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* 1. An 87-year-old Medicare beneficiary with CAD, HTN, DM2, and CKD3 undergoes a transcatheter aortic valve replacement.  The patient was initially admitted as inpatient, but discharge is planned after one midnight; the provider changes the patient’s status to “extended surgical recovery”, and the case manager contacts you for further advice.  What is the appropriate status?

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* 2. A Medicare beneficiary is undergoing a planned inpatient-only procedure; after induction of anesthesia, the elevation mechanism on the operating table fails and the procedure is aborted.  What is the proper billing status?

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* 3. A Medicare beneficiary presents to the ED at 0130 with abdominal pain; evaluation reveals appendicitis with fecalith. Surgery is recommended; however, the patient takes a DOAC and the surgeon wants a 48-hour washout prior to surgery.  Antibiotics are started in the meantime.  What status would you recommend?

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* 4. Mrs. Jones, a 62-year-old female with a controlled history of COPD was admitted for surgical replacement of her left hip, which had been injured in motor vehicle injury at the age of 34. Her payor had declined to preauthorize the admission for an inpatient level of care.
During her anticipated short stay in the post-anesthesia care unit, she remained unacceptably somnolent, dropping her oxygen level to 89% during attempts to wean from oxygen over a 2.5-hour area period. There were no focal neurological deficits, and she had no specific cognitive deficits when aroused in the PACU. She had scattered rales and minimal diffuse wheezing with a respiratory rate of 20 to 22 breaths per minute. The patient was transferred to a hospital room, maintained on 3 liters of oxygen by nasal canula and every four-hour nebulizer treatments. The patient had no chest pain. A chest x-ray was negative.
On post-op day #1, her oxygen level the next morning was in the area of 92% on 2 liters of oxygen, but dropped to 89% with ambulation to the rest room. By afternoon she was seen by a pulmonary consultant who suspected no additional pathology and recommended chest percussion be added to continuation of bronchodilator nebulizer treatments and incentive spirometry. By late afternoon her oxygen levels had improved slightly but she still had not reported flatus.
The next morning, bowel sounds were infrequently heard, and with sips of fluid became significantly nauseated. She vomited once. Repeated electrolytes showed a sodium of 134, a potassium of 3.2, a CO2 of 20, creatinine of 1.6 and a BUN of 28. She was continued on IV fluids.  Tolerating fluids on the morning of the third day she was placed on a clear liquid diet. With a bowel movement at noon, the patient’s diet was advanced. Her oxygen levels remained at 93% or above with light ambulation. With continued improvement, the decision was made at three in the afternoon of the third day to discharge the patient.
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