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AAPC Exam CPC Topic 1 Question 20 Discussion

Actual exam question for AAPC's Certified Professional Coder (CPC) Exam exam
Question #: 20
Topic #: 1
[All Certified Professional Coder (CPC) Exam Questions]

View MR 099405

MR 099405

CC: Shortness of breath

HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.

Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.

ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.

PMH: Asthma

SH: Lives with both parents.

FH: Family hx of asthma, paternal side

ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child's family and no changes reported.

PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.

Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva

Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.

Lymph nodes: normal.

Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.

Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.

GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly

Skin: normal warm and dry. Pink well perfused

Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.

Assessment: Asthma, acute exacerbation

Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.

What E/M code is reported?

Show Suggested Answer Hide Answer
Suggested Answer: B

by Roosevelt at Apr 14, 2024, 01:45 PM

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Annmarie
8 days ago
Hold on, did anyone else notice the 'observation status' part? That might be a clue that 99222 is the correct code, as it's for initial hospital care under observation or inpatient status.
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Antonette
10 days ago
Yeah, I think you're on the right track. The key difference between 99284 and 99285 is the complexity of the medical decision-making. Based on the information provided, I'd say this is a moderately complex case, so 99284 might be the better choice.
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Jin
11 days ago
Hmm, I'm leaning towards either 99284 or 99285. Those codes are for emergency department visits, and the patient's acuity and level of care seem to fit those criteria. The 99221 and 99222 codes are for initial hospital admissions, which doesn't seem to be the case here.
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Penney
12 days ago
Okay, let's go through this step-by-step. The patient is a 16-year-old female with a history of asthma, presenting to the ED with shortness of breath, coughing, and chest pain. She's currently on Advair, which is not working, and has been using Albuterol more frequently. The physician has admitted her to observation status, which suggests a higher level of care.
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Joye
14 days ago
I agree, this is a straightforward question, but it's still important to get it right. Let's review the options carefully and discuss the rationale for each one.
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Elliott
16 days ago
This question is testing our knowledge of E/M coding, which is essential for accurately billing and getting reimbursed for the services we provide. The patient's presentation with an acute asthma exacerbation and the fact that she was admitted to observation status are key factors in determining the appropriate code.
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