MEDICAL INSURANCE CODING AND BILLING PROJECT

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CASE STUDY 2-7

Fp?o9d?rMstFe?t`?’A¥:,h€rt:Nt:2345. (ioi) 111.2222 Case study Npl: 3345678901

PROVIDER(S): HENRY C. CARDIAC, M.D. EIN. 22-1234567 Npl: 3456789012

PATIENT INFORMATION: Name:

Address:

City.

Sfate:

Zip Code:

Telephone:

Gender:

Date of Birth:

Occupation:

Employer:

Spouse’s Employer.

Esau Gonzales

14 Ridley St

Nc>where

NY

12346-1234

(101) 111-7689

Male

09-10-1933

Retired

INSURANCE INFORMATION: Patient Number. 2 -7

Place of service: Office

Primary Insurance plan: Medicare

Pnmaryln§uranceplanlD#. 101234591A

Group #.

Primary policyholder. Sel f

Po!icyholder Date of Birth`

Relationship to Patient:

Secondary Insurance Plan:

Seconclary Insurance Plan lD #:

Secondary Policyholder:

Patientstatus I Married I Divorced ill single

DIAGNOSIS INFORMATION

5.

6

7.

8.

I student I other

Diagnosis

PROCEDURE INFORMATION Description of Procedure or Service

1. office visit, level IV 2 EKG, routine with interpretation 3.

4.

5.

6.

SPECIAL NOTES:

Diagnosis

Date 06-20-¥¥¥¥

0 6 -2 0 -Y¥¥Y

Code

Code Charge loo . 00

65 . 00

 

 

GOODMEDICINE CLINIC 1 Provider Street . Anywhere, NY 12345 . (101) 111-2222

PROVIDER: HENRY C. CARDIAC, M.D.

Patient Record

GONZALES, ESAU

OFFICE VISIT 06/20/YYYY

S: Elderly African American male returns, after a two-year hiatus, for follow-up of coronary artery disease and associated problems. Since triple coronary bypass surgery four years ago, he has had no chest discomfort. It should be noted that he had no chest discomfort during a markedly abnormal stress test performed just two weeks before the bypass surgery. He now reports intermittent dyspnea that occurs at rest and spontaneously abates. He does not notice any discomfort c)n exertion, but he does report that his lifestyle is sedentary. He denies orthopnea, paroxysmal nocturnal dyspnea, .or edema. He has continued to follow up with his internist, Dr. Gooddoc, for treatment of his dyslipidemia and hypertension. He is on Cholestin and Tenormin.

0: Patient is a mildly obese, African American male appearing his stated age, in no acute distress. Weight is 210. Height is 5’8″. Pulse 16. BP 162/82, 172/82, and then 188/82 in the office. HEENT grossly unremarkable. Neck reveals normal jugular venous pressure, without hepatojugular reflux. Normal carotid pulses; no bruits present. Lungs are clear to A&P. Heart reveals regular rhythm, Sl and S2 are normal. There is no murmur, rub, click, or gallop. Cardiac apex is not palpable. No heaves or thrills are detected. Abdomen is soft, nontender, with normal bowel sounds, and no bruits. No organomegaly, including abdominal aorta, or masses noted. Extremities reveal a surgical scar in the right leg, presumably from saphenous venectomy. Femoral pulses are normal, without bruits. Dorsalis pedis and posteric)r tibial pulses are also normal. There is no cyanosis, clubbing, or edema. Neurological is grossly within normal limits.

A: 1. Dyspnea.

2. Hypertension. 3. Hypercholesterolemia. 4. Status post aortocoronary bypass surgery four years ago.

Per ERG, an inferior myocardial infarction may have occurred sometime in the past. There is independent suggestion of this on stress-thallium test performed six months ago. Additionally, he still has symptoms of dyspnea .

P: 1. Patient was instructed to follow-up with Dr. Gooddoc for hypertension and dyslipidemia.

2. Schedule treadmill stress test for next week.

J/eape.eaha,M.3>. Henry C. Cardiac, M.D.