Medical Auditing Training: CPMA®: Practical Application Workbook

2019
Medical Auditing Training: CPMA®

Practical Application Workbook
Disclaimer
This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information
within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable
guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of
information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This
guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations.
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CPT® is a registered trademark of the American Medical Association.
Clinical Examples Used in this Book

AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees.
All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure
notes donated by AAPC members.
To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the
stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or
to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.
© 2018 AAPC
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Updated 10312018. All rights reserved.
ISBN 978-1-626886-841
CPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.
ii 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter
7
Case 1
Psychiatry
Re: Jeffrey P. Cook Date of Service: January 5, 20XX
MR # 700-1
Past psych history: 1x past psychiatric admission in 8/20XX, past psychiatric medications - Celexa, no drug rehab. Has been in AA.
Hypertension
Digestive Problems
Depression
Anxiety
Tobacco Use
Smoking
Status: current smoker
Patient is: Thinking about quitting
Usage per day: 0.5 packs
Type: cigarettes
Smoking cessation packet: previously given
Age started: 20
How often does the patient smoke: every day
Patient is a: moderate tobacco smoker (10-19 cigarettes per day)
Psychiatric:
Suicidal thoughts -Pt admits to suicidal ideation, but no plan and does not believe he is a danger to himself at the moment. He has
been requested to go to St. Mary’s should he feel like hurting himself. Other concerns- none.
Session Note – Follow-up Exam:

Patient’s Report- This patient was present and on time for this appointment. States “Not too good”. Today patient is distraught,
sad, tearful, staring into space, complains of memory lapse, forgetfulness even losing his way on his journey down here today.
Patient gives himself a 2 on a scale of 10 for wellbeing. That is the most distressed that I have seen him. He continues to hear
voices that he finds hard to distinguish.
Behavioral Observation- Mental Status is alert, engaged, talkative, but sad and pensive.
Intervention Used- CBT, Solution-Focuses, Supportive.
Focus of Session- Pt volunteers that his job has terminated so he believes he has lost his insurance. I suggested that if he has to choose
his treatment modalities based on the cost factor, the one relationship he cannot jeopardize is that with Dr. G since medications are
essential for him to be able to function. He complains that he and his wife are struggling because he does not feel well enough to
engage with her and the family. He states, “I keep apologizing but I just can’t function in any relationship”. He takes his medication
when he remembers; He has forgotten on occasion. He had a Social Security hearing but not all data was available. We are inquiring
about sending Dr. G’s records. Dr. C’s and mine have been sent. His case will be continued for 3 more months. When I asked about
his children, he cried pretty intently and the source of his tears is the remorse that he feels because he is not fulfilling his role as a
father as he believes he should. They are financially surviving. They are working on credit rating to acquire a better home. When
asked about a miracle he would like to see occur in his home, his wish was that his health be restored so that he could contribute to
the family as he believes he ought. He wants life to get back to normal.6
CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 163
Chapter 7
Assessment of Progress: Patient Response- Pt. is distraught and sad today and doesn’t feel well.
Plan Continue counseling.
Start time: 11:05 AM
End Time: 12:01 PM
1. Schizoaffective disorder, unspecified

2. Suicidal ideations
3. Depression
Rule out dependency personality traits.
Clinical Notes: Continue counseling
Electronically signed by Kevin Cooper, LPC on 01/05/20XX at 1422
Psychiatry Coding Fee Ticket
Patient Name Jeffrey P. Cook

Medical Record Number/Account Number 700-1
Provider Kevin Cooper, LPC
Insurance Company United Behavioral Health
Comments
Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
1/5/20XX AAPC Physician 11 90834 F25.9 1 $200.00
Group F17.209
Total $200.00
1. The documentation supports what CPT® code(s)?
A. 90791
B. 90832
C. 90832, 90785
D. 90837
2. What discrepancies have been identified?
A. The procedure code is reported incorrectly and billed under the wrong provider.
B. The diagnosis code is reported incorrectly.
C. The procedure and diagnosis codes are reported incorrectly.
D. The procedure code and diagnosis code are reported incorrectly and billed under the wrong provider.
164 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 7
Case 2
Psychiatry
Re: Matthew W. Sullivan Date of Service: January 6, 20XX
MR # 700-2
Tobacco Use:
Smoking
Status: never smoked
Smokeless Tobacco
Current user: No
Former user: No
Drugs/Alcohol:
Drugs
Use: never used drugs
Allergies: Penicillin
Psychiatric:
Schizoaffective disorder

Patient’s Report: This patient was present and on time for this appointment. “Ok, I’m overwhelmed with stuff and I’m not happy
with where I am at.” Has felt locked in and down in the dumps. He made the observation that every year this time he ends up
struggling emotionally. He attributes this to his work which he finds boring. As an IT specialist, he anticipates a huge update. The
patient feels inadequately prepared to lead the update and doesn’t have the energy to study to learn how the process works.
Behavioral Observation: Mental Status: Focused alert, engaged, talkative.
Intervention Used: CBT, Solution-Focuses, Supportive.
Focus of Session: Pt. characterizes himself as a round peg in a square hole at work. He was a lot happier at his old job which
was taken from him. It involved much more hands on, which is his preference. Computer work is not his first love. He also feels
locked into his job because he is 4 yrs from retirement and cannot find another job that could match what he makes now. He is
responsible, through his job, to provide insurance for his wife and kids. I have suggested that medication is not the fix but that if
he is locked into his present job that he will have to accept that it is what it is. He will have to find his energy and inspiration from
outside his work, which would be his hobbies, love for camping, and his relationship with his wife and children. Pt’s daughter
recently moved out and he and his wife have the house to themselves. References were made to his dependency needs and
knowing when to reach down and pull himself up by his own boot straps.
Assessment of Progress/Patient Response: Patient’s affect is flat and emotionally down.
Plan: Continue counseling
Start Time 9:30 AM
End Time 10:21 AM
1. Major depressive disorder, recurrent episode, in partial or unspecified remission
2. Generalized anxiety disorder
3. ADHD (attention deficit disorder with hyperactivity)
Rule out dependent personality trait 3 Weeks
Chapter 7
Patient Name Matthew W. Sullivan

Comments

Group F41.9
F91.8
Total $200.00
1. The documentation supports what CPT® code?
A. 90791
B. 90837
C. 90834
D. 90836
A. No discrepancies, CPT® and diagnosis codes are reported correctly on the fee ticket.
B. Date of service and place of service are incorrect.
C. Services billed under the wrong provider.
D. The diagnosis codes are reported incorrectly.
Chapter 7
Case 3
Psychiatry
Re: Ryan P. Andrews Date of Service: January 7, 20XX
MR # 700-1
Tobacco Use:
Smoking
Status: former smoker
How long has it been since the patient last smoked? 1-3 months
Type: cigarettes
Smokeless Tobacco
Current user: Yes
Usage per day: less than 1 can or pouch
Age started: 15
Patient is: ready to quit
Drugs/Alcohol:
Drugs
Use: None
Type: N/A
Time since patient last used: N/A
Alcohol Screen
Did you have a drink containing alcohol in the past year? Yes
How often did you have 6 or more drinks on one occasion in the past year? Four or more times a week (4 points)
How many drinks did you have on a typical day when you were drinking in the past year? 5 or 6 drinks (2 points)
How often did you have a drink containing alcohol in the past year? Weekly (3 points)
Points 9
Interpretation Positive
Psychiatric:
Suicidal thoughts no. Other concerns none.
Session Note – Follow-up Exam

Patient’s Report This patient was present and on time for this appointment., “Pretty good” Pt. gives himself a 7/8 on the 10 scale.
Pt. Says, “I’m doing good and living life.” Patient spends his weekends enjoying his friends and family. Spent the last weekend
on the river and this weekend going with his favorite cousin to south MO to visit his uncle. Overall pt. says he feels better about
himself and is taking time now to focus on doing what he enjoys and making himself happy rather than worrying about what
others think and want.
Behavioral Observation/Mental Status: Alert, engaged, talkative, focused.
Intervention Used: CBT, Solution-Focused, Supportive.
Focus of Session: A major issue for patient has been his use and abuse of alcohol which he has used excessively as he has tried to
deal with the sudden death of his wife three years ago on June 3rd. He indicates he has continued to use alcohol but had reduced
his consumption. He has been warned that his addictive tendencies make control drinking an impossibility in most cases. Spent
Easter with his family. He is more open today about dealing with the death of his wife. He still has not discarded some of her
Chapter 7
things although he did sell her Jeep at the beginning of this year. His wife’s grandpa died a month ago and being with her family
brought a lot of things back. He has not been dating anyone in particular. “I’m just trying to be now.”
Assessment of Progress/Patient Response Mood and affect are stable.
Plan Continue counseling.
Start Time 8:02 AM.
End Time 8:59 AM.
1. Alcohol dependence
2. Major depression in partial remission
Clinical Notes: Continue Counseling.
Patient Name Ryan P. Andrews

Comments

Group F33.41
Z87.891
Total $200.00
A. 90791
B. 90832
C. 90832, 90785
D. 90837
2. What discrepancy has been identified?
A. The ICD-10-CM code F10.10 is for alcohol abuse and it should be for alcohol dependence F10.20.
B. A code for drug dependence should also be reported.
C. The CPT® code is not correct.
D. No discrepancies, the CPT® and diagnoses codes are reported correctly.
Chapter 7
Case 4
Psychiatry
Re: Clinton T. Lewis Date of Service: January 13, 20XX
MR # 700-4
1. Wife will attend.
History
Pneumothorax (past)
Lisinopril: swelling/trouble breathing: Allergy
Tobacco Use:
Smoking
How long has it been since the patient stopped smoking: 2 years
Smokeless Tobacco
Current user: no
Former user: yes
How long has it been since the patient used tobacco: > 10 years
Drugs/Alcohol:
Drugs
Use: never used drugs
Alcohol Screen
Did you have a drink containing alcohol in the past year? Yes
How often did you have 6 or more drinks on one occasion in the past year? Four or more times a week (4 points)
How many drinks did you have on a typical day when you were drinking in the past year? 7 to 9 drinks (3 points)
How often did you have a drink containing alcohol in the past year? Daily or almost daily (4 points)
Points 11
Interpretation Positive
Audit C Questions 4-10

How often during the last year have you found that you were not able to stop drinking once you had started? Weekly (3
points)
How often during the last year have you failed to do what was normally expected of you because of drinking? Weekly (3
points)
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking
session?
Never (0 points)
How often during the last year have you had a feeling of guilt or remorse after drinking? Monthly (2 points)
How often during the last year have you been unable to remember what happened the night before because of your
drinking?
Monthly (2 points)
Have you or someone else been injured because of your drinking? Yes, during the last year (4 points)
Chapter 7
Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut
down? Yes, during the last year (4 points)
Total Points: 18
Psychiatric:
Session Note - Follow Up Exam:

Patient’s Report This patient was present and on time for this appointment, “Pretty good.” Pt is here for his second visit. He was
accompanied by his wife whom I requested be present for this visit since it was her wish that he be seen originally. Reviewed notes
from last visit with patient to confirm its accuracy. Pt. was uncomfortable with my indicating black outs and denies depression
but takes the SSRI Lexapro for anxiety which was prescribed after his past Cardiac issues.
Behavioral Observation/Mental Status: Alert, engaged, talkative, focused, good mental status.Intervention Used: CBT,
Solution-Focused, Supportive.
Focus of Session: Patient is still adamant that he wants to control drink and has put in place accountability measures to help
him do that. Believes he has reduced his consumption from a fourth to a half. His wife is involved in setting up these measures
and holding him accountable. I reiterated the fact that the disease is progressive and that in time he may get back to his abusive
drinking. He does not deny the diagnosis of addiction. Admits to feeling better with his reduced consumption. Patient gave
marriage a 5 on the 10 scale and his wife gave the relationship a 6/7. Her unmet needs include spending more time together,
reduced alcohol intake, better communications. She is a psychiatric nurse. She is familiar with the diagnosis and its ramifications
on her husband’s health and on their marriage. Because his work is in a high-risk job, I warned him that there may come a time
when his work needs to be notified. Pts youngest son is in treatment for Heroin addiction. PT. will check back in 6 weeks.
Assessment of Progress/Patient Response: Patient’s mood and affect are stable.
Plan: Continue counseling.
Start Time 8:12.
End Time 9:10.
1. Alcohol dependence with withdrawal
Clinical Notes: Continue Counseling.
Patient Name Clinton T. Lewis

Comments
Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
Group Z87.891
Total $250.00
Chapter 7
A. 90847
B. 90832
C. 90832, 90785
D. 90837
A. Documentation has a discrepancy for the smoking.
B. CPT® code is incorrect
C. ICD-10-CM code F17.200 should be reported.
D. The procedure code and diagnosis code are reported under the wrong provider.
3. What is another error noted in performing the audit for Case 4?
A. Date of service discrepancy.
B. The provider did not sign and date the note.
C. Time was not documented in the medical record as required.
D. Place of service is incorrect.
Chapter 7
Case 5
Psychiatry
Re: Mario Flores Date of Service: January 25, 20XX
MR # 700-5
Recent discontinuation of testosterone, hypogonadism related to bodybuilding supplements, heart murmur, hypertension, sleep
apnea, knee surgery x2 (all by report)
Tobacco Use:
Smoking
Smokeless Tobacco
Current user: None
Usage per day: N/A
Age started: N/A
Patient is: N/A
Psychiatric:
Session Note - Follow-up Exam:

Patient’s Report: Patient was present and on time for his appointment, “Pretty good”.
Behavioral Observation/Mental Status: Depressed, blunted affect, fleeting eye contact, increased psychomotor; guarded; nega-
tive for suicidal/homicidal ideation; judgment fair and insight partial.
Intervention Used: Solution-Focused, Supportive.
Focus of Session: Patient had to get it resolved that he could go on to school property in order to take his son to school, go to
teachers’ meetings, and so forth. He was restricted from coming on to the property when they fired him even though he had a
letter from a psychiatrist saying he was no danger to himself or others. He can now go on to the property. He has been looking
for work and has had no luck. He feels ‘bad’ (ashamed) that he is living with his parents. He is getting very low on money and he
worries about money. He has done better about detaching from his ex until he explored that relationship in here today. He does
not understand the power she has over him. The counselor suggested that he is addicted to her despite the toxic nature of it all.
Focusing on self and self-esteem work. He is sleeping more again but still going to the gym. Processing, Venting. He was listened
to and had feelings validated.
Assessment of Progress/Patient Response: The Positive Value of Negative Feelings and Managing Our Emotions sent home to read
and then give feedback to this counselor. He is depressed. His depression lifted from a 4, on a 1-10 scale with 10 being highest/best
mood, to a 6 in one week. He will be gainfully employed. Will revisit progress and address any new developments next session.
Plan: Continue counseling, See in 1 week.
Start Time: 02:02 PM
End Time: 02:58 PM
1. Major depressive disorder, recurrent severe without psychotic features

2. Anxiety state, unspecified
3. Amphetamine and other psychostimulant dependence, episodic
4. Amphetamine or related acting sympathomimetic abuse, continuous use
Financial, occupational problems, primary support GAF65.
Clinical Notes: Individual Therapy.
Chapter 7
Counseling:
Tobacco use:
Patient counseled on the dangers of tobacco use and urged to quit.
Electronically signed by Kevin Cooper, LPC on 01/25/20XX at 15:15
Patient Name Mario Flores

Comments

Group F41.9
F15.20
F15.10
Total $200.00
1. The documentation supports what CPT® code?
A. 90791
B. 90834
C. 90832
D. 90837
2. W hich of the following needs to be addressed?
A. No discrepancies, CPT® and ICD-10-CM codes are reported correctly.
C. Provider’s signature is missing.
D. The procedure and diagnosis codes are reported incorrectly
Chapter 7
Case 6
Psychiatry
Re: Carla D. Hall Date of Service: January 26, 20XX
MR # 700-6
Folic acid deficiency
Thyroid disease
Psychiatric:

Patient’s Report: Patient and husband were present and on time for this appointment. She complained of being tired and her
eyes hurting.
Behavioral Observation/Mental Status: Depressed, flat affect, very poor eye contact; probably histrionic, guarded; negative for
suicidal/homicidal ideation; judgment fair and insight partial.Intervention Used: Supportive.
Focus Of Session: Patient was guarded and not volunteering information to the counselor. She did answer questions. She has been
doing her art, some journaling, some exercise. Her eyes are hurting and there may be an issue with a psychotropic medication. “I
don’t want to change medicine.” She was encouraged to do what is best for her despite how she might feel about it. She really was
not engaged in the counseling session and said after she first sat down that she wanted to go home. Supportive counseling.
Assessment of Progress/Patient Response: Guarded. Patient will engage in her counselling session next visit. Suicidal thoughts
will be eliminated 100% one day at a time. Will revisit progress and address any new developments next session.
Plan: Continue counseling. See in 1 week.
Start Time: 04:00 PM
End Time: 04:40 PM
1. Depressed
Problems related to the social environment GAF51.
Electronically signed by Kevin Cooper, LPC on 01/26/20XX at 19:47
Patient Name Carla D. Hall

Comments

Group
Total $200.00
Chapter 7
A. 90791
B. 90832
C. 90839
D. 90834
A. No discrepancy, CPT® and ICD-10-CM codes are correct.
C. The CPT® code is reported incorrectly.
D. Both B and C.
Case 7
Psychiatry
Re: Daphne Stewart Date of Service: January 27, 20XX
MR # 700-7
Past medical history: High blood pressure, diagnosed migraines, PMDD, Anxiety
Screening tests had Lipid/Cholesterol 2013
Immunizations up to date
Migraine headaches
Tobacco Use:
Smoking
Erythromycin: stomach upset
Psychiatric:
Suicidal thoughts no. Other concerns none

Patient’s Report: Patient was present and on time for her appointment. Dr. Morris requested 4 more weeks sick leave for her
and she was thankful. She is discouraged in finding other employment but is active in seeking it out.
Behavioral Observation/Mental Status: Depressed, tearful, anxious; negative for suicidal/homicidal ideation; judgment fair
and insight gaining. Intervention Used: Solution-Focused, supportive.
Chapter 7
Focus of Session: Patient processed her thoughts and feelings regarding her unemployment and her need to find work other than
the job she is presently in. It is an ongoing struggle for her to keep going. Self-Change Creed and Just for Today...also Autogenic
Training as a means to relax and reduce stress, Education, Processing, Venting. Supportive counseling and feelings expressed
given validation by the counselor
Assessment of Progress/Patient Response: Depressed, anxious. Patient’s depression will lift, on a 1-10 scale with 10 being
highest/best mood, from a 4-5 to a 6 in one week. Her anxiety, on a 1-10 scale with 10 being most severe, will decrease from a
7 to a 5-6 in one week. Will revisit progress and address any new developments next session.
Start Time: 02:00 PM[
End Time: 02:55 PM[
1. Major depressive disorder, single episode, severe with anxious distress
2. Anxiety disorder, unspecified
Axis II: Cluster B traits vs. disorder
Occupational stress severe, health
GAF:55.
Patient Name Daphne Stewart

Comments

Group F41.8
Total $200.00
A. 90791
B. 90837
C. 90838
D. 90834
Chapter 7
2. W hich of the following needs to be addressed?
A. Procedure code is reported incorrectly.
B. Place of service is incorrect.
C. ICD-10-CM code is reported incorrectly.
D. All of the above.
Case 8
Psychiatry
Re: Elizabeth J. Bailey Date of Service: January 28, 20XX
MR # 700-8
As per medical record
Tobacco Use:
Smoking
Smokeless Tobacco
Current user: No
Former user: No
Psychiatric:

Patient’s Report: Patient was present and on time for her appointment. She just returned from St. Louis for a day and will go
back tomorrow. Her father is sick now.
Behavioral Observation/Mental Status: Depressed, angry, resentful, resistant; negative for suicidal/homicidal ideation; judg-
ment fair to poor and insight partial.
Intervention Used: Solution-focused.
Focus of Session: The counselor introduced The Positive Value of Negative Feelings. She seemed resistant to this. She is unwilling
at this point to forgive and sees herself as doomed to misery....at least till she gets out of her current residence. Her friends are
her dad and her son. She seeks no other relationships. She vented about her sad state of affairs and is clearly bitter and resentful.
Discussion on what spirituality IS and what it IS NOT. Challenged to go inward and find herself. Venting.
Assessment of Progress/Patient Response: Angry and bitter and resentful and self-pitying. Static. Patient will continue consid-
ering forgiveness and letting go. Her depression will lift from a 4 to a 5-6 in one week. Will revisit progress and address any new
developments next session.
Start Time: 03:02 PM[
End Time: 03:58 PM
Chapter 7
1. Major depressive disorder, recurrent episode, severe with anxious distress
2. Anxiety disorder, unspecified
3. Personality disorder
Primary support, other psychosocial and environmental problems, unemployment GAF50.
Patient Name Elizabeth J. Bailey

Comments

Group F41.9
F60.9
Total $200.00
A. 90791
B. 90837
C. 90839
D. 90834
2. Which of the following needs to be addressed?
A. Procedure and diagnosis codes are reported incorrectly.
B. Date of service discrepancy.
C. Both A and B.
D. The patient encounter was documented correctly.
Chapter 7
Case 9
Psychiatry
Re: Tessa S. Olson Date of Service: January 5, 20XX
MR # 700-9
Behavioral Health Treatment:

Patient is accompanied by both parents.
Since our last visit mother read about Reactive Attachment Disorder (RAD) and says, “that fits”--
The oppositional defiant patterns continue severe and consistent. Gets upset easily when not getting her way. She yells, disobeys.
Mood mildly improves when she takes her meds. When there is “any kind of authority” she become more defiant. She has been
told no boys in the house, but she has “big issues with boys”--sneaking them in and her sneaking out to be with them. They are
afraid she verges on being sexually active (is on BCPs, mother is sure she takes them). Her LMP was a week ago. No suicidal
ideations.
There is much tension in the session, she is passive aggressive, argues, parents are clearly stressed.
Mother says, “bipolar disorder” was just mentioned a couple of times. Nothing was said about reactive attachment disorder.
Lexapro (Escitalopram Oxalate) 10 mg Tablet 1 tablet every morning
Abilify (ARIPiprazole) 10 mg Tablet 1 tablet every morning
Irregular menses- controlled by OCP
Medication List reviewed and reconciled with the patient
Seasonal allergies
Surgical History:
Tonsillectomy & Adenoidectomy age 3
Family History:
Mother: alive, HTN
Father: alive, HTN
Tobacco Use:
Smoking
Smokeless Tobacco
Current user: No
Former user: No
Medication Allergies: PCN: vomiting and rash
Mental Status Exam:

APPEARANCE: tall, proportionate weight, appropriate dress and grooming, appears her age.
ORIENTATION: alert and oriented x 3.
MOOD: sullen, angry appears depressed.
AFFECT: as above.
Chapter 7
BEHAVIOR: no abnormalities.
SPEECH: normal.
INSIGHT: poor.
THOUGHT PROCESSES: not adequately assessed today.
MEMORY PROBLEMS: grossly intact
PSYCHOTIC THOUGHTS CONTENT: denies SI and HI, no psychotic symptoms.
EYE CONTACT: minimal.
ATTENTION: normal.
JUDGEMENT: poor.
ATTITUDE: angry with parents all session.
1. Bipolar disorder, in full remission
2. Oppositional defiant disorder worsening
3. Probable reactive attachment disorder.
Increase Lexapro Tablet, 10 MG, 1 and one half tablet every morning 135, Refills 0
Refill Abilify Tablet, 10 mg, 1 tablet every morning, 90, Refills 0
Clinical Notes: Read more about RAD, complete RAD scales. Still need to clarify any “bipolar” aspects. Resume counseling -
recommend strong component of therapy for parents as well as patient with additional therapy sessions.
Psychotherapy:
Total Time 45 minutes.
Intensive psycho-education session regarding RAD, its various problems, course, and treatment.
Electronically signed: Ana Bell, DO 1/5/20xx 1426
Patient Name Tessa S. Olson

Provider Ana Bell, DO
Comments

Group F91.3
F94.1
Group F91.3
F94.1
Total $274.00
Chapter 7
1. The documentation supports what CPT® codes?
A. 99214, 90834
B. 99215, 90836
C. 99213, 90834
D. 99214, 90836
2. What errors were noted in performing the audit?
A. No errors, procedure and diagnosis codes are reported correctly.
B. Modifier 25 should be appended to the established office patient E/M code.
C. Time was not documented in the medical record as required.
D. The CPT® E/M code and psychotherapy code were reported incorrectly as well as a diagnosis code.
Case 10
Psychiatry
Re: Victoria K. Burns Date of Service: January 5, 20XX
MR # 700-10
Anxiety
Patient is accompanied by her husband.
Both agree she has been improving. No manic symptoms. She also continues lithium and Effexor regularly as prescribed. Again,
neither feel changes in psychotropics are needed.
She continues part-time at the School. She won’t work there this summer due to low enrollment.
Physical health remains good, no suicidal ideations. Her PCP of record is Dr. Henry, although she has not seen her yet. I encour-
aged her to make an appointment and establish care.
Discussed my retirement at the end of this year and follow-up care options.
Medications:
Seroquel (QUEtiapine Fumarate) 100 MG Tablet 1/2 or 1 at bedtime
Lithium Carbonate 300 MG Capsule 1 twice daily
Effexor XR (Venlafaxine HCI ER) 37.5 MG Capsule Extended Release 24 Hour 1 capsule with food daily
Medication List reviewed and reconciled with the patient
Surgical History:
C section 19XX, 19XX, 19XX
Arthroscopic knee surgery 20XX
Hand surgery 9/20XX
Chapter 7
Tobacco Use:
Smoking
Smokeless Tobacco
Current user: No
Former user: No
Mental Status Exam:

APPEARANCE: average height and weight, appropriate dress and grooming, appears stated age.
ORIENTATION: alert and oriented
MOOD euthymic.
AFFECT: normal range.
BEHAVIOR: no abnormalities.
SPEECH: normal.
INSIGHT fair.
THOUGHT PROCESSES: logical and coherent.
MEMORY PROBLEMS: grossly intact.
THOUGHT CONTENT: denies SI and HI, no psychotic symptoms.
EYE CONTACT: normal.
ATTENTION: tracks okay
INTELLECT: average.
JUDGEMENT: fair.
ATTITUDE: appropriate, pleasant
1. Bipolar disorder, in full remission
Refill Seroquel Tablet, 100 MG, 1/2 or 1 at bedtime, 90, Refills 1
Refill Lithium Carbonate Capsule, 300 MG, 1 twice daily, 180, Refills 1
Refill Effexor XR Capsule Extended Release 24 Hour, 37.5 MG, 1 capsule with food daily, 90, Refills 1
Clinical Notes: Discussed my retirement in December. Encouraged her to establish with a PCP.
Return 6 months
Chapter 7
Electronically signed:

Patient Name Victoria K. Burns
Provider Ava Bell, DO
Comments

Group
Total $111.00
A. 99214
B. 99213
C. 90832
D. 90833
A. The procedure code is reported incorrectly and billed under the wrong provider.
B. The document was not signed by the provider, and the diagnosis code was reported incorrectly.
C. The procedure and diagnosis codes are reported incorrectly.
D. The procedure code and diagnosis code are reported incorrectly and billed under the wrong provider.

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What information is provided about CPT codes?

What information is provided about CPT codes?

2019

Medical Auditing Training: CPMA®

CPT® is a registered trademark of the American Medical Association.

Clinical Examples Used in this Book

Session Note – Follow-up Exam:

1. Schizoaffective disorder, unspecified

Rule out dependency personality traits.

Clinical Notes: Continue counseling

Electronically signed by Kevin Cooper, LPC on 01/05/20XX at 1422

Psychiatry Coding Fee Ticket

Patient Name Jeffrey P. Cook

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

1. The documentation supports what CPT® code(s)?

2. What discrepancies have been identified?

B. The diagnosis code is reported incorrectly.

C. The procedure and diagnosis codes are reported incorrectly.

Session Note – Follow-up Exam:

End Time 10:21 AM

1. Major depressive disorder, recurrent episode, in partial or unspecified remission

2. Generalized anxiety disorder

3. ADHD (attention deficit disorder with hyperactivity)

Rule out dependent personality trait 3 Weeks

Electronically signed by Kevin Cooper, LPC on 01/06/20XX at 1205

Psychiatry Coding Fee Ticket

Patient Name Matthew W. Sullivan

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

1. The documentation supports what CPT® code?

2. What discrepancies have been identified?

B. Date of service and place of service are incorrect.

C. Services billed under the wrong provider.

D. The diagnosis codes are reported incorrectly.

Session Note – Follow-up Exam

2. Major depression in partial remission

Clinical Notes: Continue Counseling.

Electronically signed by Kevin Cooper, LPC on 01/07/20XX at 1300

Psychiatry Coding Fee Ticket

Patient Name Ryan P. Andrews

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

1. The documentation supports what CPT® code(s)?

2. What discrepancy has been identified?

B. A code for drug dependence should also be reported.

C. The CPT® code is not correct.

D. No discrepancies, the CPT® and diagnoses codes are reported correctly.

1. Wife will attend.

Audit C Questions 4-10

Session Note - Follow Up Exam:

1. Alcohol dependence with withdrawal

Clinical Notes: Continue Counseling.

Psychiatry Coding Fee Ticket

Patient Name Clinton T. Lewis

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

1. The documentation supports what CPT® code(s)?

2. What discrepancy has been identified?

A. Documentation has a discrepancy for the smoking.

B. CPT® code is incorrect