for ICD 10 CM and CPT and the additional coding steps provided for ICD 10 PCS to find the codes you will need to completely code your documentation in the appropriate code book.

4. You may use your 3M or Clintegrity encoder for references, coding clinics, and double checking your coding.

Case Scenarios

1. The physician documented that during a routine office visit for removal of skin tags with a 40-year-old male patient. An additional lesion was noted on his back that was suspicious for cancer. They physician excised the lesion measuring .5cm in the office to have it biopsied. A simple closure was done. The patient also had 3 skin tags removed from his neck by excision during the office visit.

2. A patient came to the ER and was diagnosed with acute appendicitis with a small perforation and abscess. He was admitted as an inpatient to the hospital for an emergent open appendectomy.

3. The patient came into the ER with slurred speech. An MRI with no contrast was done and a TIA was discovered. In addition, the patient was diagnosed with hypertension and hyperlipidemia based on the results of lab work done in the ER. The physician in the ER did a detailed history, a detailed examination, and a medical decision making of moderate complexity. Do not code or identify the lab work in your response.

4. A patient was sent from the physician office to a direct admit to the hospital for acute abdominal pain and nausea and vomiting that was severe. The hospital physician ordered labs and blood work and discovered the patient had gallstones along with acute pancreatitis. Further testing revealed acute cholelithiasis along with cholecystitis. The patient was taken to the operating room for a laparoscopic cholecystectomy, intraoperative cholangiography with fluoroscopy, low osmolar contrast. Make sure you read guidelines on when to code signs and symptoms and when not to.

5. A morbidly obese patient with a BMI of 48.2 had a gastric bypass surgery at an Ambulatory Surgical Center. Prior to the surgery (at the same time and place), an EGD was performed and the patient was discovered to have a growth on the larynx. A hot biopsy forceps was used during the EGD to remove and biopsy the growth.