Medical coding cases with answers

Professional Coder Practicum Documentation

Medical coding is the conversion of medical diagnosis, equipment, procedures, and medical services into universal medical alphanumeric codes. The procedure and diagnoses codes are taken from medical record documentation such as laboratory, radiologic results, and transcription of doctor’s notes. Professional coder practicum make sure the codes are applied correctly during the medical billing process. In this paper four cases has been reviewed to see if there is any missing data in documentation that can be needed by coder. The first case is of a patient suffering from invasive ductal carcinoma (Nie, Liqiang, et al. 2015).

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The patient is suffering from invasive ductal carcinoma of the right breast. the patient is 57 years old female with an extensive surgical history involving her bilateral breasts including prior mastopexies as well as breast augmentation. The patient was brought to the preoperative area and was marked for an inferior pedicle wise pattern reduction. According to the coding summary provided by supervisor all the information such as reason for visit, primary diagnosis, secondary diagnosis, procedural details, cancer follow up information, pertinent laboratory tests, medical history, current medication list, and symptoms of disease is present for this case. All the information is present for coder and there is no missing data for this patient.

The second case is of a patient suffering from benign neoplasm of ascending colon.

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The patient had colonoscopy at 4/11/2014. Multiple resected polyps diagnosed as tubulovillous adenomas and tubular adenomas. Patient states that not all areas were resected and he is presenting for colonoscopy with endoscopy mucosal resection. The medical notes contain information about his evaluation and detailed medical history which include allergies, anesthetic complications, and cardiovascular history. The case also provide information about patient’s vitals, physical exam details, lab tests details, anesthesia assessment plan, home medications, current hospital medications, pathology consultation report, and procedural details. There is no missing information in this case. The doctor clearly diagnosed the disease and coding is always done on definitive diagnosis. There is information related to gene analysis which has not been assigned any code as per clinic policies.

The third case is of a patient suffering from epidermal cyst.

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The patient had the cyst at the site many years ago and recently she has noticed the scar has enlarged, become itchy and at times drains foul smelling material. The female patient is 49 years old and has no other medical condition. The medical notes contain the diagnosis, past medical history, past surgical history, medication details, family history, social history, anesthesia complication, physical exam details, assessment, plan, and detail of the procedure performed on patient. There was no occupational history available in the file. There were no lab tests mentioned in the file which can be used by coder while documentation.

The fourth and last case is of a patient suffering from dental abnormalities.

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The patient is 45 years old man who presents with profound development delay and autistic behavior. He is unable to tolerate necessary dental treatment while conscious. The decision was made to utilize general anesthesia for completion of all necessary dental treatment in one appointment. The medical report contained information regarding patient’s medical history, diet details, medication details, wound care instructions, follow up details, operation performed details, anesthesia complication, procedural details, and record of completed medication. Preoperative diagnosis, and postoperative diagnosis were missing in the case file.

Work Cited

Nie, Liqiang, et al. "Bridging the vocabulary gap between health seekers and healthcare knowledge." IEEE Transactions on Knowledge and Data Engineering 27.2 (2015): 396-409.

ducation for the Negro. Krill Press via PublishDrive, 2015.