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Zena Awtrey, a 58-year-old female, sees Dr. Lunden for the first time for a variety of medical
problems. She was diagnosed 5 years ago with insulin-dependent diabetes mellitus with
complicating eye and renal problems. In addition, she suffers from hypertensive heart disease
with episodes of congestive heart failure. Her peripheral vascular disease has worsened, and
she can walk only a block before being crippled with extreme leg pain. The patient reports that a
new problem has surfaced: throbbing headaches with radiating neck pain. Dr. Lunden and Zena
thoroughly discuss her health concerns and issues. In order to manage and investigate the
multiplicity of problems, Dr. Lunden takes a complete PFSH. A complete review of systems
(ROS) is performed and comprehensive physical exam is completed. Dr. Lunden has to take a
multitude of factors into consideration, as the patient’s problems are highly complex.
99205
Ira Morgan, a 16-month-old male, was brought to radiology for a real-time, limited, static
ultrasound of his hips.
76886
Dr. Harrington provided care plan oversight services for Verniece Dantini, one of her patients
at the Bracker Assisted Living Center. It took her 20 minutes.
99339
Dennis Lederrick, a 39-year-old male, had surgery on his left foot. To enable him to take a
shower safely, Dr. Willrodt gave him a tub stool to sit on.
E0245
Raymond Catertell, a 23-year-old male, is the son of two alcoholics. Dr. Lowen spends 40
minutes with him providing risk factor reduction behavior modification techniques to help
him avoid becoming an alcoholic himself.
99403
After Allen Jeter (previous case study) received his kidney transplant, the nurse gave him an
oral dose of 250 mg of CellCept (mycophenolate mofetil) in the hospital. Code the drug.
J7517
Brianna Haralson, a 24-year-old female, is brought into Dr. Duncan’s office with sharp pains
in her lower right abdomen, shooting across to the left side. Dr. Duncan ordered some blood
work and an MRA to confirm the suspected diagnosis of acute appendicitis. Code the MRA.
74185
Dr. Logan saw Jason Miolo, a 38-year-old male, with a swollen right eye and loss of vision.
Dr. Logan ordered a CT with contrast of the right eye and area, which revealed marked
, proptosis of the right orbit, thrombosis, and enlargement of the right superior ophthalmic
vein.
70481-RT
Shirley Loveichelle, an 82-year-old female, was having trouble eating for such a long period
of time that she was exhibiting signs of malnutrition. Therefore, Dr. Milliner ordered enteral
formula (Ensure) to be administered through a feeding tube at 500 calories per day. Code for
the nutritional supplement only.
B4150x5
Maxine Zeigleman, newly diagnosed with metastatic lumbar spinal tumors, has been referred
to Dr. Appleton for the creation of a simple radiation therapy plan.
77261
Daniel Hair, a 56-year-old male with end-stage renal disease (ESRD), was fitted for a
reciprocating peritoneal dialysis system. Code the supply of the equipment.
E1630
Carl Gadsden, a 66-year-old male, was diagnosed with intrinsic laryngeal cancer, supraglottic
T1 tumor. With the tumor confined to one subsite in the supraglottis, Dr. Yoshihashi provided
radiation treatment delivery, with a single port, simple block, of 4.5 MeV.
77402
Sandra Lewis, a 55-year-old female, has been experiencing pain in her lower left back that
wraps around to her inner thigh. Dr. Janson does a renal ultrasound, limited, real time with
image documentation.
76775
Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated around
her trunk. She was also suffering with spastic muscle weakness. Dr. Maxwell ordered a
radioisotope bone scan of Jonelle’s lumbar spinal area. The scan identified a metastatic
invasion of L1–L3.
78300
Jonelle Graybar, a 73-year-old female, was experiencing pain in her back that radiated around
her trunk. She was also suffering with spastic muscle weakness. Dr. Maxwell ordered a
radioisotope bone scan of Jonelle’s lumbar spinal area. The scan identified a metastatic
invasion of L1–L3.
E0160
Johnette Potash, a 13-year-old female, lost her retainer at camp. She is at Dr. Rivera’s office
to get a replacement.
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