Compare the visit note to the CMS-1500 to detect the CPT coding error(s) and supply the correct coding assignment. (The ICD-9-CM codes are provided for reference only.) Fill in the blank:

Compare the visit note to the CMS-1500 to detect the CPT coding error(s) and supply the correct coding assignment. (The ICD-9-CM codes are provided for reference only.)
Fill in the blank:

1. What is the government’s audit plan called? ______________________________

Instructions: Following are excerpts from three CMS-1500 billing forms. In each problem, compare the visit note to the CMS-1500 to detect the CPT coding error(s) and supply the correct coding assignment. (The ICD-9-CM codes are provided for reference only.)

2. CMS-1500 Question #1—Visit Note

CC—Eye pain

S—This new patient comes in with his right eye red and mattering for the last day. He wears contacts and has them in at this time. He has no sore throat, no stuffy nose, and no temperature, earaches, or coughing. He is currently on no medication and is not allergic to any medication. He also is concerned about a wart on his hand.

O—He is in no acute distress. Vital signs are normal. TMs look okay. Pharynx was good. Pupils equal, round, react to light and accommodation. No evidence of any iritis. Bulbar conjunctivae of the right eye is red. Some mattering is noted on the right side; left eye looks okay. Right hand shows a wart at the base of thumb.

A—Right eye conjunctivitis, wart on right hand

P—Liquid nitrogen was applied to the wart. Retreat in about seven to ten days, if necessary. Will treat the conjunctivitis by removing contacts and wearing only regular eyeglasses for at least one week. Started on Gentamycin Ophthalmic, one to two drops in the eye, four times a day, warm compresses to the eye. Be careful not to infect the left eye. Sterilize the contacts before putting them back into the eyes. He will return for retreatment of the wart or sooner if he has any further problem with his eye. He will schedule a baseline physical exam within the next month.

CMS-1500 #1:

21. Diagnosis or nature of illness or injury

1. 372.30 (Conjunctivitis) 3. ______

2. 078.10 (Wart) 4. ______

24 CPT/HCPCS Dx

99202
17340–25

1
2

Explanation & Answer

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