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Learning Goal: I’m working on a rocket science question and need guidance to help me learn.FIRST QUARTER
1. Emergency and Radiology Services
Gladys Swain slipped from a sidewalk curb and twisted her right ankle. Because of the severe
pain she was suffering and the inability to bear weight on the foot, she sought treatment at her
neighborhood hospital emergency department. The treating physicians were fairly confident that
Ms. Swain had an ankle injury. The physician completed a problem-focused history regarding
the injury and a problem-focused physical examination of her right foot and ankle. The MDM
complexity was straight-forward. The patient was immediately sent to the radiology department
for an x-ray. A two-view x-ray of the right ankle was completed. The radiologist confirmed a
simple non-displaced closed fracture of the medial malleolus. The patient then returned to the
emergency department, where the physician immobilized the ankle. The patient was referred to
an orthopedic surgeon. Code the emergency department service and the radiology service.
2. Evaluation and Management, Home Service
George White, an established patient of Dr. York, needed to be seen for his recent inguinal
hernia, which has been giving him problems for several days. Mr. White’s wife was also ill and
no one else was available to bring Mr. White to the physician’s office, so the physician decided
to visit Mr. White at home. After performing a problem-focused interval history and problemfocused physical examination, Dr. York concluded that Mr. White was improving but should
remain at home for the next 2 weeks. The MDM complexity was straightforward.
3. Emergency, Radiology, and Pathology/Laboratory Services
A 26-year-old female presented to the Emergency Department with complaint of severe
headaches of 16-hour duration. A detailed history and examination were performed. The MDM
was of moderate complexity. Following are the services that were provided:
Service Description CPT/HCPCS Code(s)
ED service Glucose, body fluid
Total protein (serum) Smear Gram stain
Fluid cell count/differential
Aerobic culture of lumbar fluid, bacteria Lumbar puncture
Fluoroguidance, spinal CT, brain w/o contrast Morphine,
10 mg Subcutaneous injection
The physician would bill the ED visit, spinal tap, and fluoroguidance with modifier -26. The
drug would be billed by the hospital as well as the CT scans and labsFirst Quarter
1. Emergency and Radiology Services (Fill in the missing information)
CPT Codes: (Evaluation and Management, Emergency Department ),
73600 (Radiology, Ankle)
ICD-10-Codes: S82.54 Fracture, traumatic, ankle, medial malleolus [displaced]),
(Fall, _____, _____, ____)
2. Evaluation and Management, Home Service
CPT Code: 99347
ICD-10-Code:
(_____)
(Hernia, inguinal)
(continued on back of page…)
3. Emergency, Radiology, and Pathology/Laboratory Services
Service Description CPT/HCPCS Code(s)
Emergency Department _____99284_________
Glucose, body fluid ___________________
Total protein (serum) ___________________
Smear Gram stain ___________________
Fluid cell count with differential _____ 89051________
Aerobic culture of lumbar fluid, bacteria ___________________
Lumbar puncture, diagnostic ___________________
Fluoroscopic, spine ______77003________
CT, brain without contrast ___________________
Morphine Sulfate, 10 mg __________(HCPCS Code)
Subcutaneous injection ___________________
The physician would bill the ED visit, spinal tap, and fluoroguidance with modifier -26. The drug would be
billed by the hospital as well as the CT scans and labs
Requirements: min