AAPC CPC Exam Final with Answer 2016

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2016 Final with Answers 10000 Series 1. While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. Immobilization was accomplished with a plaster splint. What CPT® code is reported? a. 15574 c. 15750 b. 15740

d. 15758

ANS: A Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Subsection guidelines for Flaps state the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer. 2. A patient presents to the ED physician with multiple burns. After examination the physician determines the patient has 3rd degree burns of the anterior and posterior portion of his left leg, starting at the knee extending above the ankle (4.5%). He also has 3rd degree burns of the anterior portion of the left side of his chest (4.5%). The patient also has 2nd degree burns of the posterior portion of his upper back and left upper arm (13.5%). What ICD-10-CM codes are reported? a. T24.292A, T24.192A, T31.20 b. c. d.

T21.399A, T21.39XA, T21.29XA, T22.299A, T31.31 T24.109A, T25.112A, T21.21XA, T22.392A, T21.23XA, T31.31XA T24.392A, T21.31XA, T21.23XA, T22.232A, T31.20

ANS: D Rationale: ICD-10-CM Guidelines 1.C.19.d.1 indicate, when more than one burn is present to sequence first the code reflecting the highest degree of burn. In the Index to Diseases and Injuries, look for Burn/lower/limb/multiple sites, except ankle and foot/left/third degree T24.392-. Third degree burns to the left leg at the knee extending above the ankle (multiple sites) are coded as T24.392-; third degree burns to the left side of the chest is indexed Burn/chest wall/third degree referring you to code T21.31-; second degree burns to the posterior upper back is indexed Burn/back/upper/second degree referring you to code T21.23-; and second degree burns to the left upper arm is indexed Burn/upper limb/above elbow - see Burn, above elbow. Look for Burn/above elbow/left/second degree referring you to code

T22.232. The Tabular List indicates these codes need seven characters. The seventh character A is reported for all the burn codes and use X place holders to keep the A in the seventh position. Last code to report is the extent or percentage of the body burned. Look for Burn/extent (percentage of body surface). Category T31 is used to identify the extent of the body surface involved. The fourth character identifies the total body surface area (TBSA) involved (all degree burns totaled), the TBSA is 22.5% (T31.2-). The fifth character identifies the percentage of body surface involved in only the third-degree burns. Third degree burns total 9% reporting the fifth character 0. This is coded with T31.20. The TBSA codes are only five characters long and does not need a seventh character extender to complete the code. 3. Patient is an 81-year-old male with a biopsy proven basal cell carcinoma of this posterior neck just near his hairline; additionally the patient had two additional areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck, I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed in layers using 4.0 Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5cm. Attention was then directed to the other two suspicious lesions on his cheek; after administering local anesthesia I proceeded to take a 3mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported? a. 13132, 11623-51, 11100-59, 11101 c. 12042, 11623-51, 11100-59, 11101 b. 13131, 11622-51, 11100-59, 11100-59

d. 13132, 11623-51, 11440-51, 11440-51

ANS: A Rationale: Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range 11600-11646. The range is narrowed by the location (neck, 11620-11626). The excision was 2.6 cm making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of multiple suture materials support use of a complex closure. Complex repairs are indexed under Repair/Skin/Wound/Complex referring you from range 13100-13160. The range is narrowed again by location (neck, 13131-13133). The repair length is 4.5 cm making 13132 the correct code. After the lesion of the neck is removed the provider took two biopsies on the cheek. Look in the CPT® Index for Skin/Biopsy which refers you to codes 11100 and 11101. 11100 is used for the first biopsy and add-on code 11101 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use modifier 59 for the first biopsy indicating it was performed at a different location than the excision. A modifier 59 is not used on the second biopsy code because it is an add-on code. 4. Patient is a 53-year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on

the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea; then Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound; the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported? a. 14021-22 c. 14301 b. 14021, 15004-51 d. 14301, 15004-51 ANS: D Rationale: A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq. cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq. cm. 14301 is reported for the first 30 sq. cm – 60.0 sq. cm. Wound preparation was also performed, in the CPT® index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to codes 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed. 5. Patient presents to the emergency department with multiple lacerations due to a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported? a. 13132, 12035-59, 12004-59 b. 13132, 12034-59, 12032-59, 12004-59 c. 13132, 12036-59 d. 13152, 12035-59, 12004-59 ANS: A Rationale: Four lacerations are repaired. The lacerations are separated first by classification (simple, intermediate, complex); then by location. There is one simple closure which is 7.6 for the right forearm (12004). Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm (12035). The last repair is a complex repair of the neck, 4.7 cm (13132). Subsection guidelines state to append Modifier 59 to indicate that multiple repair procedures are performed. These codes are indexed in CPT® under Skin/Wound Repair.

6. Patient presents to the operative suite with a biopsy proven squamous cell carcinoma of the left ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The lesion was excised as drawn and documented as measuring 2.4 cm with margins. Using the Padgett dermatome the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1.5 x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon and the lower extremity was wrapped with bulky cast padding and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin graft measured 9cm² in total. What CPT ® and ICD-10-CM codes are reported? a. 15100, 11603-51, C44.729 c. 15120, 13100-51, D22.72 b. 15100, C44.729 d. 15240, 11603-51, C44.729 ANS: A Rationale: The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant, you are referred to code range 11600-11646. The lesion is on the ankle (leg) narrowing the code range to 11600-11606. The lesion is 2.4 cm making the correct code 11603. The guidelines for Excision – Malignant Lesions tell us to report reconstructive closure (15002-15261, 15570-15770) separately. In this case a split thickness skin graft was used. Look in the CPT® Index for Skin Graft and Flap/Split Graft which refers us to code range 15100-15101, 15120-15121. 15100 is the correct code choice. The diagnosis is squamous cell carcinoma. In the Alphabetic Index look for Carcinoma – see also Neoplasm, by site, malignant. Look in the Table of Neoplasms for Neoplasm, neoplastic/skin NOS/ankle and you are referred to see also Neoplasm, skin, limb, lower. Skin/limb NEC/lower/squamous cell carcinoma refers you to C44.72-. In the Tabular List a sixth character is reported for laterality. The code is specific to the left extremity (C44.729). 7. Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician marked the area for excision. The lesion measured 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported? a. 11401, D22.62 c. 13121, 11401-51, D22.62 b. 12031, 11401-51, L72.3 d. 11402, L72.3 ANS: B Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for Skin/Excision/Lesion/Benign referring you to code range 11400-11446. The lesion is coded based on size and location for 11401. The note also indicates the wound was closed in layers allowing for intermediate closure, also coded based on location and size, 12031. In the ICD-10-CM Alphabetic Index, look for Cyst/sebaceous directs you to L72.3. Verify in the Tabular List.

8. Operative Report: Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheek Suspicious lesion, left nose Suspicious lesion, left forehead Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear margins Compound nevus, left nose with clear margins Epidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy-proven basal cell carcinoma of his forehead and a biopsy-proven basal cell carcinoma of his right cheek. We were not quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6-mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well. What ICD-10-CM codes are reported? a. C44.310, D04.39, D48.5, D23.39 b. C44.310, D23.39 c. C44.202, C44.40, D22.23, D23.39 d. C44.202, C44.309, D48.5, D49.2 ANS:

B

Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Alphabetic Index look for Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic, skin NOS/forehead - see also Neoplasm, skin, face. Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma refers you to code C44.310. Next, is basal cell carcinoma, right cheek, which also directs you to see also Neoplasm, skin, face (C44.310). Because, both basal cell carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the Alphabetic Index for Nevus/skin/nose directs you to D23.39. Nevus/skin/forehead directs you to D22.39. Because the codes are the same. The code is reported only once. 9. 56-year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages? a. 17311, 17315 c. 17311, 17312, 17315 b. 17313, 17314, 17315 d. 17311, 17312 ANS: C Rationale: Mohs codes are selected based on location and number of stages, each including up to five blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the CPT® Index, see Mohs Micrographic Surgery. Code 17311 is for the first stage and 17312 for the second stage, based on the documentation of the site: “forehead.” The second stage consisted of six tissue blocks; the sixth tissue block is reported with the add-on code 17315. 10. Which statement is true regarding the Neoplasm Table in ICD-10-CM? a. The Neoplasm Table is found by looking for “Neoplasm” in the Index to Diseases and Injuries. b. There is not a Neoplasm Table in ICD-10-CM. c. The Neoplasm Table is found in the Tabular List. d. There are six columns in the Neoplasm Table; Primary malignancy, secondary malignancy, CA in situ, benign, and uncertain behavior. ANS: D Rationale: The Neoplasm Table in ICD-10-CM is broken down into six columns; Primary malignancy, secondary malignancy, CA in situ, benign, and uncertain behavior.

20000 Series 11. 44-year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. The intraoperative mounting parameters, deformity parameters, and initial strut settings are inserted into the computer prior to Jim’s discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) should be reported? a. 20696

c. 20694

b. 20697 ANS:

d. 20692, 20697 B

Rationale: The exchange of a computer assisted external strut is coded with 20697. There is a parenthetical note under code 20697 that it is not to be used in combination with 20672 or 20696. 20697 can be found in the CPT ® Index under External Fixation /Application/Stereotactic Computer Assisted 12. A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT® code is reported for this service? a. 20205

c. 20225

b. 20206

d. 27324

ANS:

B

Rationale: In the CPT® Index, look for Biopsy/Muscle. You are referred to 20200-20206. The biopsy is taken through the skin, or percutaneous with a needle. Although the biopsy is deep, it is performed percutaneous, which is reported with 20206. 13. The patient presents today for closed reduction of the nasal fracture. The depressed right nasal bone was elevated using heavy reduction forceps while the left nasal bone was pushed to the midline. This resulted in good alignment of the external nasal dorsum. What CPT® code is reported for this procedure? a. 21325

c. 21315

b. 21310

d. 21337

ANS:

C

Rationale: In the CPT® Index, look for Fracture/Nasal Bone/Closed Treatment. You are referred to 21310-21320. Review codes to choose the appropriate service. 21315 is the correct code to report a displaced nasal fracture that is manipulated with the forceps to realign the nasal bones. Code 21310 is reported when a non-displaced fracture of the nose requires no manipulation just treatment by prescribing medication and application of ice. 14. A 22-year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened by a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and closed with sutures. What CPT® code is reported? a. 10120-F4

c. 20670-F4

b. 20680-F4

d. 10121-F4

ANS:

B

Rationale: In the CPT® Index, look for Removal/Fixation Device. You are referred to 20670-20680. Review the codes to choose the appropriate service. 20680 is the correct code because a deep incision was made all the way to the bone to locate the wire for removal. Modifier F4 is reported to indicate the finger the procedure is performed on. 15. The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported? a. 29880

c. 29881, 29877-59

b. 29870, 29877-59

d. 29881

ANS:

D

Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Knee. You are referred to 29871-29889. Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the “medial meniscus”. A meniscectomy as well as debridement with a shaver (or chondroplasty) were performed. 29877 would not be reported as this is covered with code 29881. 29880 is not appropriate as the procedure would have had to be performed on both the medial and lateral compartments. The surgery started out as a “diagnostic procedure,” but changed when the physician decided to perform surgical procedures on the knee, rather than only examining the knee for diagnostic purposes. 16. A 3-year-old is brought into the ER crying. He cannot bend his left arm after his older brother twisted it. The physician performs an X-ray to diagnose the patient has a dislocated nursemaid’s elbow. The ER physician reduces the elbow successfully. The patient is able to move his arm again. The patient is referred to an orthopedist for follow-up care. What CPT® and ICD-10-CM codes are reported? a. 24640-54-LT, S53.032A, W50.2XXA b. 24565-54-LT, S53.194S, Y33.XXXA c. 24640-54-LT, S53.091A, W50.2XXA d. 24600-54-LT, S53.002A, W49.9XXA ANS:

A

Rationale: In the CPT® Index, look for Elbow/Dislocation/Closed Treatment. You are referred to 2460024605, and 24640. Review the codes to choose appropriate service. 24640 is the correct code to report treatment of a dislocated nursemaid’s elbow with manipulation. Modifier 54 is used to report that the ED physician performed the surgical portion of the service only. The patient is referred to an orthopedist for follow-up care. Modifier LT is appended to indicate the procedure was performed on the left side. In the ICD-10-CM Index to Diseases and Injuries, look for Nursemaid’s/elbow. You are referred to S53.03-. Reviewing the subcategory code in the Tabular List the sixth character indicates the selection is

based on left or right. Documentation supports this as the left arm. A 7th character is also required to indicate the episode of care. Because the patient is in the ER, this supports initial encounter and A is used. The complete code is S53.032A. In the ICD-10-CM External Cause of Injuries Index, look for Twisted by person(s) (accidentally) referring you to W50.2. In the Tabular List this code requires a 7th character, in which the character A is used and X will be used as a placeholder for the fifth and sixth character positions. 17. A 50-year-old male had surgery on his upper leg one day ago to remove an intramuscular tumor and presents with serous drainage from the wound. He was taken back to the operating room for evaluation of a hematoma. His wound was explored down to the rectus femoris muscle, and there was a hematoma, which was very carefully evacuated. The wound was irrigated with antibacterial solution, and the wound was closed in multiple layers. What CPT® and ICD-10-CM codes are reported? a. 10140-79, M96.810

c. 10140-76, T81.9XXA

b. 27603-78, T81.4XXA

d. 27301-78, M96.831

ANS:

D

Rationale: In the CPT® Index, look for Hematoma/Leg, Upper. You are referred to 27301. Verify the code for accuracy. Modifier 78 is appended to 27301 to indicate that an unplanned procedure related to the initial procedure was performed during the postoperative period. In the ICD-10-CM Index to Diseases and Injuries, look for Complications/surgical procedure (on)/hematoma/post procedural – see Complication, post procedural, hemorrhage. Look for Complication/post procedural/hemorrhage (hematoma)/musculoskeletal structure/following non-orthopedic surgery referring you to M96.831. His wound was explored down to the level of the rectus femoris muscle, so the excision of the mass did not just involve the skin. The codes selection is specific to the location of the hematoma as well as the body system for which the procedure was performed. Review the code in the Tabular List for accuracy. 18. A 22-year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture while on vacation. The patient was put under general anesthesia and the elbow was reduced and was stable. The medial elbow was held in the appropriate position and was reduced in acceptable position and elevated to treat non-surgically. A long arm splint was applied. The patient is referred to an orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported? a. 24575-54-RT, 24615-54-51-RT c. 24577-54-RT, 24600-54-51-RT b. 24576-54-RT, 24620-54-51-RT d. 24565-54-RT, 24605-54-51-RT ANS:

D

Rationale: In the CPT® Index, look for Fracture/Humerus/Epicondyle/Closed Treatment. You are referred to code 24560-24565. Review the codes to choose the appropriate service. 24565 is the correct code to report an epicondyle fracture manipulated (reduced) without a surgical incision to perform the procedure. In the CPT® Index, look for Dislocation/Elbow/Closed Treatment. You are referred to 24600, 24605. Review the codes to choose appropriate service. 24605 is the correct code because the patient was put under general anesthesia to perform the procedure. Modifier 54 is used to report the physician performed the surgical portion only. The patient is referred to an orthopedist for follow up or

postoperative care. Modifier 51 is used to report multiple procedures were performed. Append modifier RT to indicate the procedure is performed on the right side. 19. A 45-year-old presents to the operating room with a right index trigger finger and left shoulder bursitis. The left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. An incision was made over the A1 pulley in the distal transverse palmar crease, about an inch in length. This incision was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. Clean dressing was applied. What CPT® codes are reported? a. 26055-F6, 20610-76-LT

c. 26055-F6, 20610-51-LT

b. 20552-F6, 20605-52-LT

d. 20553-F6, 20610-51-LT

ANS:

C

Rationale: In the CPT® Index, look for Trigger Finger Repair. You are referred to 26055. Review the code to verify accuracy. In the CPT® Index, look for Injection/Joint. You are referred to 20600-20610. Review the codes to choose appropriate service. 20610 is the correct code since the shoulder was injected. Modifier F6 is used to report the right index finger that was repaired. Modifier LT is used to indicate the left shoulder joint. Modifier 51 is used to indicate multiple procedures were performed. 20. What ICD-10-CM code is used to report effusion of the right ankle joint? a. M25.471

c. M25.48

b. M25.474

d. M25.571

ANS:

A

Rationale: Look in the Index to Diseases and Injuries for Effusion/joint/ankle. In the Tabular List, code M25.47- Effusion, ankle and foot requires the application of a sixth character to specify the location (foot or ankle) and laterality. M25.471 Effusion, right ankle

30000 Series 21. A patient presents with wheezing and shortness of breath. After evaluating the patient, the physician determines the patient is suffering from an exacerbation of his asthma. The physician orders nebulizer treatments to be administered in his office. According to the ICD-10-CM guidelines for coding signs and symptoms, what is/are the correct ICD-10-CM code(s)? a. J45.901 b. J45.902, R06.2, R06.02 ANS:

A

c. R06.2, R06.02 d. J45.902

Rationale: Because the type of asthma is not indicated, the correct code is J45.901. In the Index to Diseases and Injuries, look for Asthma, asthmatic/with/exacerbation (acuter) directing you to J45.901. The Tabular List verifies this code choice. Wheezing and shortness of breath are signs and symptoms of an exacerbation of asthma and not reported separately. According to the Official ICD-10-CM Guidelines (Sect I. B. 4) do not report signs and symptoms when a definitive diagnosis has been established. 22. The provider performs a diagnostic thoracoscopy followed by the thoracoscopic excision of a pericardial cyst. What CPT® code(s) is/are reported? a. 32601, 32662-51

c. 32658

b. 32601, 32661-51

d. 32661

ANS:

D

Rationale: Endoscopy guidelines state that surgical thoracoscopy always includes a diagnostic thoracoscopy and, therefore, is not coded separately. In the CPT® Index, look up Thoracoscopy/Surgical/with Excision Pericardial Cyst, Tumor and/or Mass and you are directed to 32661. 23. What ICD-10-CM code is reported for COPD with acute bronchitis? a. J44.9, J22.9 c. J40 b. J44.1 ANS:

d. J44.0, J20.9 D

Rationale: COPD stands for Chronic Obstructive Pulmonary Disease. In the ICD-10-CM Alphabetic Index look for Disease/lung/obstructive/with/acute bronchitis referring you to J44.0. Verification in the Tabular List confirms code selection and gives additional instruction to use additional code to identify the infection. The infection is reported with a code from category code J20 Acute Bronchitis. Because there is no indication of the infectious agent for the acute bronchitis, an unspecified code is used. Bronchitis/acute or subacute refers you to J20.9. 24. A patient with AML (Acute Myelogenous Leukemia) has just learned his sister is an HLA match for him. Stem cells taken from the donor (the patient’s sister) will be transplanted into the patient to help with his treatment. What CPT® code is used to report the harvesting of the stem cells from the donor, his sister? a. 38204 c. 38206 b. 38205

d. 38207

ANS: B Rationale: In the CPT® Index, look under Stem Cell/Harvesting. This directs you to code range 3820538206. Code selection is based on whether it is allogenic (from a donor) or autologous (from the patient). This is allogenic making 38205 the correct code choice.

25. A patient with recurrent pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos-free talc was introduced into the pleural space via the catheter. What CPT® and ICD-10-CM codes are reported? a. 32650, J95.811 c. 32601, 32560, J95.811 b. 32560, J93.81

d. 32650, 32560, J93.11

ANS: B Rationale: Chemopleurodesis is represented by codes 32560-32562. In the CPT® Index, look for Pleurodesis/Instillation of Agent. Code 32560 is appropriate for the described actions taken to instill the talc used to treat recurrent pneumothorax. Look in the Index to Diseases and Injuries for Pneumothorax NOS/chronic which directs you to code J93.81. Verification in the Tabular List confirms code selection. 26. A physician performs a four-vessel autogenous (one venous, three arterial) coronary bypass on a patient who had a previous CABG two years ago, utilizing the saphenous vein, radial artery and the left and right internal mammary arteries. Select the CPT® codes for this procedure. a. 33535, 33510-51, 33530, 35600 c. 33533, 33519, 33530, 35600 b. 33534, 33518, 33530 ANS:

d. 33535, 33517, 33530, 35600

D

Rationale: Because this is a combo graft, codes 33517-33523 must be coded for the venous portion of the graft. Also, this is a redo more than one month after the original surgery, so the add-on code 33530 is appropriate. This is found in the CPT® Index under Coronary Artery Bypass Graft (CABG)/ArterialVenous Bypass 33517-33523, and Arterial Bypass 33533-33536. Also listed under this section in the Index is Reoperation 33530. In this same section under CABG is Harvest/Upper Extremity Artery 35600. Look up the codes in the procedure listing, and you see all additional codes are add-on codes; therefore, no modifiers are required. 27. The cardiologist advances a 6 French catheter into the left renal artery via a right common femoral puncture. It is selectively catheterized and angiographic films are taken. The catheter was then removed and a diagnostic guiding type, RDC catheter was used and the left renal artery was selectively engaged. A 0.014 Supracore wire was used and the lesion was crossed. A 6.0 X 18 mm balloon expandable Racer stent was introduced. This was expanded around 8 atmospheres of pressure which is nominal. Angiography revealed excellent results with no residual stenosis. a. 36245-LT, 75625-26, 37236 b. 36245-LT, 37236 c. 36245-LT, 36251, 37236 d. 36246-LT, 37236

ANS: B Rationale: The left renal artery is a first order vessel as noted in Appendix L of the CPT® codebook (36245-LT). The selective catheterization code is found in the CPT® Index under Artery/Abdomen/Catheterization 36245-36248. Angiography of the left renal vessel was performed; however, there is no mention in the report of the results of the angiography. This is not a diagnostic angiography, rather it is angiography for mapping (checking out known stenosis). The stent was deployed (37236) in the left renal artery; this code also includes the radiologic supervision and interpretation. Code 37236 is found in the CPT® Index under Stent/Placement/Transcatheter/Intravascular. Follow-up renal angiography is bundled with the stent procedure. 28. Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failure Postoperative Diagnosis: Same Anesthesia: General endotracheal Incision: Median sternotomy Description of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization. She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed. Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta. The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What are the CPT® codes? a. 33400, 33533-51, 33510 c. 33405, 33533-51, 33510, 35500 b. 33405, 33533-51, 33517, 35600 ANS:

B

d. 33411, 33533-51, 33517, 35600

Rationale: A mechanical valve was placed (33405). Code 33405 is found in the CPT® Index under Replacement/Aortic Valve. A one-artery, one-venous CABG was performed (33533, 33517). Look in the CPT® index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass 33517-33519, and also look at Arterial Bypass 33533-33536. The left radial artery is an upper extremity artery and separately reportable (35600), as noted in the guidelines preceding categories Combined Arterial Venous Grafting for Coronary Artery Bypass and preceding Arterial Grafting for Coronary Artery Bypass. Modifier 51 is appended to 33533, because it is an additional procedure performed during the same session. The other codes are add-on codes; therefore, modifier 51 exempt. 29. During an inpatient hospitalization, a patient who suffered myocardial infarction had a combined right and left heart catheterization. Access was achieved through the right femoral artery and the right femoral vein. Selective catheterization of the coronary arteries and selective catheterization of the left ventricle were followed by injections of contrast and angiography. During right heart catheterization, angiography of the right atrium was performed. Imaging supervision, interpretation and report for all angiography was performed during the cardiac catheterization. Select the CPT® code(s) for this procedure by the cardiologist. a. 93453-26, c. 93460 b. 93460-26, 93566 d. 93460, 93565 ANS:

B

Rationale: There are three parts to cardiac catheterization: selective catheter placement, injection of contrast, and radiologic supervision and interpretation and report, which are included in most of the cardiac catheterization codes. In the CPT® Index, look for Cardiac Catheterization/Combined Left and Right Heart/with Left Ventriculography 93453, 93460-93461. Code 93460 includes right and left heart catheterization, coronary angiography, and left ventriculography. None of the combined right and left heart catheterizations include right atrial angiography; therefore, the add-on code 93566 is reported. Modifier 26 is required to report the professional service. The add-on code 93566 for the injection procedure is a professional service, and modifier 51 is not required. 30. A 35-year-old patient presented to the ASC for PTA of an obstructed hemodialysis AV graft in the venous anastomosis and the immediate venous outflow. The procedure was performed under moderate sedation administered by the physician performing the PTA. The physician performed all aspects of the procedure, including radiological supervision and interpretation. Code for all services performed. a. 35460, 99144, 75978-26 c. 35476, 75978-26 b. 35460, 75978-26 d. 35476, 99144, 75978-26 ANS: C Rationale: PTA stands for percutaneous transluminal angioplasty; code 35460 is for an open procedure. There is a bull’s eye symbol in front of code 35476, indicating moderate sedation is bundled and not reported. Venoplasty includes three zones for AV fistulas: the A/V graft and peripheral veins, the central veins, and the vena cava. Only one venoplasty is reported for the A/V graft and peripheral veins. Read

the guidelines above 36147, Interventions for Arteriovenous (AV) Shunts Created for Dialysis (AV Grafts and AV Fistulae) for guidance. Code 35476 is found in the CPT® Index under Percutaneous Transluminal Angioplasty/Vein. The notes under Transluminal Angioplasty indicate “For radiological supervision and interpretation, see 75962-75968 and 75978”. Code 75978 is correct for venous angioplasty radiological supervision and interpretation. Modifier 26 reports the professional services.

40000 Series 31. What is the correct coding for a physician who performs an UGI radiological evaluation of the esophagus, stomach and first portion of the duodenum with barium and double-contrast in the hospital GI lab? (Physician is not employed by the hospital) a. 74246 c. 74246-26 b. 74249 d. 74249-26 ANS: C Rationale: A radiological evaluation is an X-ray. UGI stands for Upper Gastrointestinal (GI). Look in the CPT® Index for Gastrointestinal Tract/X-ray/with Contrast (for the double-contrast) we are directed to code 74246-74249. Code 74249 represents the same if done with small intestine follow through but here we only performed up to the first portion of duodenum. This is performed in the hospital using hospital equipment. The physician is not indicated to be an employee of the hospital so we must report for the professional services (component) only by appending modifier 26. 32. 40-year-old male patient is in the surgical suite to have an incarcerated hernia of his belly button repaired. What are the correct CPT® and ICD-10-CM codes reported? a. 49582, K42.0 c. 49590, K42.9 b. 49587, K42.0 d. 49572, K42.9 ANS: B Rationale: In the CPT® Index look for Repair/Hernia/Umbilical/Incarcerated. This directs you to codes 49582, 49587 and 49653. Code 49587 represents this procedure is performed on a patient 5-years-old and above. Look in the ICD-10-CM Index to Diseases and Injuries for Hernia, hernia (acquired) (recurrent)/umbilicus, umbilical/with obstruction, directing you to K42.0. Verification of this code in the Tabular List, confirms code K42.0 represents an incarcerated umbilical hernia. 33. A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service? a. 11442, 12011-51 c. 40510 b. 11442, 40510 d. 40510, 12011-51 ANS:

C

Rationale: Because the physician is not only removing the lesion, but also removing part of lip along with doing a repair, code 11422 is not reported. The lesion along with a portion of the lip is removed by a transverse wedge technique. Look in the CPT® Index for Wedge Excision/Lip referring you to code 40510. The code description for code 40510 includes primary closure (suture repair), indicating the suture repair is included in code 40510 and therefore, an integumentary system repair code (12011) is not reported separately. 34. What CPT® and ICD-10-CM codes are reported for a gastric restriction by placing a gastric band via laparoscopic surgery for an adult patient diagnosed as morbidly obese having a BMI of 43 with type 2 uncontrolled diabetes with blood sugar readings continually very high each day? a. 43771, E66.01, Z68.41, E10.9 c. 43770, E66.01, Z68.41, E11.9 b. 43842, E66.01, Z68.41, E11.9 d. 43644, E66.9, Z68.41, E10.9 ANS: C Rationale: In the CPT® Index, look for Laparoscopy/Stomach (represented by the word gastric)/Gastric Restrictive Procedures or Laparoscopy/Gastric Restrictive Procedures. This directs you to codes 4377043775. In reviewing the codes, 43770 is correct. Look in the Index to Diseases and Injuries for Obesity/morbid directing you to code E66.01. Next look for Body, bodies/mass index (BMI)/adult/40.0-44.9 referring you to Z68.41. Look for Diabetes/type 2, directing you to subcategory code E11.9 Verification of the codes in the Tabular List confirms code selections. 35. What is the correct CPT® coding for a partial distal gastrectomy with Roux-en-Y reconstruction with vagotomy? a. 43621, 43635 c. 43633, 43635 b. 43634, 43635 d. 43633, 43640-51 ANS: C Rationale: In CPT® Index look for Gastrectomy/Partial, which directs us to several codes including 43631-43635. When reviewing these codes in the main section of CPT®, code 43633 code descriptor represents a partial gastrectomy with Roux-en-Y reconstruction. Code 43635 represents the vagotomy. Modifier 51 is not used, as code 43635 is an add-on code and is modifier 51 exempt. 36. How do you report a screening colonoscopy performed on a 65-year-old Medicare patient with a family history of colon cancer? The patient’s 72-year-old brother was just diagnosed with colon cancer. The physician was able to pass the scope to the cecum. What CPT® and ICD-10-CM codes are reported? a. G0104, Z13.818, Z85.038 c. 45378, Z12.11, Z85.038 b. G0105, Z12.11, Z80.0 d. 45330, Z13.818, Z80.0 ANS: B Rationale: For a Medicare patient, the preferred code to report a screening colonoscopy is HCPCS code G0105 Colonoscopy/cancer screening/ patient at high risk. In the ICD-10-CM Index to Diseases and Injuries look for Screening/colonoscopy leads to Z12.11. The patient is high risk due to a family history of

colon cancer, which is reported with Z80.0. Look in the Index to Diseases and Injures for History/family (of)/malignant neoplasm/gastrointestinal tract. 37. 56-year-old patient complains of occasional rectal bleeding. His physician decides to perform a rigid proctosigmoidoscopy. During the procedure, two polyps are found in the rectum. The polyps are removed by a snare. What CPT® and ICD-10-CM codes are reported? a. 45320, K62.1 c. 45309, 45309, K63.5 b. 45385, K63.5 d. 45315, K62.1 ANS: D Rationale: CPT® code 45315 is the correct code for the removal of more than one polyp by snare technique. In the CPT® Index, look for Proctosigmoidoscopy/Removal/Polyp directing you to 4530845315. During the proctosigmoidoscopy, polyps were removed by snare technique. The correct ICD-10-CM code is K62.1 because the polyps are located in the rectum. In the Index to Diseases and Injuries, look for Polyp, polypus/rectum directing you to K62.1. K63.5 is for polyps that are located in the large intestine. 38. 42-year-old patient is brought to the operating room for a repair of a recurrent incarcerated incisional hernia using mesh. What CPT® and ICD-10-CM codes are reported? a. 49561, K40.90 c. 49566, 49568, K43.0 b. 49566, K43.0 d. 49561, 49568, K43.1 ANS: C Rationale: An incisional hernia (ventral hernia) is a bulging of the abdominal wall at the site of a past surgical incision. This is an incarcerated incisional hernia, which means that intestine is protruding through an abnormal opening in the abdominal wall. This repair was performed by an open approach, because it is not documented that the procedure was performed laparoscopically. The code is indexed under Hernia Repair/Incisional/Recurrent/Incarcerated referring you to code 49566. When a recurrent incisional hernia is repaired, the age of the patient is not a factor in choosing the correct CPT® code for the repair. Mesh was used in the repair. Coding Tip note under code 49566 in the CPT® codebook states the use of mesh (49568) can be reported with incisional hernia repair codes. The ICD-10-CM diagnosis code is indexed under Hernia/incisional/with obstruction, coding is K43.0. Review of the Tabular List will verify that code K43.0 is reported for an incarcerated incisional hernia with obstruction. The inclusion terms under this include: irreducible, strangulated or causing obstruction. 39. 11-year-old patient is seen in the OR for a secondary palatoplasty for complete unilateral cleft palate. Shortly after general anesthesia is administered, the patient begins to seize. The surgeon quickly terminates the surgery in order to stabilize the patient. What CPT® and ICD-10-CM codes are reported for the surgeon? a. 42220-52, Q35.7, R56.9 c. 42215-53, Q35.9, R56.9 b. 42220-53, Q35.9, R56.9 d. 42215-76, Q35.7, R56.9

ANS: B Rationale: In the CPT® Index, look for Palatoplasty. Code 42220 represents a secondary repair to a cleft palate. Modifier 53 is appended because the procedure was terminated after anesthesia due to extenuating circumstances. The diagnosis of a complete unilateral cleft palate is indexed in ICD-10-CM under Cleft/palate referring you to code Q35.9. Code R56.9 is reported because the patient began to seize after administering the general anesthesia. This is indexed in the ICD-10-CM under Seizure(s). 40. A patient is admitted for a simple primary examination of the gastrointestinal system to rule out GI cancer. An EGD is performed that includes the esophagus, stomach, and portions of the small intestine. During the examination, a stricture of the esophagus is identified and subsequently dilated via balloon dilation (20 mm). What CPT® and ICD-10-CM codes are reported? a. 43235, C15.9 c. 43249, K22.2 b. 43248, Q39.3 d. 43235, K22.2 ANS: C Rationale: EGD is the abbreviation for esophagogastroduodenoscopy. A diagnostic EGD is represented by code 43235. During the exam, a stricture of the esophagus is identified and a surgical endoscopy balloon dilation performed; correct code for this scenario is 43249. Surgical endoscopy always includes diagnostic endoscopy. In the CPT® Index, look for Esophagogastroduodenoscopy/Transoral/Dilation of Esophagus directing you to 43233, 43249. The ICD-10-CM code is indexed under Stricture/esophagus giving us code K22.2. We do not code for GI cancer, as “rule out” diagnoses are not reported in outpatient coding. There is no supporting documentation that the stricture of the esophagus is congenital, so it is not reported.

50000 Series 41. A 63-year-old gentleman comes into the ED complaining of the urge to urinate but has been unable to empty his bladder. The physician decides to place a Foley catheter to relieve the urine retention due to prostate hypertrophy. What is the code selection for the procedure and diagnosis codes? a. 51701, R33.8, N40.1

c. 51702, R33.9, N40.1

b. 51702, N40.1, R33.8

d. 51701, N40.1, R33.9

ANS:

B

Rationale: In the CPT® Index look for Catheter/Bladder referring you to codes 51701-51703. CPT® code 51702 is correct to report for this scenario since an indwelling catheter (e.g., Foley catheter) is left in the bladder and urine is drained. Code 51701 is used when a non-dwelling catheter is inserted to determine post-void residual urine; this is sometimes called a “straight-cath.” The patient is diagnosed with urine retention and prostate hypertrophy. In the ICD-10-CM Index to Diseases and Injuries look for

Enlarged/prostate/with/lower urinary retention guiding you to code N40.1. Find N40.1 in the Tabular List; we are instructed to Use additional code for associated symptoms, when specified. Code R33.8 is the correct additional code to report the urinary retention. 42. Cystoscopy, left ureteroscopy, holmium laser lithotripsy, stone manipulation, stent removal and replacement are performed. The holmium laser was used to break up a cluster of stones at the UP (ureteropelvic) junction, which were removed with a basket and a Gibbons stent was exchanged. Previous CT scan showed stones in the lower right pole, it was decided to proceed with ureteroscopy. Ureteroscope was inserted in the right ureter, confirming multiple stones within the proximal ureter, these were basketed and removed. What CPT® codes are reported for this service? a. 52356-LT, 52352-59-RT b. 52353-LT, 52352-59-RT, 52332-51-LT c. 52310, 52353-51, 52352-59 d. 52353-LT, 52353-59-RT ANS:

A

Rationale: When a stent is removed and replaced, the removal of the initial stent is included in the stent replacement and is not reported. One code is reported for performing the lithotripsy and replacement of the stent in the left ureter. In the CPT® Index, look for Lithotripsy/with indwelling Ureteral Stent Insertion directing you to 52356. Usually the basketing of the stones is included with the laser lithotripsy; however, because basketing of stones is performed on a different ureter (RT) than the laser lithotripsy (LT), it is appropriate to add modifier 59 to CPT® 52352. In the CPT® Index, look for Cystourethroscopy/Removal/Calculus directing you to 52352. 43. Circumcision with adjacent tissue transfer was performed on a two month old. What CPT® code(s) is/are reported for this service? a. 14040

c. 54163

b. 54161-22

d. 14040, 54161-51

ANS:

D

Rationale: When a circumcision is performed requiring tissue transfer or reconstruction, you report the circumcision and the tissue transfer codes. You do not append modifier 22 to the circumcision code, and reporting only the tissue transfer is incorrect. Reporting repair of an incomplete circumcision is also incorrect, as we have no documentation to support a previous circumcision. In the CPT® Index, look for Circumcision/Surgical Excision directing you to 54161. In the CPT® Index, look for Tissue/Transfer/Adjacent/Skin directing you to 14000-14350.

44. A 32-year-old woman with a previous cesarean delivery presents in spontaneous labor with the baby in cephalic presentation. She has had an uneventful pregnancy and after laboring for 10 hours she delivers a single female child with brief use of a vacuum extractor over an episiotomy that is repaired by the delivering physician. There are no complications. What are the diagnosis codes for this delivery? a. O80, Z3A.00, Z37.0

c. O75.89, O34.21, Z3A.00, Z37.0

b. O80, O70.9, O75.9, Z3A.00

d. O75.89, O70.9, O82, Z3A.00, Z37.0

ANS:

C

Rationale: You do not code a normal delivery, code O80, because the delivery needed a vacuum extractor to deliver the baby. In the ICD-10-CM Index to Diseases and Injuries look for Delivery/complicated/by/specified complication NEC referring you to code O75.89. The second code reports the previous cesarean delivery. In the ICD-10-CM Index to Diseases and Injuries, look for Delivery/previous/cesarean delivery, guiding you to code O34.21. Instructional note in the beginning of Chapter 15 a code from Z3A should be reported with the pregnancy codes. Z3A.00 indicates unspecified weeks. Your last code to report is the outcome of the delivery. Look for Outcome of delivery/single NEC/liveborn, guiding you to code Z37.0. 45. A 56-year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally. The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review. What are the CPT® and ICD-10-CM codes reported for this procedure? a. 56637, C51.9, C79.89

c. 56632-50, D07.1

b. 56640-50, C51.9, C77.4

d. 56633, 38765-50, C51.9, C77.4

ANS:

B

Rationale: The patient has her vulva removed to treat malignancy (vulvectomy, radical complete). She also has removal of skin and deep subcutaneous tissue from of the vulva, inguinofemoral, iliac and pelvic lymph nodes. In the CPT® Index, look for Vulvectomy/Radical/Complete/ with Inguinofemoral, Iliac, and Pelvic Lymphadenectomy giving you code 56640. All these parts being removed are found in the code description for code 56440. There is a parenthetical note under this code stating: For bilateral procedure, report 56640 with modifier 50. This scenario needs two ICD-10-CM codes. The first one is to show the carcinoma of the vulva. This is indexed in the ICD-10-CM Index to Diseases under Carcinoma – see also Neoplasm, malignant by site. Go to the Table of Neoplasms look for Neoplasm, neoplastic/vulva/Malignant Primary (column) guiding you to code C51.9. The second diagnosis code is for the metastasis of the cancer to the lymph nodes. This is indexed in the Table of Neoplasms under Neoplasm, neoplastic/lymph, lymphatic channel NEC/inguinal, inguinal/Malignant Secondary (column), guiding you to code C77.4

46. A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure? a. 59430

c. 59510 x 2

b. 59400, 59409-51

d. 59409 x 2

ANS:

B

Rationale: The delivery is not specified as vaginal or cesarean and is coded to the lesser RVU, vaginal. In the CPT® Index, look for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care, the vaginal delivery would be global, described by 59400. The second delivery is coded with 59409 with modifier 51 appended stating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and is not global for both deliveries (59430). 47. 50-year-old male is diagnosed with a tumor of the skull base just below the occipital tonsils. The neurosurgeon performs a transpetrosal approach to the posterior cranial fossa. He then performs an intradural removal of the tumor of the midline skull base. Dural repair is done and the area is closed with Neurolon. What CPT® code(s) is/are reported? a. 61521

c. 61598, 61608-51

b. 61524

d. 61597, 61608-51

ANS:

C

Rationale: In the CPT® Index, look for Skull Base Surgery/Posterior Cranial Fossa/Transpetrosal Approach (61598) and Middle Cranial Fossa (removal of midline skull base)/Intradural (61608) which includes the repair. Modifier 51 is added to indicate the same surgeon performed more than one procedure. 48. A patient has a right thyroid lobectomy for a thyroid follicular lesion. An incision is made two cm above the sternal notch and carried through the platysma. The right thyroid was dissected free from the surrounding tissues. The isthmus was divided from the left thyroid lobe. The left thyroid lobe was explored revealing a single nodule. The right thyroid lobe was completely removed from the trachea and surrounding tissues. It was marked and sent off the table as a specimen. What CPT® code is reported? a. 60200

c. 60220

b. 60210

d. 60240

ANS:

C

Rationale: The patient had a unilateral thyroidectomy. Because only the right side is removed, it is a total unilateral (partial) thyroidectomy. In the CPT® Index, look for Thyroidectomy/Partial and you are directed to code range 60210-60225. 60220 reports a unilateral thyroidectomy with or without an isthmusectomy.

49. 37-year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5-S1, the physician uses the transforaminal approach. The spinal needle is inserted, and the patient experienced paresthesias into her left lower extremities. The anesthetic drug is injected into the epidural space. What CPT® code(s) is/are reported for this procedure? a. 64483, 64484

c. 64493, 64494

b. 64493

d. 64483

ANS:

D

Rationale: In the CPT® index, look for Nerves/Injection/Anesthetic. You are referred to 01991-01992 or 64400-64530. Review the codes to choose appropriate service. 64483 is the correct code since the anesthetic was injected into the epidural space in one single level (L5-S1) in the transforaminal approach. 50. 36-year-old male suffered back pain after heavy lifting and was found to have bilateral disc herniation. The patient was placed prone and general anesthesia given. Incision was then made with a 10-blade knife and dissection was carried downward through the thick adipose tissue to the fascia in a subperiosteal plane. The paraspinous muscles were reflected off L5 and S1. A laminotomy was drilled with the Midas Tex AMB on the inferior end of L5. The thecal sac was retracted medially. The microscope was brought in, direct with microdissection there was a massive disk herniation on the right side underneath the nerve root as well as the left. The disc was incised with an 11-blade knife and was cleaned out with a series of straight and angled curettes and rongeurs. The disc was intertwined with the posterior longitudinal ligament. The space was cleaned out, the foramina were checked and no further compression was found on any of the neural elements. What CPT® codes are reported for this procedure? a. 63047-50, 69990

c. 63030-50, 63035-50, 69990

b. 63030-50, 69990

d. 63005-50, 69990

ANS:

B

Rationale: A laminotomy is also known as a hemilaminectomy. In the CPT® index, look for Hemilaminectomy and you are directed to code range 63020-63044. Code selection is based on the number of interspaces and the section of spine. This is the lumbar spine and only 1 interspace is treated making 63030 the correct code. The parenthetical instructions state to use modifier 50 for a bilateral procedure. This occurred on the left and right side, so modifier 50 is appended. According to CPT®, 69990 is not inclusive to 63030 and should be reported separately. According to NCCI, 69990 is inclusive and cannot be reported separately. For this note, we are following CPT® guidelines. We have included it on all choices to avoid confusion.

60000 Series 51. 89-year-old patient who has significant partial opacities in the lens of the left eye presents for phacoemulsification and lens implantation. What ICD-10-CM code is reported? a. H26.9

c. H26.112

b. H25.9

d. H26.40

ANS:

A

Rationale: In the ICD-10-CM Index to Diseases and Injuries, look for Opacity, opacities/lens-see Cataract. Look for Cataract and you are directed to the default code H26.9. Confirmation in the Tabular List confirms code selection. 52. 6-year-old female with prominent ears undergoes a bilateral otoplasty. Under conscious sedation, the surgeon makes an incision just behind the ear in the natural fold where the ear is joined to the head exposing the cartilage. Cartilage is trimmed and shaped and the incision is closed. Temporary sutures are placed to secure the ear until healing is accomplished. The procedure is repeated on the other ear. What CPT® code(s) is/are reported? a. 69300 x 2

c. 69300-50, 99144

b. 69300-50

d. 69120-50, 99144

ANS:

B

Rationale: In the CPT® Index, look for Otoplasty, it directs you to code 69300 and is confirmed by the code description Auditory System Section. The parenthetical note beneath 69300 instructs us to report the code with modifier -50 for a bilateral procedure. The bulls-eye symbol next to the code indicates that moderate sedation is included with the procedure and would not be coded separately. 53. A patient has heavy skin and muscle (myogenic) that is drooping down and blocking his vision due to ptosis of upper muscular eyelid disorder. The physician performed a bilateral upper blepharoplasty. What ICD-10-CM code is reported? a. H02.423

c. H02.31, H02.34

b. H02.421, H92.422

d. H02.531, H02.534

ANS:

A

Rationale: Drooping (ptosis) of the upper eyelid is due to a muscle disorder (myogenic). In the ICD-10CM Index to Diseases and Injuries, look for Ptosis/eyelid – see Blepharoptosis. Look for Blepharoptosis/myogenic and you are directed to H02.42-. Tabular List indicates sixth character is needed to indicate laterality. Sixth character of 3 is for bilateral. Only one code is reported for both eyelids, not two separate codes.

54. A patient presents to the emergency room with a severely damaged eye. The injury was sustained when the patient was a passenger in a multi-car accident on the public highway. The patient sustained a large open lacerated wound to the left eye. The posterior chamber was ruptured and significant vitreous and some intraocular tissue was lost. The eyeball was not repairable, and so was removed, en masse. A permanent implant was inserted, but not attached to the extraocular muscles. The patient was released with an occlusive eye patch. What CPT® and ICD-10-CM codes are reported? a. 65091-LT, S05.22XS, V49.59XS, Y92.411 b. 65103-LT, S05.22XA, V49.59XA, Y92.488 c. 65093-LT, S05.22XA, V43.92XA, Y92.411 d. 65101-LT, S05.22XD, V89.2XXD, Y92.488 ANS:

B

Rationale: Enucleation is the removal of the eye. At the time of surgery, an implant was inserted and extraocular muscles were not attached to it. In the CPT® Index, look for Enucleation/Eye which gives codes 65101, 65103, 65105. Code 65103 best describes this procedure. The LT modifier is appended to indicate that this was the left eye. In the Index to Diseases and Injuries look for Laceration/eye (ball)/with prolapse or loss of intraocular tissue directing you to S05.2-. Tabular List indicates that seven characters are reported to complete the code. The fifth character 2 is reported to indicate left eye. X is used as placeholder for the sixth character position. The seventh character is A to report initial encounter for the patient receiving active treatment in the ED. Documentation does not provide sufficient details of the “multi-car accident” to specify whether the other cars were in motion and if a collision occurred with other objects/persons. Look in the ICD-10-CM External Cause of Injuries Index for Accident/transport/passenger/collision (with)/motor vehicle NOS (traffic)/specified type NEC (traffic) V49.59-. The sixth character X as a placeholder and seventh character A for initial encounter in the ED. Look for Place of occurrence/highway (interstate) directing you to Y92.411. 55. Xenon laser photocoagulation for prophylaxis of a recent right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. What are the procedure and diagnosis codes for this service? a. 67145, H33.031, W21.03XA b. 67141 c. 67105, H33.001, T15.01XA d. 67145 ANS:

A

Rationale: In the CPT® Index, look for Prophylaxis/Retina/Photocoagulation which lists code 67145. Code 67145 is used for the repair a retinal detachment with tear using laser or xenon arc (photocoagulation). The laser light goes through the dilated pupil without an incision. The physician burns spots at the site of the retinal weakness to seal the retina into place. In ICD-10-CM Index to Diseases and Injuries, look for Detachment/retina/with retinal/break/giant tear directs you to code

H33.03-. In the Tabular List a sixth character 1 is reported for the right eye. In the External Causes of Injuries look for Struck (accidentally) by/ball (hit) (thrown)/baseball. You’re directed to W21.03-. In the Tabular List seven characters is reported to complete the code. The sixth character is a placeholder (X) and the seventh c character A is used to identify the encounter – surgical management represents an initial encounter. 56. A patient with a cyst-like mass on his left external auditory canal was visualized under the microscope and a microcup forceps was used to obtain a biopsy of tissue along the posterior superior canal wall. What CPT® code is reported? a. 69100-RT

c. 69140-RT

b. 69105-LT

d. 69145-LT

ANS:

B

Rationale: In the CPT® Index, look for Auditory Canal/External/Biopsy. Verify in the CPT® Auditory System Section. Code 69105 with modifier LT is correct since the biopsy was taken from the left ear in the auditory canal. 57. What CPT® code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear? a. 69644-RT

c. 69646-RT

b. 69636-RT

d. 69632-RT

ANS:

B

Rationale: In the CPT® Index, look for Tympanoplasty/with Antrotomy or Mastoidotomy/with Ossicular Chain Reconstruction and you are directed to 69636. Append modifier RT to identify the procedure is performed on the right ear. 58. A patient with right and left prominent ears presents for an otoplasty. What CPT® and ICD-10-CM codes are reported? a. 69300, Q17.5 b. 69300-50, Q17.5 ANS:

c. 69310, H61.113 d. 69320, H61.113

B

Rationale: In the CPT® Index, look for Otoplasty and you are directed to 69300. The parenthetical instruction below 69300 states to use modifier 50 to report a bilateral procedure. In the ICD-10-CM Index to Diseases and Injuries, look for Prominence/auricle (congenital) (ear) and you are directed to Q17.5.

59. A patient with mixed conductive and sensorineural hearing loss in the right ear has tried multiple medical therapies without recovery of her hearing. Patient has consented to have an electromagnetic bone conduction hearing device implanted. What CPT® and ICD-10-CM codes are reported? a. 69710-RT, H90.11

c. 69710-RT, H90.71

b. 69714-RT, H90.8

d. 69930-RT, H90.0

ANS:

C

Rationale: In the CPT® Index, look for Hearing Aid/Implants/Bone Conduction/Implantation. You are referred to 69710. Review the code to verify accuracy. In the ICD-10-CM Index to Diseases and Injuries, look for Loss (of)/hearing - see also Deafness. Look for Deafness/mixed conductive and sensorineural/unilateral. You are referred to H90.7-. Review the code in the Tabular List to verify accuracy and fifth character 1 is for right ear. 60. 26-year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia was harvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high-speed drill a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT® code is reported? a. 69436-LT

c.69632-LT

b. 69631-LT

d. 69641-LT

ANS:

B

Rationale: In the CPT® Index, look for Tympanoplasty/without Mastoidectomy. You are referred to 69631. Review the code to verify accuracy. This is the correct code with LT modifier because the repair of the left ear is performed (tympanoplasty) with a canaloplasty, without an ossicular chain replacement or mastoidectomy (removal of a portion of the mastoid of the posterior temporal bone).

Evaluation & Management 61. Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss of consciousness while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. Drake Rinaldi, a prominent member of the neurology faculty at the university saw Mrs. Jones last month. Dr. Howitzer performs a history including 3 HPI elements and 2 ROS, a detailed exam and has medical decision making of high complexity. The final diagnosis given is transient loss of consciousness. The patient makes a follow-up appointment to see Dr. Rinaldi in one week. What is the appropriate diagnosis and E/M code for this visit? a. 99214, R55 c. 99203, R55 b. 99215, R40.1 d. 99202, R40.1

ANS: A Rationale: E/M Guidelines define an established patient as one who has received professional services from the physician – or another physician of the same specialty who belongs to the same group practice – within the past three years. The patient was seen the previous month by another member in the same group practice of the neurology department making this an established patient. The level of history is expanded problem focused defined by a brief HPI and an extended ROS The exam is described as detailed and the MDM is of high complexity. For an established patient, you must meet or exceed two of the three key elements—making this a detailed visit. Two of the three key elements in this visit meet the requirements for 99214. Look in the ICD-10-CM Index to Diseases Injuries for Loss/consciousness, transient directing you to code R55. 62. When tissue glue is used to close a wound involving the epidermis layer how is it reported? a. As though it was a simple closure c. It is not billable b. As a 99211 d. As though it was a complex closure ANS: A Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. 63. Dr. Jones documents Mrs. Smith’s condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and a low medical decision making. What CPT® code should be reported? a. 99221 c. 99232 b. 99231 d. 99233 ANS: B Rationale: This is a subsequent hospital care visit. Subsequent hospital care codes are 99231-99233. Codes in this section require 2 of 3 key components be met. A problem focused exam and low medical decision making supports a 99231. 64. A patient is in the hospital after a wedge resection of the left lung cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient’s family is not present. What CPT® code is reported? a. 99252 c. 99367 b. 99366 d. 99368 ANS:

C

Rationale: In CPT® Index, look for Conference/Interdisciplinary Team and you are directed to code range 99367-99368. 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code. 65. A pediatrician is asked to be in the room during the delivery of a baby at risk for complications. The pediatrician is in the room for 45 minutes. The baby is born and is completely healthy, not requiring the services of the pediatrician. What CPT® code(s) is/are reported by the pediatrician? a. 99219 c. 99360 b. 99252 d. 99360 x 2 ANS: C Rationale: The physician provider standby services. In the CPT® Index, look for Standby Services and you are directed to 99360. 99360 is reported based on time. Each 30 minutes is reported if only the entire 30 minutes is met. 99360 with 1 unit is the correct code choice. 66. 28-year-old female patient is returning to her physician’s office with complaints of RLQ pain and heartburn with a temperature of 100.2. The physician performs a detailed history, detailed exam and determines the patient has mild appendicitis. The physician prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter? a. 99214, K37, R12 c. 99213, K37 b. 99202, R10.31, K37 d. 99203, R50.9, R12, R10.31, K37 ANS: A Rationale: This is an established patient E/M level of service due to the indication she returning to her physician for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-10-CM Official Coding Guidelines Section I.B.6-8, a definitive diagnosis is reported when it has been established. Look in the ICD-10-CM Index to Diseases and Injuries for Appendicitis K37. Any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code. Look in the Index to Diseases and Injuries for Heartburn R12. Verification in the Tabular List confirms code selections. 67. Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer’s disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit? a. 99238, 99305 c. 99239 b. 99238 d. 99239, 99304 ANS:

D

Rationale: Hospital discharge is a time-based code. The documentation states that the physician spent 45 minutes discharging the patient. In the CPT® Index, look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF), where he is a resident. CPT® guidelines preceding the Nursing Facility Services codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission should be reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305. 68. 37-year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics, it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a Pulmonologist PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study. a. 99213 c. 99214 b. 99212 d. 99215 ANS: B Rationale: This is a follow up visit indicating an established patient seen in the clinic. In the CPT® Index, look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History – PF (HPI-Brief, ROS-None, PFSH-Pert), Exam – Problem Focused, MDM – Moderate (Mgmt options - 1 stable problem, one new problem with workup; Data reviewed – lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported. 69. 45-year-old established, female patient is seen today at her doctor’s office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the physician documents a moderate complexity MDM. What CPT® code should be reported for this visit?

a. 99214 b. 99215

c. 99203 d. 99204

ANS: A Rationale: This is a follow up visit indicating an established patient seen in the clinic. In the CPT® Index, look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Detailed (HPI-Extended; ROS-Extended, PFSH-Complete), Exam – Detailed, MDM Moderate. 99214 is the level of visit supported. 70. An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days, on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the physician reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and re-X-ray then. What CPT® code should be reported? a. 99214 c. 99335 b. 99242 d. 99213 ANS: D Rationale: The patient was seen in the clinic, which is an outpatient service. The physician performed a problem focused history (brief HPI, no ROS, and pertinent PFSH) + expanded problem focused exam + moderate MDM (new problem to examiner, three data points, and acute illness with systemic symptoms and prescription drug management). Established patient office visits require two of three components be met. Code 99213 is the appropriate code for this visit. Anesthesia 71. Using your CPT® Index, look up anesthesia for a cholecystectomy. What CPT® code is reported for the anesthesia? a. 00790

c. 00840

b. 00797

d. 00842

ANS:

A

Rationale: Cholecystectomy is not listed separately in the Anesthesia Section. The anesthesia code selections are listed under Anesthesia/Abdomen/Intraperitoneal in the CPT® Index. Cholecystectomy refers to the gallbladder, which is an intraperitoneal organ located in the upper abdomen to assign the correct anesthesia code, 00790. The same code is reported whether the cholecystectomy is an open procedure, or performed laparoscopically. Hint – If your anatomy is not up to par, try looking up the surgical code for a cholecystectomy. The Tabular Listing 47562 offers an anatomical illustration of the gallbladder removal.

72. Using your CPT® Index, look for anesthesia for a complete removal of the penis, including removal of both the left and right inguinal and iliac lymph nodes. What CPT® code is reported for the anesthesia? a. 00932

c. 00936

b. 00934

d. 00938

ANS:

C

Rationale: Look in the CPT® Index under Anesthesia/Penis which provides a range of codes, 0093200938. Review the codes in the Anesthesia Subsection “Perineum” to determine 00936 is the appropriate code selection. Anesthesia code 00932 does not fully describe the procedure, and 00934 does not include removal of the iliac lymph nodes. The correct code is 00936. 73. What is the appropriate code for a patient who had regional block anesthesia provided for carpal tunnel surgery? a. 20526

c. 01820

b. 00400

d. 01810

ANS:

D

Rationale: In this example, it is important to understand the type of anesthesia provided will not determine the anesthesia code. CPT® code 20526 is a therapeutic injection into the carpal tunnel. Anesthesia code 00400 refers to an integumentary procedure and 01820 describes a closed procedure on the lower arm and hand. The code options are located in the CPT® Index under Anesthesia/Arm/Lower. To capture the correct anesthesia code, 01810, the coder must know carpal tunnel surgery refers to the median nerve in the wrist. Hint – If your anatomy is not up to par, try looking up the surgical code for clues to the anatomical area. 74. What is/are the appropriate anesthesia code(s) for an obstetric patient who had neuraxial labor analgesia provided by the anesthesiologist? The delivery was expected to be a normal delivery; however, the obstetrician performed a cesarean delivery when the fetal heart rate dropped. What CPT® code(s) is/are reported for the anesthesia? a. 62319

c. 01968

b. 01967

d. 01967, 01968

ANS:

D

Rationale: The continuous epidural catheter from the surgical section is a flat-fee or surgical code and does not accurately describe the anesthesia service. 01967 describes the initial service, without the cesarean delivery and +01968, an add-on code for a cesarean section following neuraxial labor cannot be reported alone. The anesthesia codes are located in the CPT® Index under Anesthesia/Neuraxial/Labor and Anesthesia/Cesarean Delivery.

75. 42-year-old patient was undergoing anesthesia in an ASC and began having complications prior to the administration of anesthesia. The surgeon immediately discontinued the planned surgery. If the insurance company requires a reported modifier, what modifier best describes the extenuating circumstances? a. 53

c. 73

b. 23

d. 74

ANS:

C

Rationale: The modifier 73 best describes an anesthesia service discontinued prior to administration of anesthesia in an ASC. Refer to Appendix A in your CPT® codebook under the heading Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use. 76. Anesthesia start time is reported as 7:14 am, and the surgery began at 7:26 am. The surgery finished at 8:18 am and the patient was turned over to PACU at 8:29 am, which was reported as the ending anesthesia time. What is the anesthesia time reported? a. 7:14 am to 8:18 am (64 minutes)

c. 7:26 am to 8:18 am (52 minutes)

b. 7:14 am to 8:29 am (75 minutes)

d. 7:26 am to 8:29 am (63 minutes)

ANS:

B

Rationale: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Anesthesia time ends when the anesthesiologist is no longer in personal attendance. Ending time is generally reported when the patient is safely placed under postoperative supervision, usually in the Post Anesthesia Care Unit (PACU) or equivalent area. Anesthesia start time (7:14) and anesthesia end time (8:29) calculates as one hour and 15 minutes of total anesthesia time. 77. A pre-anesthesia assessment was performed and signed at 10:21 a.m. Anesthesia start time is reported as 12:26 pm, and the surgery began at 12:37 pm. The surgery finished at 15:12 pm and the patient was turned over to PACU at 15:26 pm, which was reported as the ending anesthesia time. What is the anesthesia time reported? a. 10:21 am to 15:12 pm (291 minutes)

c. 12:26 pm to 15:12 pm (146 minutes)

b. 12:26 pm to 15:26 pm (180 minutes)

d. 12:37 pm to 15:26 pm (169 minutes)

ANS:

B

Rationale: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Pre-anesthesia assessment time is not part of reportable anesthesia time, as it is considered in the base value assigned for the procedure. Anesthesia time ends when the anesthesiologist is no longer in personal attendance. Ending time is generally reported when the patient is safely placed under postoperative supervision, usually in the Post

Anesthesia Care Unit (PACU) or equivalent area. Anesthesia start time (12:26) and the anesthesia end time (15:26) calculates as three hours or one hundred eighty (180) minutes of total anesthesia time. 78. Code 00350 Anesthesia for procedures on the major vessels of the neck; not otherwise specified has a base value of ten (10) units. The patient is a P3 status, which allows one (1) extra base unit. Anesthesia start time is reported as 11:02 am, and the surgery began at 11:14 am. The surgery finished at 12:34 am and the patient was turned over to PACU at 12:47 am, which was reported as the ending anesthesia time. Using fifteen-minute time increments and a conversion factor of $100, what is the correct anesthesia charge? a. $1,500.00

c. $1,700.00

b. $1,600.00

d. $1,800.00

ANS:

D

Rationale: Determining the base value is the first step in calculating anesthesia charges and payment expected. Time reporting is the second step. Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in either the operating room or an equivalent area. Anesthesia time ends when the anesthesiologist is no longer in personal attendance. Ending time is generally reported when the patient is safely placed under postoperative supervision, usually in the Post Anesthesia Care Unit (PACU) or equivalent area. Physical status modifiers and/or qualifying circumstances may also be added to the charge. In the scenario above, Base units equal ten (10) plus one (1) physical status modifier unit (Base 10 + PS 1 = 11 units). Seven (7) time units, in fifteen minute increments, is calculated by taking the anesthesia start time (11:02) and the anesthesia end time (12:47) and determining one hour 45 minutes (105/15 = 7) of total anesthesia time. Eighteen units (11 + 7 = 18) are then multiplied by the $100 conversion factor (18 X $100 = $1,800.00).

Radiology 79. A patient reports to the hospital radiology department for a functional MRI of the brain. The technologist asks the patient to perform small tasks. He takes the images of the patient at rest and while performing the tasks. What CPT® code is reported? a. 70554

c. 70551

b. 70555

d. 70552

ANS:

A

Rationale: The test performed is a functional MRI of the brain. From the CPT® Index, look for Magnetic Resonance Imaging (MRI)/Diagnostic/Brain. You are referred to 70551-70555. Refer to the code descriptions. There are two codes describing functional MRI, which are 70554 and 70555. Because the test is performed by the technician, not a physician, the service is reported with 70554.

80. A parent brings her child to the ED. She thinks she swallowed a small toy figure. A radiology exam from the nose to the rectum is performed. The foreign body is not located. What CPT® code(s) is/are reported for the radiology services? a. 70160, 70370, 71010, 74245

c.76010

b. 43235, 44363

d. 70160, 70370, 71010, 43235, 44363

ANS:

C

Rationale: The radiology exam is performed to locate a foreign body, yet no foreign body is found. In the CPT® Index, look for X-ray/Nose to Rectum/Foreign Body. The correct code is 76010. 81. Procedure: Body PET-CT Skull Base to Mid-thigh History: A 65-year-old male Medicare patient with a history of rectal carcinoma presenting for restaging examination. Description: Following the IV administration of 15.51 mCi of F-18 deoxyglucose (FDG), multiplanar image acquisitions of the neck, chest, abdomen and pelvis to the level of mid-thigh were obtained at one-hour post-radiopharmaceutical administration. What CPT® code(s) is/are reported? a. 78815

c. 70542, 71555, 74182

b. 70491, 71551, 74176

d. 78816

ANS:

A

Rationale: The procedure performed is a PET-CT scan. The appropriate code is selected based on the anatomical location of the study. In this scenario, we know the test was performed on the skull base to the mid-thigh. In the CPT® Index, see Nuclear Medicine/Diagnostic/Positron Emission Tomography (PET)/with Computed Tomography 78814-78816. According to CPT® coding guidelines, the IV administration of FDG (96365) is not reported separately. It is bundled in the service for the radiology procedure. 82. 25-year-old female in her last trimester of her pregnancy comes into her obstetrician’s office for a fetal biophysical profile (BPP). An ultrasound is used to first monitor the fetus’ movements showing three movements of the legs and arms (normal). There are two breathing movements lasting 30 seconds (normal). Non-stress test (NST) of 30 minutes showed the heartbeat at 120 beats per minute and increased with movement (normal or reactive). Arms and legs were flexed with fetus’ head on it chest, opening and closing of a hand. Two pockets of amniotic fluid at 3cm were seen in the uterine cavity (normal). Biophysical profile scored 9 out of 10 points (normal or reassuring). What CPT® code is reported by the obstetrician? a. 76818

c. 76815

b. 76819

d. 59025, 76818

ANS:

A

Rationale: A biophysical test (BPP) measures the health of the fetus during pregnancy. Points are given (0, 1 or 2) in five areas (fetal movement, tone, heart rate, breathing, amniotic fluid volume). A non-stress test (NST) monitors the baby's heart rate over a period of 20 minutes or more looking for accelerations with baby's movement. Because fetal non-stress test is included in code 76818, code 59025 Fetal nonstress test, should not be reported separately. This is found in the CPT® Index under Fetal Biophysical Profile directing you to 76818-76819. 83. A patient 14 weeks pregnant is coming back to her obstetrician’s office for a repeat transabdominal ultrasound to measure fetal size and to confirm abnormalities seen in a previous scan. The obstetrician documented the ultrasound results in the medical record. What CPT® code is reported by the obstetrician? a. 76805

c. 76816

b. 76805-26

d. 76816-26

ANS:

C

Rationale: The patient is coming back for a follow-up (repeat) ultrasound to re-evaluate conditions affecting the fetus seen on the last ultrasound scan. No modifier 26 is needed because the ultrasound and the interpretation of the results were performed in the obstetrician’s office. In the CPT® Index, look for Ultrasound/Pregnant Uterus to find the code range. 84. The patient has malignant ascites due to ovarian cancer. She is coming back to the operating room for a planned ultrasound guided abdominal paracentesis. This is the second time she needed fluid removed from the abdominal cavity. What CPT® and ICD-10-CM codes are reported? a. 49083-78, 77002-26, R18.0

c. 49082, 77012-26, R18.0, C56.9

b. 49082-76, 76942-26, R18.0, C56.9

d. 49083, C56.9, R18.0

ANS:

D

Rationale: The patient is coming in for a subsequent (second or staged) abdominal paracentesis. However, 49083 has 000 for the global day’s indicator. Modifier 58 is not required. Code 49083 includes imaging guidance. In the CPT® Index look for Paracentesis/Abdomen directing you to 49082-49083. Look in the Index to Diseases and Injuries for Cancer and you are directed to see also Neoplasm, by site, malignant. Go to the Table of Neoplasms. Look for Neoplasm, neoplastic, ovary/Malignant Primary (column) guiding you to code C56.-. Tabular List a fourth charter is reported, complete code is C56.9. Malignant ascites is indexed under Ascites/malignant, guiding you to code R18.0. In the Tabular List, there is a Code first note under code R18.0 indicated to Code first malignancy, such as: malignant neoplasm of ovary (C56.-); secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6).” This means the malignant ascites is reported as a secondary code and the ovarian cancer is reported as the primary diagnosis code.

85. 82-year-old female with a right leg medial malleolar non-healing ulcer elected to proceed with peripheral angiography. Using a RIM catheter, from a left femoral artery access, the contralateral right iliac artery was accessed and the catheter was gradually advanced to the right common femoral artery. The right lower extremity angiography was performed with both C02 injection and subsequently localized pictures of femoral distal bypass grafts were performed using contrast injections. This revealed the right superficial femoral artery is 100% occluded at its origin. Decision for angioplasty was made and intervention was performed through this area with a 7 mm x 20 mm balloon inflated up to 7 atmospheres. The gradual inflation resulted in enlarging the artery to a more normal flow of blood. What CPT® codes is/are reported? a. 37224, 75716-26-59

c. 35472, 36246, 75962-26-59

b. 37224, 75710-26-59

d. 37220, 75710-26-59

ANS:

B

Rationale: The second order selective catheterization (36246) for the diagnostic angiography will not be reported as an additional code, because the catheterization was performed through the same access site as the interventional angioplasty, code 37224. The diagnostic angiography is reported with 7571026-59. Because the decision to perform the angioplasty was made after reading the films for the diagnostic angiography, modifier 59 is appended to show that it is not bundled with code 37224.This information is found in the Vascular Procedures Guidelines of the Radiology Section in the CPT® codebook. In the CPT® Index, look for Angioplasty/Femoral Artery/Intraoperative direction you to 37224. Look for Angiography/Leg Artery directing you to 73706, 75635, 75710-75716. 86. Myocardial Perfusion Imaging—Office Based Test Indications: Chest pain. Procedure: Resting tomographic myocardial perfusion images were obtained following injection of 10 mCi of intravenous Cardiolite. At peak exercise, 30 mCi of intravenous Cardiolite was injected, and poststress tomographic myocardial perfusion images were obtained. Post stress gated images of the left ventricle were also acquired. Myocardial perfusion images were compared in the standard fashion. Findings: This is a technically fair study. There were no stress induced electrocardiographic changes noted. There are no significant reversible or fixed perfusion defects noted. Gated images of the left ventricle reveal normal left ventricular volumes, normal left ventricular wall motion, and an estimated left ventricular ejection fraction of 50%. Impression: No evidence of myocardial ischemia or infarction. Normal left ventricular ejection fraction. What CPT® code(s) is/are reported? a. 78472

c. 78453

b. 78452

d. 78454

ANS:

B

Rationale: Tomographic myocardial perfusion imaging was performed. In this procedure the patient receives an intravenous injection of a radionuclide, which localizes in nonischemic tissue. SPECT (single photon emission computed tomographic) images of the heart are taken immediately to identify areas of perfusion vs. infarction. In the CPT® Index, look for Heart/Myocardium/Perfusion Study 78451-78454. A single study SPECT was performed, 78451. The MPI was performed at rest and exercise (which is stress), reporting code 78452 for multiple studies. 87. After intravenous administration of 5.1 millicuries Tc-99m DTPA, flow imaging of the kidneys was performed for approximately 30 minutes. Flow imaging demonstrated markedly reduced flow to both kidneys bilaterally. What CPT® code is reported? a. 78710

c. 78708

b. 78701

d. 78725

ANS:

B

Rationale: The nuclear imaging test follows the blood as it flows to the kidneys identifying any obstruction and to determine the rate at which the kidneys are filtering. The scenario does not document the function of the tubes and ducts. In the CPT® Index, look for Nuclear Medicine/Diagnostic/Kidney/Vascular Flow directing you to code range 78701-78709. 88. An oncology patient is having weekly radiation treatments with a total of seven conventional fractionated treatments. Two fractionated treatments daily for Monday, Tuesday and Wednesday and one treatment on Thursday. What radiology code(s) is/are appropriate for the clinical management of the radiation treatment? a. 77427

c. 77427 x 2

b. 77427 x 7

d. 77427-22

ANS:

A

Rationale: There are seven fractions given in this patient’s weekly treatment. According to CPT® guidelines, radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time-period in which the services are furnished. Code 77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment, one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately.” This instruction is found in CPT® under the heading “Radiation Treatment Management” in the Radiology/Radiation Oncology Section of the Radiology Chapter. In the CPT® Index look for Radiation Therapy/Treatment Management/Weekly directing you to 77427. Laboratory and Pathology 89. A patient has a traumatic head injury and some cerebrospinal fluid (CSF) is removed to limit potential damage from swelling of the brain. The CSF is sent to pathology for examination and the

results show unusual cytological counts, although no specific findings. The patient has had no previous symptoms known to his family members. What is the ICD-10-CM code for this examination of CSF? a. R83.6 c. S06.1X0A b. A39.0 d. Z00.001 ANS: A Rationale: Code R83.6 is used to describe non-specific abnormal findings on examination of CSF. If the patient had previously identified disease or symptoms or if the study findings are definitive for a specific disease process, that would have been coded instead. In the ICD-10-CM Index to Diseases and Injuries, look for Abnormal/cerebrospinal fluid/cytology, R83.6.Verification in the Tabular List confirms code. 90. If the findings on examination of a Pap smear are normal and described as “negative for intraepithelial lesion or malignancy” this is an example of what type of results reporting? a. Cytogenetics c. Bethesda b. Non-Bethesda d. surgical pathology ANS: C Rationale: This is an example of reporting by the Bethesda method. In the CPT® Index, look for Bethesda System referring you to 88164-88167. On the page before this code range, read the Guidelines where it discusses the Bethesda & non-Bethesda reporting of Pap smears. 91. 27-year-old male dies of a gunshot wound. An autopsy is performed to gain evidence for the police investigation and any subsequent trial. What CPT® code is reported? a. 88005 c. 88040 b.88025 d. 88045 ANS: C Rationale: Services related to legal investigations and trials are forensic examinations. This can be found in the CPT® Index under Forensic Exam, or under Autopsy/Forensic Exam directing you to 88040. 92. A patient presents with right upper quadrant pain, nausea, and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders an albumin; bilirubin, both total and direct; alkaline phosphatase; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. What CPT® code(s) is/are reported? a. 82040, 82247, 82248, 84075, 84155, 84460, 84450, 82565 b. 80076, 82565 c. 80076 d. 80076-22 ANS: B Rationale: Code the laboratory panel anytime all of the tests listed in the panel are completed. If additional tests are also performed, they are coded separately. In the CPT® Index, see Blood Tests/Panels/Hepatic Function. Also, see Creatinine/Blood

93. 35-year-old that is a type II diabetic is feeling weak. The physician performs a stat glucose test in which a finger stick is done placing the drop of blood on a reagent strip. The test indicates the patient is hypoglycemic. The physician gives the patient some glucose supplements and performs another stat glucose test using the same lab test as before 30 minutes later. The second test shows the glucose levels returned to normal. How are the lab tests reported? a. 82947, 82947-91 c. 82948, 82948-91 b. 82947, 82947-76 d. 82948, 82948-76 ANS: A Rationale: Look in the CPT® Index for Glucose/Blood Test referring you to codes 82947-82948, 82950. The lab test used a reagent strip for the glucose test reporting code 82948. Modifier 91 is the correct modifier to use when a laboratory test is performed more than once. 94. A couple with inability to conceive has fertility testing. The semen specimen is tested for volume, count, motility and a differential is calculated. The findings indicate infertility due to oligospermia. What CPT® and ICD-10-CM codes are reported? a. 89310, 89320, Z31.41 c. 89320, N46.11 b. 89257, Z31.41 d. 89264, N46.11 ANS: C Rationale: Choose the CPT® code completely identifying the service. Only use multiple codes if there is no code describing everything performed. In this case, a very specific diagnosis is known and the code is used. In the CPT® Index, look for Semen Analysis directing you to code range 89300-89322. Code 89320 reports all of the tests performed. For the ICD-10-CM diagnosis code, look in the Index to Diseases and Injuries for Infertility/male/oligospermia leading you to N46.11. Verification in the Tabular List confirms this code is reported for Oligospermia NOS. 95. In a legal hearing to determine child support there is a dispute about the child’s paternity. The court orders a paternity test, and a nasal smear is taken from the plaintiff and the child. The plaintiff is confirmed as the father of the child. Choose the CPT®, ICD-10-CM codes and modifier for the paternity testing. a. 89190-32, Z31.448 c. 86900, Z02.81 b. 86910-32, Z02.81 d. 86910, Z31.448 ANS:

B

Rationale: Always choose codes identifying the service and reason for the service as specifically as possible. Parenthetic comments in CPT® can sometimes assist in finding a challenging code. Modifier 32 is appropriate when services are mandated by courts or insurers. In the CPT® Index, look for Paternity Testing. For the ICD-10-CM code, look in the Index to Diseases and Injuries for Encounter (with health service) (for)/administrative purpose only/examination for/paternity testing directing you to Z02.81. 96. A virus is identified by observing growth patterns on cultured media. What is this type of identification is called? a. Definitive c. Quantitative b. Qualitative d. Presumptive ANS: D Rationale: Presumptive identification identifies microorganisms like viruses by observing growth patterns and other characteristics. 97. A couple has been trying to conceive for nine months without success. Preliminary studies show the woman ovulates and the husband’s sperm count is good. A sperm sample is submitted for both a post coital Huhner test and a hamster penetration test. Report the codes. a. 89300, 89320 c. 89300, 89329 b. 89310, 89330 d. 89325, 89260 ANS: C Rationale: The post coital test is described by code 89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital), and is listed in the CPT® Index under Huhner Test/Semen Analysis. It is not specified as a complete. The second test ordered and performed on the sperm sample is a hamster penetration test, specified by code 89329 Sperm evaluation; hamster penetration test. This can be found in the CPT® Index under Hamster Penetration Test/Sperm Evaluation. 98. Esther Glass has a primary cancer located in the intra-hepatic biliary tract and had a cholecystectomy and biopsy of the duodenum was done. Two separate specimens (gall bladder, biopsy of duodenum) were sent to the pathologist working at a hospital laboratory. The technician prepared the slides and the pathologist (self-employed) read them. Select the best code or codes for the pathologist’s services. a. 88305-26 x2 c. 88304-26 x2 b. 88304-26, 88305-26 d. 88304, 88305 ANS: B Rationale: Two different specimens from two different locations were sent to pathology. The first specimen is the gall bladder as evidenced by the documentation for cholecystectomy. Code 88304 is a level III specimen. Code 88305 corresponds to a level IV biopsy of the duodenum. In the CPT® Index, see Pathology and Laboratory/Surgical Pathology/Gross and Micro Exam. Modifier 26 is added to each code because the pathologist was not an employee of the hospital lab and provided the professional component only.

Medicine 99. 59-year-old male experienced left arm pain while cleaning the garage. There was no injury. His physician scheduled a 30-minute stress test using the Bruce Protocol at the hospital. There was no arm pain while on the treadmill; he did have a slight heart rhythm abnormality. The patient rested for 2 minutes. He had no further symptoms or pain. The cardiologist supervised the study, interpreted the test and dictated a report. What CPT® code(s) is/are reported? a. 93015 c. 93016, 93018 b. 93015-26 d. 93018 ANS: C Rationale: In the CPT® Index, look for Stress Tests/Cardiovascular you are directed to code range 9301593024. The Bruce Protocol requires use of a treadmill. Code 93015 is used when the stress test is performed in a clinic because it includes the technical component. According to the CPT® Assistant, January 2010, when a physician performs the stress test in a hospital, the separate components of the portions the physician performed are reported. In this case, he performed supervision (93016) and interpretation with report (93018). 100. 70-year-old patient with chronic obstructive asthma is brought to the urgent care center with increased wheezing and coughing. The physician initiated an Albuterol inhalation treatment, one dose, delivered by nebulizer. After treatment, the patient’s exacerbation was somewhat improved but the physician determined a second treatment was necessary. What codes are reported? a. 94644-76, J7609, J45.909 c. 94680, J7609, J45.901 b. 94664, J7609, J44.1 d. 94640, 94640-76, J7609 x 2, J44.1 ANS: D Rationale: In the CPT® Index, look for Inhalation Treatment/for Airway Obstruction/Pressured or Nonpressured and you are directed 94640. Inhalation treatment was given therapeutically in treating the acute airway obstruction. Two treatments were given so code 94640 is reported twice. Under code 94640, there is a parenthetical instruction stating to use modifier 76 if more than one inhalation treatment is performed on the same date. Because treatment is in the office (urgent care is considered office treatment), the physician will also bill for the medication used. In this case, it is albuterol. J7609 is reported for albuterol per dose. Two doses were given, J7609x2 which is found in the HCPCS Level II book. For the diagnosis, in the Index to Diseases and Injuries look for Asthma/chronic obstructive/with exacerbation (acute) directing you to J44.1. There is no mention of status asthmaticus, but exacerbation is mentioned. The diagnosis code is J44.1. Verification in the Tabular List confirms code selection.

101. A patient diagnosed with amyotrophic lateral sclerosis has increasing muscle weakness in the upper extremities. The physician orders needle electromyography (EMG) to record electrical activity of the muscles. What CPT® and ICD-10-CM codes are reported? a. 95860, G12.21 c. 95861, G12.22 b. 95861, G12.21 d. 95869, G12.22 ANS: B Rationale: In the CPT® Index, look for Electromyography/Needle/Extremities and you are directed to code range 95860-95864. Code selection is based on the number of extremities studied. In this case, two extremities (upper) are studied making 95861 the correct code selection. Amyotrophic lateral sclerosis (ALS) is also known as Lou Gehrig’s disease. In the ICD-10-CM Index to Diseases and Injuries, look for Sclerosis/amyotrophic (lateral), you are directed to code G12.21. Verification in the Tabular List confirms code selection. 102. A baby was born with a ventricular septal defect (VSD). The physician performed a right heart catheterization and transcatheter closure with implant by percutaneous approach. What codes are reported? a. 93530, 93581-59, Q21.9 c. 93530, Q20.4 b. 93581, Q21.0 d. 93530, 93581-59, Q21.0 ANS: B Rationale: In the CPT® Index, look for Septal Defect/Closure/Ventricular you are directed to code 93581 and some other code ranges. There is a parenthetical note under code 93581 not to report code 93530 with code 93581. VSD is a congenital condition (present at birth). In the ICD-10-CM Index to Diseases and Injuries, look for Defect/ventricular septal, you are directed to Q21.0. Verification in the Tabular List confirms code selection. 103. 49-year-old female was brought to the emergency department. She was lethargic, but awake. She is 4 years post liver transplant. Neurology was consulted who determined the patient was encephalopathic with altered mental status. There was some question whether she had had a seizure. An EEG and WADA test were performed. What CPT® and ICD-10-CM codes are reported? a. 95950, 95958, R41.82 b. 95950, 95958-59, R41.82, Z94.4 c. 95958, G93.40, R41.82, Z94.4 d. 95950, 780.93, Z96.89 ANS: C Rationale: In the CPT® Index, look for WADA Activation Test and you are directed to code 95958. You can also see Electroencephalography/Monitoring/with WADA Activation. The WADA activation test is coded as 95958 and includes EEG monitoring.

For the diagnoses, look in the ICD-10-CM Index to Diseases and Injuries for Encephalopathy, you are directed to G93.40. Next, look for Alteration/mental status directing you to R41.82. The patient is also status post liver transplant, which is found in the Index to Diseases and Injuries under Transplant(ed) (status)/liver Z94.4. Verification of the codes in the Tabular List confirms code selections. 104. A patient with carcinoma of the descending colon presents for chemotherapy administration at the infusion center. The infusion was started with 1000 cc of normal saline. Heparin, 1000 units was added and then Fluorouracil, 800 mg was added and infused over 2 hours. Dexamethasone, 20 mg was administered, IV push. At the end of the 2 hours, the IV was disconnected and the patient was discharged. What codes are reported? a. 96413, 96415, 96375, J9190 x 2, J1100 x 20, J1644, Z51.11, C18.6 b. 96413, 96375, J9190 x 2, J1100 x 20, Z51.12, C18.8 c. 96413, J9190, J1100, J1642, Z51.11, C18.6 d. 96415, 96375, J9190, J1100, J1644, Z51.0, C18.9 ANS:

A

Rationale: Chemotherapy infusion administration is reported as 96313 for the 1st hour and 96315 for each additional hour. In the Index, see Chemotherapy/Intravenous/Infusion. The chemotherapy ran for 2 hours; report 96413 & 96415. Dexamethasone was administered as a push technique; report as 96375. This is a sequential infusion following the initial service of chemotherapy. Dexamethasone is not a chemotherapy agent. This is found in the CPT® Index under Injection/Intravenous Push 96374-96376. The chemotherapy drugs are Fluorouracil, J9190 (HCPCS Level II). It is listed as 500 mg, therefore 2 units are charged for 800 mg administered. Heparin (J1644) is listed as 1,000 units, therefore one unit is reported for the 1000 units given. Dexamethasone is packaged in 1 mg; charge 20 units for the 20 mg administered (J1100). A visit for the purpose of chemotherapy is reported as Z51.11. In the Index to Diseases and Injuries, look for Chemotherapy/cancer. Report also the reason for the chemotherapy. In this case, it is carcinoma of the descending colon, code C18.6. Look for Carcinoma- see also Neoplasm, by site, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic/intestine, intestinal/large/descending/Malignant Primary column C18.6. Verification in the Tabular List confirms code selection. 105. A patient with Sickle cell anemia with painful sickle crisis received normal saline IV, 100 cc per hour to run over 5 hours for hydration in the physician’s office. She will be given Morphine & Phenergan, prn (as needed). What codes are reported? a. 96360, 96361 x 4, J7050 x 2, D57.00

c. 96360, 96361 x 3, J7030, D57.00

b. 96360 x 5, J7050, D57.1

d. 96360, J7030, D57.819

ANS:

A

Rationale: In the CPT® Index, look for Hydration, you are directed to codes 96360-96361. The hydration will run 5 hours at 100 cc per hour. Code the hydration therapy as 96360 for the first hour, then 96361 x

4 to get a total infusion time of 5 hours. Code for the normal saline with J7050 x 2 units for 500 cc (HCPCS Level II). The type of Sickle Cell anemia is not identified, but the patient has painful sickle crisis. In the ICD-10-CM Index to Diseases and Injuries, look for Diseases/sickle-cell/with crisis. Apply code D57.00. Verification in the Tabular List confirms code selection. 106. A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid. What HCPCS Level II and ICD-10-CM codes should be reported? a. V5140, H90.3, Z46.1

c. V5140, H90.6

b. V5261, Z46.1, H90.3

d. V5261, Z01.110, H90.3

ANS:

B

Rationale: The hearing aid is reported with V5261, digital binaural behind the ear appliance. The purpose of the visit is the fitting of the hearing aid. Look in the Index to Disease and Injuries for Fitting (and adjustment) (of)/hearing aid directing you to Z46.1. The condition necessitating the hearing aid is bilateral sensory hearing loss. In the Index to Diseases and Injuries, look for Deafness/sensorineural/bilateral. This is reported with H90.3. Verification in the Tabular List confirms code selection. 107. 55-year-old patient had several episodes of fecal incontinence. A colonoscopy had been performed one year ago with normal results. Anorectal manometry was performed to determine the pressure on the sphincter muscles. The test indicated a mild relaxation of the sphincter. Biofeedback training was prescribed. What CPT® and ICD-10-CM codes are reported? a. 90901, R10.0, R15.0

c. 91122, 90911, R10.0

b. 91122, 90911, K62.0

d. 91122, K62.89, R15.9

ANS:

D

Rationale: In the CPT® Index, look for Manometry/Anorectal, you are directed to 91122. Biofeedback training is not reported since it was not performed; it is prescribed to be performed. The diagnosis, relaxation of anal sphincter is reported with K62.89, other disorders of rectum and anus. In the ICD-10-CM Index to Diseases and Injuries, look for Relaxation/anus (sphincter). Next look for Incontinence/feces directing you to R15.9. Verification in the Tabular List confirms code selection. 108. 49 year old patient had several episodes of esophageal reflux and underwent a gastroesophageal reflux test to measure the pH balance (a measure of the degree of acidity or alkalinity). The test was performed with a mucosal attached capsule. The physician provided an interpretation and report. The physician stated the diagnosis as gastroesophageal reflux. What CPT® and ICD-10-CM codes are reported? a. 91034, K21.9

c. 91037, R12

b. 91034, K21.0

d. 91035, K21.9

ANS:

D

Rationale: In the CPT® Index, look for Acid Reflux Test/Esophagus, you are directed to code range 91034-91035, 91037-91038. The physician measured the pH balance and used a mucous capsule, which attaches the electrode to the mucous in the esophagus. Catheter placement of the electrode is becoming rare with the development of the mucous attaching capsule. In the ICD-10-CM Index to Diseases and Injuries, look for Reflux/gastroesophageal. The diagnosis code for gastroesophageal reflux without esophagitis is K21.9. Reflux is regurgitation of gastric contents into the mouth, caused by incompetence of the lower esophageal sphincter. Verification in the Tabular List confirms code selection.

Medical Terminology 109. The meaning of the root “blephar/o” is: a. Choroid c. Eyelid b. Sclera d. Uvea ANS: C 110. The meaning of heteropsia (or anisometropia) is: a. Blindness in half the visual field c. Unequal vision in the two eyes b. Double vision d. Blindness in both eyes ANS: C 111. The radiology term “fluoroscopy” is described as: a. Technique using magnetism, radio waves and a computer to produce images b. An X-ray procedure allowing the visualization of internal organs in motion c. A scan using an X-ray beam rotating around the patient d. Use of high-frequency sound waves to image anatomic structures ANS: B 112. Sialography is an X-ray of : a. Sinuses c. Salivary glands b. Liver d. Ventricles of the brain ANS: C 113. A projection is the path of the X-ray beam. If the projection is front to back it would be:

a. Lateral b. Recumbent

c. Decubitis d. Anteroposterior

ANS: D 114. Cytopathology is the study of: a. Tissue c. Blood b. Cells d. Organs c. ANS: B 115. The process of preserving cells or whole tissues at extremely low temperatures is known as: a. Cryotherapy c. Cryalgesia b. Cryopexy d. Cryopreservation ANS: D 116. A gonioscopy is an examination of what part of the eye: a. Anterior chamber of the eye c. Lacrimal duct b. Interior surface of the eye d. Posterior segment ANS: A

Anatomy 117. Which cells produce hormones to regulate blood sugar? a. Eosinophils c. Hemoglobin b. Pancreatic islets d. Target cells ANS: B 118. Which part of the brain controls blood pressure, heart rate and respiration? a. Cortex c. Cerebellum b. Cerebrum d. Medulla ANS: D 119. What are chemicals which relay, amplify and modulate signals between a neuron and another cell? a. Neurotransmitters c. Interneurons b. Hormones d. Myelin

ANS: A 120. Which of the following conditions results from an injury to the head? The symptoms include headache, dizziness and vomiting. a. Meningitis c. Concussion b. Parkinson’s disease d. Epilepsy ANS: C 121. Lacrimal glands are responsible for which of the following? a. Production of tears c. Production of vitreous b. Production of zonules d. Production of mydriatic agents ANS: A 122. Which of the following does NOT contribute to refraction in the eye? a. Aqueous c. Cornea b. Macula d. Lens ANS: B 123. A patient diagnosed with glaucoma has: a. A lens that is no longer clear c. Abnormally high intraocular pressure b. Bleeding vessels on the retina d. Corneal neovascularization ANS: C 124. Which of the following is true about the tympanic membrane? a. It separates the middle ear from the inner ear b. It separates the external ear from the middle ear c. It sits within the middle ear d. It sits within the inner ear ANS: B

ICD-10-CM 125. What is the ICD-10-CM code for swine flu? a. A08.4 b. J11.1 c. J09.X2 d. J10.1 ANS: C Rationale: Look in the ICD-10-CM Alphabetic Index for Flu/swine. You are directed to J09.X2. Verify code selection in the Tabular List. 126. What is the ICD-10-CM code for UTI? a. A54.00 b. N71.9 c. T80.29XA d. N39.0 ANS: D Rationale: UTI stands for urinary tract infection. Look in the ICD-10-CM Alphabetic Index for Infection/urinary (tract) N39.0. Verify code selection in the Tabular List. There is an instructional note “Use additional code to identify organism.” There is no documentation to support an additional code so no additional code is reported. 127. A patient presents to the Emergency Department with nausea and vomiting, abdominal pain and fever. The physician suspects appendicitis. The test results are pending. What ICD-10-CM code(s) is/are reported? a. R11.2, R10.9, R50.9 b. K37 c. R11.2, R10.9, R50.9, K37 d. R11.0, R11.10, R10.9, R50.9

ANS:

A

Rationale: General Coding Guideline Section 1.B.4 indicates codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a physician has not established (confirmed) the diagnosis. Section II.H, states do not code a diagnosis documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis.” Nausea and vomiting has a combination code. Coding Guideline Section I.B.9 states that multiple coding should not be reported when a combination code clearly identifies all the elements documented in the diagnosis. 128. What diagnosis code is reported for secondary neoplasm of the descending colon? a. C18.6

c. C19

b. D01.0

d. C78.5

ANS:

D

Rationale: ICD-10-CM Alphabetic Index, Table of Neoplasms, look for Neoplasm/colon. You are directed to See also Neoplasm, intestine, large. Find Neoplasm/intestine/large/colon/descending and use the code from the Malignant Secondary column guiding you to code C78.5. Verify in the Tabular List. 129. What ICD-10-CM code is reported for a patient who is a habitual abuser of cannabis? a. F12.129

c. F12.159

b. F12.10

d. F12.121

ANS:

B

Rationale: In the ICD-10-CM Alphabetic Index, look for Abuse/drugs/cannabis guiding you to subcategory code F12.10. Verify in the Tabular List. 130. A 22-year-old patient status post-surgery developed a post-operative infection. The patient quickly deteriorated and became septic, developed gas gangrene (gas bacillus infection) and went into shock. With aggressive intravenous antibiotic management, the patient improved. What ICD-10-CM codes are reported? a. T81.12XA, T81.4XXA, A48.0, R65.21 b. T81.4XXA, A48.0, R65.21 ANS:

c. R65.21, T81.4XXA, T81.12XA d. T81.4XXA, R65.21, A48.0

D

Rationale: Assign code T81.4XXA Infection following a procedure, as the principal diagnosis. There is a note indicating to use additional code to identify infection and a use additional code to identify severe sepsis (R65.2-). For the infection, look in the ICD-10-CM Alphabetic Index for Gangrene, gangrenous/gas (bacillus) A48.0 to report the infection. In the Tabular List, there is an instruction to code first the underlying infection under R65.2- and a guideline to code also the systemic infection. Refer to ICD-10CM guideline I.C.1.d.5.c.

131. A patient with hypertensive heart disease is now experiencing accelerated hypertension due to papillary muscle dysfunction. What ICD-10-CM code(s) is/are reported? a. I11.9

c. I10, I11.9

b. I11.9, I51.89

d. I10, I51.89

ANS:

A

Rationale: Per ICD-10-CM guidelines, Section I.C.9.a.1., Heart conditions (I50.- or I51.4-I51.9) are assigned from category I11 when a causal relationship is stated (due to hypertension or implied (hypertensive). The same heart conditions with hypertension, but without a stated causal relationship, are coded separately. In the ICD-10-CM Alphabetic Index, look for Hypertension/due to/heart disease I11.9. This will be the only code to report since there is a casual relationship between the hypertension and the heart disease. Verify in the Tabular List. 132. The patient is here for his chemotherapy for metastatic carcinoma of the liver secondary to cancer of the male areola. What ICD-10-CM codes should be reported? a. Z51.11, C78.7, C50.029

c. Z51.11, C50.029, C78.7

b. C78.7, C50.029, Z51.11

d. C22.9, C50.019, Z51.11

ANS:

A

Rationale: ICD-10-CM Coding Guideline, Section I.C.2.e.2, states if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for radiation therapy, or Z51.11, encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy is the first-listed or principal diagnosis. In the ICD-10-CM Alphabetic Index, look for Encounter (with health service) (for)/chemotherapy for neoplasm, guiding you to code Z51.11. Next go to the Table of Neoplasms, look for Neoplasm, neoplastic/ liver/Malignant Secondary column guiding you to code C78.7. Next look for Neoplasm, neoplastic/ areola/Malignant Primary column or breast/areola/Malignant Primary column guiding you to subcategory code C50.0-. In the Tabular List the sixth character is reported for the sex of the patient. In this case the patient is a male. The seventh character is for laterality. The complete code is C50.029 because there is no indication of cancer being in the right or left male breast. When looking for breast cancer make, sure to select the correct sex of the patient. The secondary cancer is listed first because the chemotherapy is directed to the secondary site (Section I.C.2.b). 133. A 16-year-old male is brought to the ED by his mother. He was riding his bicycle in the park when he fell off the bike. The patient’s right arm is painful to touch, discolored, and swollen. The X-ray shows a closed fracture of the ulna. What ICD-10-CM codes should be reported? a. S52.201A, V18.0XXA, Y92.830 c. S52.201A, V18.4XXA, Y92.831 b. S52.209A, V18.4XXA, Y92.830 d. S52.201A, V19.9XXA, Y92.830 ANS:

A

Rationale: In the ICD-10-CM, Alphabetic Index, look Fracture, traumatic/ulna (shaft) guiding you to subcategory S52.20-. Tabular List indicates seven characters are needed to complete the code. For the sixth character 1 is for the right arm, and A as the seventh character for an initial encounter for closed fracture. To find the external cause codes you will look in the ICD-10-CM External Cause of Injuries Index. Look for Accident (to)/transport/pedal cyclist/driver/noncollision accident/nontraffic guides you to subcategory V18.0. Turn to the Tabular List which indicates the codes needs seven characters. An appropriate seventh character is to be added to each code from category V18. Therefore you will need two X placeholders for the fifth and sixth characters and the seventh character is A. The final code is V18.0XXA. The second external cause code identifies the Place of Occurrence. Find Place of occurrence/park (public) guiding you to code Y92.830. Cross-reference the code in the Tabular List. 134. The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. She developed severe vomiting secondary to the radiation. What ICD-10-CM code(s) should be reported? a. C79.51, C80.1

c. C79.51, C80.1, R11.10, Z51.0

b. R11.10

d. Z51.0, C79.51, C80.1, R11.10

ANS:

D

Rationale: The reason for the encounter is for radiation Z51.0. ICD-10-CM Coding Guideline, Section I.C.2.e.2, states if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for radiation therapy, or Z51.11, encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. ICD-10-CM Coding Guideline, Section I.C.2.b, states the secondary cancer is listed first because the radiation therapy is directed to the secondary site. In the ICD-10-CM Alphabetic Index, look for Encounter (with health service) (for)/radiation therapy (antineoplastic) guiding you to code Z51.0. Next go to the ICD-10-CM Table of Neoplasms, look for Neoplasm, neoplastic/bone (periosteum)/Malignant Secondary column which is C79.51. When the site of the primary cancer is unknown, code C80.1, Neoplasm, neoplastic/Malignant Primary column is reported. The last code is for the vomiting that developed during treatment. Look in the ICD-10-CM Alphabetic Index for Vomiting guiding you to code R11.10.

HCPCS 135. How many days does it take for CMS to implement HCPCS Level II Temporary Codes that have been reported as added, changed, or deleted? a. 365 c. 30 b. 90 d. 60 ANS: B Rationale: Per CMS Temporary codes can be added, changed, or deleted on a quarterly basis. Once established, temporary codes are usually implemented within 90 days, the time needed to prepare and issue implementation instructions and to enter the new code into CMS's and the contractors' computer systems and initiate user education. This time is needed to allow for instructions such as bulletins and

newsletters to be sent out to suppliers to provide them with information and assistance regarding the implementation of temporary CMS codes. http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/LevelIICodingProcedures.pdf 136. HCPCS Level II includes code ranges which consist of what type of codes? a. Category II codes, temporary national codes, and miscellaneous codes. b. Dental codes, morphology codes, miscellaneous codes, and permanent national codes. c. Permanent national codes, dental codes, category II codes. d. Permanent national codes, miscellaneous codes, and temporary national codes. ANS: D Rationale: HCPCS Level II codes consist of permanent national codes, miscellaneous codes, and temporary national codes. 137. The Table of Drugs in the HCPCS Level II book indicates various medication routes of administration. What abbreviation represents the route where a drug is introduced into the subdural space of the spinal cord? a. IM c. INH b. SC d. IT ANS: D Rationale: In the HCPCS Level II codebook, there is an appendix that lists the abbreviations and acronyms and their meanings listed. IT stands for Intrathecal. IT is the route where a drug is introduced into the subdural space of the spinal cord. 138. A patient is seen in the physician’s office for a 2,400,000 U injection of Bicillin LA. What is the code to represent this drug? a. J2540 x 4 c. J2510 x 4 b. J0561 x 24 d. J0558 x 24 ANS: B Rationale: In the HCPCS Level II Table of Drugs, look up Bicillin LA, which directs you to code J0561. Because J0561 is for 100,000 U, 24 units are reported for 2,400,000 U.

139. How are ambulance modifiers used? a. They identify mileage traveled during the encounter. b. They identify emergency or non-emergency transport types. c. They identify the time elements of the ambulance service. d. They identify ambulance place of origin and destination. ANS: D Rationale: Transportation (ambulance) services utilize modifiers made up of two letters identifying the origin and the destination according to the guidelines in the A section (Transportation Services Including Ambulance A0021-A0999) of the HCPCS codebook.

Coding Guidelines 140. What does “non-facility” describe when calculating Physician Fee Schedule payments? a. hospitals b. nursing homes c. non-hospital owned physician practices d. hospital owned physician practices ANS: C Rationale: “Non-facility” location calculations are for private practices or non-hospital-owned physician practices. Reimbursement is higher for private practices because the practice incurs the full expense of providing the service. 141 . What three components are considered when Relative Value Units are established? a. Physician work, Practice expense, Malpractice Insurance b. Geographic region, Practice expense, Malpractice Insurance c. Geographic region, Conversion factor, Physician fee schedule d. Physician work, Physician fee schedule, Conversion factor ANS: A Rationale: Per CMS - Relative value units (RVUs) – RVUs capture the three following components of patient care: Physician work RVU, Practice Expense RVU, and Malpractice RVUs.

142. CPT® Category III codes are reimbursable at what level of reimbursement? a. 10 percent b. 100 percent c. 85 percent d. Reimbursement, if any, is determined by the payer ANS: D Rationale: Per AMA, no relative value units (RVUs) are assigned to these codes. Payment for these services or procedures is based on the policies of payers. 143. The Surgical Global Package applies to services performed in what setting? a. Hospitals c. Physician’s offices b. Ambulatory Surgical Centers d. All of the above ANS: D Rationale: The Medicare approved amount for surgery includes the following services when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, eg, in hospitals, ASCs, and physicians' offices. Visits to a patient in an intensive or critical care unit are also included if made by the surgeon. 144. What surgical status indicator represents the Surgical Global Package for endoscopic procedures (without an incision)? a. XXX c. 000 b. 010 d. 090 ANS: C Rationale: Per CMS Internet-only manuals (IOM) Medicare Claims Processing Manual – surgical status indicator 000 = Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable. 145. Which statement is TRUE regarding the Instruction for use of the CPT® codebook? a. Use an unlisted code when a procedure is modified. b. Parenthetical instructions define each code listed in the codebook. c. Select the name of the procedure or service that most closely approximates the procedure or service performed. d. Select the name of the procedure or service that accurately identifies the service performed. ANS: D Rationale: CPT® Instructions for the use of the CPT® codebook include “select the name of the procedure or service that accurately identifies the service performed.”

Practice Management 146. The Medicare program is made up of several parts. Which part is most significant to coders working in physician offices and covers physician fees without the use of a private insurer? a. Part A c. Part C b. Part B d. Part D ANS: B Rationale: Medicare Part B helps to cover medically-necessary doctors’ services, outpatient care, and other medical services (including some preventive services) not covered under Medicare Part A. Medicare Part B is an optional benefit for which the patient must pay a premium, and which requires a yearly copay. Medicare Part B is the most significant portion of the Medicare program for coders working in physician offices. 147. If an NCD doesn’t exist for a particular service/procedure performed on a Medicare patient, who determines coverage? a. To determine new codes under Current Procedural Terminology (CPT) b. Centers for Medicare & Medicaid Services (CMS) c. Medicare Administrative Contractor (MAC) d. The patient ANS: C Rationale: If an NCD doesn’t exist for a particular item, it’s up to the MAC to determine coverage. According to CMS guidelines (www.cms.gov/transmittals/downloads/R2NCD1.pdf), “Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System, the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions.” 148. Local Coverage Determinations are administered by ____? a. Each regional MAC c. LMRP’s b. NCD’s d. State Law ANS: A Rationale: Each Medicare Administrative Contractor (MAC) is then responsible for interpreting national policies into regional policies

149. When are providers responsible for obtaining an ABN for a service not considered medically necessary? a. After providing a service or item to a beneficiary b. Prior to providing a service or item to a beneficiary c. During a procedure or service d. After a denial has been received from Medicare ANS: B Rationale: Providers are responsible for obtaining an ABN prior to providing the service or item to a beneficiary. 150. HIPAA was made into law in what year? a. 1992 c. 1997 b. 1995 d. 1996 ANS: D Rationale: HIPAA was adopted into law in 1996