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OST-249 - Medical Coding Prep - Mock Exams
Terms in this set (429)
Placement of ventilation tube, left ear, with local anesthesia
(Placement of a ventilation tube, also known as a tympanostomy (create an artificial opening), is assigned 69433-LT when performed with local anesthesia only.)
Left renal stone was seen, which was right next to the stent placed previously. Stone was targeted in both AP and lateral views. Starting at an energy of 2 Kv and going to 9 Kv, the stone was fragmented utilizing ESWL. Additional 500 shocks were required for total pulverization of the stone.
(Extracorpeal shock wave lithotripsy or ESWL was performed. Code as 50590-LT.)
Electrocardiogram, interpretation and report only
(Code 93010 should be assigned for electrocardiogram when interpretation and report only is performed.)
Laceration repairs as follows: 1.5 cm arm, simple; 2.5 cm arm, simple; 1.5 cm arm, intermediate
(Two simple repairs would be summed together; therefore, 1.5 arm and 2.5 arm for a total of 4.0 simple arm = 12002-51. A 1.5 cm intermediate repair of the arm would be assigned 12031. An intermediate repair would be considered more significant and is, therefore, listed first. Subsequent procedures on the skin during the same surgical session will need a modifier -51 appended.) WRONG
Tachycardia refers to
Patient presents for follow-up for her hypertension. She is seen by another physician in the same practice. BP, pulse, and temp are taken. Chest is clear. Cardiac normal sinus rhythm. There are no new problems and her hypertension appears to be stable. MDM is straightforward. What E/M service would be assigned?
(Patient is here for follow-up; therefore, established visits 99212 or 99213 only would be appropriate. Patient presents for hypertension and only the affected problem/area are reviewed/examined, therefore, would be considered problem focused, 99212.)
In addition to the usual information submitted on each claim, what additional information must be reported when submitting ancillary services?
referring/requesting physician and NPI number
A 17-year-old presents for his initial visit with complaints of left knee pain after playing football. An expanded problem-focused history and exam were performed with straightforward MDM.
(All three elements are met for 99202.)
Bilateral microscopic ear examination and removal of bilateral cerumen impactions. Utilizing the ear speculum and surgical forceps, the external canal was cleared of impacted cerumen by surgical forceps.
(When surgical instrumentation is utilized to remove impacted cerumen, code 69210 is assigned. Since this was performed bilaterally, assign 69210-50.)
Modifier -26 indicates
codes in CPT for supervision/interpretation.
Patient admitted to observation care at 11:00 PM for chest pain. Detailed history, comprehensive exam, and low MDM are performed. Patient is discharged at 11:00 AM the following day.
(As two different dates of service, two codes would be assigned. Observation limited by low MDM to 99218 and observation discharge 99217.)
Cystoscopy was introduced into the bladder. Tumor measuring 2 cm was located on the bladder. Using cutting current, this was resected and particles removed through the evacuator. Tumor measuring 1 cm was located on the bladder base, which was also resected along with a third tumor, 2 cm, located on the upper portion of the bladder.
(CPT coding guidelines per CPT Assistant indicate the largest lesion only should be assigned, therefore, 52235 should be assigned for the 2.0 cm lesion removed cystourethroscopically.) WRONG
A superficial burn, characterized by pain, redness, and swelling is classified as a
(First-degree is characterized by pain, redness, and swelling; second-degree involves blisters; and third-degree involves full-thickness skin loss.)
Basic metabolic panel with ionized calcium
(Code 80047 is assigned for basic metabolic profile ionized calcium.)
The diaphysis of a long bone is also referred to as the
Anesthesia services for cardiac radiofrequency ablation, 63-year-old with severe atrial fibrillation
(Anesthesia code 00537 for intrathoracic procedures, radiofrequency ablation, and physical status modifier -P3 as stated as severe systemic disease)
The old tracheostomy site was palpated for signs of a tracheal defect; none was noted. A vertical incision was made through the old scar until the trachea was reached. There were significant calcifications of the tracheal rings, making identification of the individual rings difficult. A number 11 blade was used to create a vertical incision, and scar tissue over the previous tracheostoma was excised until the endotracheal tube could be visualized. A number 8 nonfenestrated, cuffed tracheostomy tube was easily inserted into the tracheostomy.
(Replaced tracheostomy tube. Not stated as emergency and, therefore, assumed planned, so code 31600 is assigned.)
Which of the following situations could be considered upcoding?
A podiatrist performs simple nail clipping services but bills for foot surgery.
A provider bills for services as though a physician rendered them, even though there was no physician involvement.
A provider bills Medicare for treating a patient with a more serious form of pneumonia than the patient has.
All of those listed.
All of those listed.
Anesthesia time is assigned in the days/units column in increments of
10 or 15 minutes depending on carrier.
CT brain is performed with and without contrast.
(CT brain with and without contrast is assigned 70470 from Diagnostic Radiology, head/brain section.)
CHF refers to
congestive heart failure.
The three parts of the small intestine are
the duodenum, the jejunum, and the ileum.
(The small intestine consists of the duodenum, the jejunum, and the ileum. The colon is part of the large intestine, the ischium is part of the pelvis, and the stomach is not considered part of the small intestine.)
CAD would be coded as
(Coronary artery disease is coded without angina unless specified otherwise codes to I25.10.)
Established patient presents for 3-year-old annual exam. Comprehensive history and exam and moderate MDM were performed based on CPT guidelines. Appropriate anticipatory guidance was provided during the encounter. Assign the appropriate E/M code(s) and modifier(s).
(Since the patient is established, a preventive medicine exam for a 3-year-old would be appropriate, code 99392.)
Left heart catheterization with left ventriculogram and right coronary vessels to perform PTCA right coronary and left circumflex. Intracoronary stent right coronary x2, left circumflex x1, left descending vessel x1
92928-RC, 92929-LC, 92929-LD
(As the left heart catheterization is the "approach" by which the interventional procedures are performed, it would not be codeable. Therefore, 92928 is assigned for right coronary (only one per vessel), 92929-LC for left circumflex, and 92929-LD for left descending.) WRONG
Renal ultrasound. Small area of echogenicity with shadowing in the midleft kidney that could represent a small calculus. Exam of right kidney is negative. Urinary bladder is not visualized.
(Renal ultrasound assigned 76775. Considered limited abdominal retroperitoneal as not all organs ordered or documented.)
The ilium, ischium, and pubis make up what bone?
A 7-year-old patient has a v-shaped laceration approximately 2.5 cm in length and a small one about 0.5 cm on the right side of the hand. Lacerations are cleaned and closed with 4-0 Ethilon sutures.
(Both repairs/closures are considered simple complexity (as not stated otherwise). Therefore, the repairs would be summed together (2.5 cm + 0.5 cm = 3.0 cm hand).) WRONG
Removal of impacted cerumen by surgical instrumentation
(When impacted cerumen is removed by surgical instrumentation, code 69210 should be assigned from the Ear, Removal External Ear section.)
Radiation treatment, two treatment areas, 20 MeV
(Code 77407 assigned for radiation treatment to two treatment areas, 20 MeV from radiation oncology section, radiation treatment category)
BMP with total calcium
(Basic metabolic profile (BMP) with total calcium is assigned disease-oriented panel code 80048.)
New office visit for patient with lupus with kidney disease, edema with cardiac problems. History was problem focused for this visit. Exam encompasses skin, CV, renal, neurovascular systems. Significant PMH and PHF of lupus and cardiac disease. No tests are ordered or interpreted, management/treatment options are moderate as well as risk.
(As this is a new office visit, all three elements (history, exam, and medical decision making) are required. As
the history was problem focused only, the level of service would be limited to 99201.) WRONG
Radial incision was made in the posterior quadrant of the left and right tympanic membrane. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears under general anesthesia.
(Assign 69436-50 as myringotomy with tube placement, also referred to as a tympanostomy, is performed bilaterally.)
Treatment of incomplete abortion.
(An incomplete abortion is a spontaneous abortion with retained products of conception. Therefore, this procedure would be coded as 59812.)
U/S-guided needle localization of right breast lesion. Excisional biopsy of right breast lesion; lesion sent to pathology revealed fibroadenoma of the right breast.
(Indicates lesion was excised, no biopsy specimen. Therefore, 19125, excision of breast lesion with preoperative radiological marker, would be assigned.)
Procedure performed: Repair of right little finger distal interphalangeal fusion nonunion with screw. Incision was made, full-thickness flaps were developed, and nonunion site was indented. It was cleaned with ronguer and Preer elevator; bony surfaces were repaired, and an Acutrak II guide wire was placed across the fusion site. It was then placed with a 28 mm screw and overdrilled with a 28 mm mini screw.
(Coded as arthrodesis, interphalangeal joint (code 26860-F9).)
Surgical pathology submitted to the pathologist is as follows: three surgical specimens taken from a liver biopsy.
(Code 88307 only is assigned for the liver biopsy, as each specimen was not individually identified.) WRONG
When multiple biopsies are performed at four different sites during the course of a colonoscopy, what code(s) should be reported?
45380 once only
(CPT code 45380 indicates single or multiple, therefore, it should be assigned only once regardless of the number of biopsies.)
Bronchoscope inserted through right nostril. Nasopharyngeal mucosa normal; vocal cords and trachea normal. There were moderate, thick mucoid secretions from the trachea that was suctioned. Right main bronchus appeared normal. Washings from the right lower lobe were obtained and sent to microbiology.
(Bronchoscopy was performed with washings, which is included in the dx bronchoscopy, 31622.)
Expressive aphasia, history of CVA
(Requires two codes, however, does not state that the expressive aphasia was due to the CVA, therefore, cannot assign "residual effects of CVA." Also Z code appropriate for "history of" CVA, not current condition.) WRONG
Medicare patient with history of adematous polyps presents for periodic screening colonoscopy.
(Patient with history of colon polyps is considered high risk; therefore, code G0105 would be appropriate.)
X-ray, hip with pelvis, 2 V, left
(Diagnostic X-ray, hip, 2 view with pelvis, assigned 73502-LT)
New patient presents with neck and back pain worsening over the past year. Pain is worse when she bends, relieved sometimes by ibuprofen. Positive aches and weakness in her muscles, tingling and numbness in arms and hands. She also reports headaches. All other systems reviewed and negative. PMH Hysterectomy, Social, recently divorced. Exam performed of eyes, ENT, respiratory, CV, GI, MS, Neur, and VS, pulse and temperature also performed. She was given prescription and set up for an MRI and physical therapy. What E/M should be assigned for this service?
(Hx - Detailed - 99203
Exam - Detailed - 99203
Medical Decision-Making - Moderate - 99204
All three elements must be met; therefore, 99203 would be assigned.) WRONG
Application of knee immobilizer, left
(No fracture repair; only application of long leg splint. Code 29505-LT.)
PTT (thromboplastin time, partial), whole blood
(Code 85730 is assigned for partial thromboplastin time or PTT.)
(Only one transfusion code is assigned, 36430, found in Arteries/Veins, Venous Procedures. The number of units of blood product is assigned HCPCS "P" codes by the facility providing the blood product.)
Arthroscope was inserted and there were areas of diffuse chondromalacia, Grade III that was treated with chondroplasty. The lateral meniscus was torn on its inner third and partial lateral meniscectomy was performed. There was an unrepairable tear on the posterior horn of the medical meniscus and this was also excised.
(Meniscectomy of both medial and lateral compartments was performed. Chondroplasty is included per CPT.)
The rapid, quivering, noncoordinated contractions of the atria or ventricles is called
(Fibrillation refers to irregular contraction of the heart. None of the other choices involve a contraction of the chambers of the heart; therefore, fibrillation is the correct choice.)
Repair of nonoxygen, durable medical equipment, 30 minutes
K0739 X 2 units
(Code K0739 is for 15 minutes DME repair. Therefore, K0739 x 2 would be appropriate.)
Gastric motility study
(Assign 91020 for gastric motility study from GI Procedures.)
Cervical laminoplasty to four vertebral segments
(Assign 63050 for laminoplasty performed at the cervical level located in the Posterior Extradural Laminectomy/Laminotomy, Exploration/Decompression Neural Elements, Excision of Herniated Disks.)
Patient presented for diagnostic bronchoscopy for possible lung nodule on radiological study. The scope was advanced into the right middle and lower lobe, where a biopsy was obtained of a suspicious nodule.
(Bronchoscopy was performed with biopsy, which codes to 31625. Code 31628 is for transbronchial biopsies, which were not performed in this instance.)
Digital rectal exam was performed, and no masses were palpable. Scope was introduced to the cecum. The scope was withdrawn, and there were several areas of liquid stools at various stages. In the sigmoid region, there were two polyps adjacent to each other, both less than 5 mm which were hot biopsied and sent to pathology.
(Colonoscopy was performed with multiple biopsies, therefore 45380 would be appropriate. The hot biopsy polypectomy code (45384) is only appropriate if the polyp, lesion, tumor is excised.) WRONG
Fracture of the right tibial shaft as a result of a fall
(Fracture is considered traumatic rather than pathological. Fracture all needs seventh character to denote treatment period.)
Abdomen, vulva, and vagina were prepped and the cervix was visualized extending outside the vagina. Anterior incision was made 2 cm from cervix. The denuded strip was approximately 2-3 cm in width. The denuded strip was grasped with the clamp, and posterior incision made. Procedure was completed by suturing the anterior vaginal mucosa to the posterior vaginal mucosa and then successive suturing to elevate the uterus and anterior bladder wall.
(The suturing of the vagina is performed with strips to correct prolapsed vagina. Assign code 57120.)
When the repair of a fracture also necessitates the application of a cast, what services are reportable?
fracture repair only
(The initial application of a cast at the time of fracture repair is included in the global procedure for the fracture. No additional services would be reported.)
Dilation and curettage
(Dilation and curettage of the corpus uteri (uterus) is assigned code 58120.)
A condition in which bones become thin and result in a decrease in bone density is referred to as
("Osteo" means "bone," and "porosis" means "abnormal condition of porous"; osteoporosis refers to a condition where the bones become thin and there is a decrease in bone density. While the other answer choices are disorders related to the bone and the joint, they do not refer to decreased bone density; therefore, osteoporosis is the most appropriate.)
According to CPT guidelines, in addition to the appropriate anesthesia CPT code(s) and modifier code(s), what other anesthesia procedural information is required to correctly report anesthesia services?
start time and stop time
(Start time and stop time are required to appropriately assign units of services for anesthesia.)
A left curvilinear breast incision was made and tissue divided down to the firm palpable mass. A silk retraction suture was placed through the area in question and dissection performed to remove the spherical-shaped 5 cm tissue sample.
(The procedure performed was an incisional breast biopsy only; therefore, 19101-LT would be appropriate.) WRONG
Craniofacial approach to the anterior cranial fossa, extradural with resection of lesion of anterior cranial fossa, extradural
(Assign code 61600 for resection lesion, anterior fossa located in the Definitive Skull Base, Anterior Fossa Procedure section. Also assign 61580-51 for craniofacial approach.)
Fracture left distal radius following fall from bus
(Code needs to encompass "distal" (Lower end) radius as well as seventh digit for treatment period and anatomical location "left.")
Abdomen flat/upright, 2 V. Punctate pelvic phleboliths on the left just below the level of the ischial spine. Deformity in left lateral iliac crest, exostoses/bone process versus postbiopsy site.
(Assign 74019 for flat/upright (Decubitus/Erect) views of abdomen. This would be considered 2 views. Found in Diagnostic Radiology, abdomen section.)
Left and right mammogram for benign fibrocystic breast disease
(Diagnostic mammogram code 77066 is already bilateral, therefore, no need for modifier -50.)
Hammertoe repair, right foot, second toe
(Hammertoe code is 28285. As this can be performed to all toes, the T modifier would be appropriate. In this instance, T6 is to indicate the second toe, right foot.)
Percutaneous liver biopsy. The upper right abdomen was prepped and 18 gauge coaxial needle was inserted into the right lobe of the liver. Needle tip was placed within one of the lesions and core biopsies X 3 were obtained.
(When percutaneous liver biopsies are performed by needle, code 47000 is assigned. This code is assigned only once regardless of the number of biopsies/specimens obtained.) WRONG
Incision and drainage, deep abscess, forearm
(Code located under Incision, Forearm, Incision and Drainage, Abscess, Deep. The code is 25028.)
Food aspiration pneumonia
(Diagnosis is specified as pneumonia "due to" food aspiration; therefore, pneumonia would not be appropriate, and pneumonia due to food would be assigned.)
Which code(s) would be utilized for a critically ill 20-day-old patient initial care?
(Per CPT 20 day is still considered infant, therefore, neonatal critical care codes 99468-99469 would be utilized for initial care.)
Chronic wound ont the right thigh. FTSG was obtained from the opposite thigh and placed on the 4 x 4 cm wound of the right thigh.
(Graft coded to recipient site, thigh, size is calculated as length x width or 16 sq cm, which codes to 15220.)
Medicaid, Incontinence pull on protective underwear, youth, disposable
(Code T4534 only code for youth, disposable underwear)
Excision of malignant lesion, 4.0 cm cheek with 8 sq cm advancement flap
(Excision of lesion included in advancement flap, and, therefore, not separately reportable. Advancement flap, cheek is assigned 14040.)
A normally healthy 50-year-old for anesthesia for repair of an incarcerated inguinal hernia
(Anesthesia code 00830 for lower abdominal hernia procedures and physical status modifier -P1)
Repair, 6.0 cm leg, intermediate
(Assigned intermediate, leg, 2.5-7.0 cm)
The rib cage is formed by the sternum and how many pairs of ribs?
(There are a total of 12 pairs of ribs in the body.)
(MRI chest assigned 71550 without contrast)
A 36-year-old presents for tonsillectomy. Tonsils were grasped with Allis forceps, and tonsil was bluntly dissected free. Identical procedure was performed on the other tonsil as well. The nasopharynx was viewed, and considerable amount of adenoidal tissue was also removed.
(Tonsils and adenoids were excised; therefore, code 42821 would be appropriate for patients over 12.)
Ballooning of a weakened portion of an arterial wall refers to a(n)
(An aneurysm refers to a weakening in the arterial wall, while an embolus is an object carrier in the bloodstream that lodges a vessel. Varicosities are enlarged tortuous vessels and thromboangiitis obliterans is the inflammation and clotting of arteries and vessels of the hands/feet.)
Additional authoritative coding guidelines for procedures may be found in what publication?
AMA CPT Assistant
(CPT Assistant provides additional information and clarification on the appropriate assignment of CPT codes.) WRONG
Psychotherapy, 45 minutes, office
(Forty-five minutes psychotherapy assigned 90834.)
Psychotherapy, 45 minutes, outpatient office
(Code 90834 should be assigned for 45 minutes of psychotherapy.)
Liver biopsy due to elevated liver enzymes. The area of biopsy site was chosen and a small nick was made on the skin and advanced to the liver capsule. Patient was told to hold her breath, biopsy gun was inserted into the liver, and the obtained biopsy was sent to pathology.
(Biopsies were not obtained by needle or wedge, and, since there are no other codes for liver biopsies, would assign unlisted liver, 47399.) WRONG
A patient with Paget's disease of the bone receives an intravenous infusion of Aredia that begins at 12:29 PM and ends at 4:11 PM. Code this drug administration service.
96365, 96366 x3
(Assigned 96365 for first hour, and 96366 for 3 additional hours of IV infusion.) WRONG
A 45-year-old man presents with severe neck pain. The physician examines the patient and makes the diagnosis of cervical nerve impingement and injects an anesthetic agent into the cervical plexus using three injections.
(Injection into the cervical plexus is assigned code 64413 as the three injections are considered one procedure.) WRONG
Bronchoscopy performed with transbronchial biopsies—two biopsies to the right upper lobe and two biopsies to the left lower lobe.
(Transbronchial biopsies are assigned codes based on each lobe; therefore, 31628 should be assigned for the first lobe and 31632 for the additional lobe.) WRONG
A psychoneurotic disorder characterized by prolonged refusal to eat resulting in extreme weight loss is known as
(Anorexia Nervosa is characterized by excessive weight loss due to prolonged periods of refusing to eat. Hypochondria is a psychiatric disorder where one has abnormal anxiety about one's health; bulimia is typically referred to as the "binge and purge" disorder; and schizophrenia is a breakdown in the relation to thought, emotion, and behavior.)
Excision of lipoma, shoulder, extending into the deep subcutaneous tissue
(Code found under Excision, Shoulder, Tumor Soft Tissue, Subcutaneous Tissue, less than 3 cm.)
Acute hepatitis panel
(Code 80074 is assigned for acute hepatitis panel from the Disease-Oriented Panel section of Pathology.)
Electrosurgical transurethral resection of prostate
(Electrosurgical TUR of the prostate is located in the urinary section, vesical neck and prostate, and assigned code 52601 for electrosurgical resection of prostate.)
Under HIPAA, all patients are entitled to:
request copies of their records.
all of those listed.
review of their records.
all records be kept confidential except as specified by the patient.
all of those listed
Ulcer at the second MPJ was circumscribed and removed in toto. An Apligraft skin graft was prepared, cut, and sutured into place.
(Tissue cultured graft was applied; therefore, 15155 would be appropriate. No size was specified; therefore, the smallest size would be appropriate. MPJ is the standard medical abbreviation for metacarpophalangeal joint.)
Anesthesia for radical orchiectomy, inguinal on 45-year-old normally healthy male
(Anesthesia code 00926 for perineum, male genital system, and physical status modifier -P1)
Modifier -FA denotes
thumb, left hand
(The modifier "FA" denotes the thumb of the left hand, per CPT. Toes are designated with "T" modifiers and the thumb of the right hand is designated as "F5.")
Gastroscope was introduced through the mouth and passed into the stomach, through the pylorus and into the second portion of the duodenum. Just inferior to the Z-line, a small polyp was identified and cold biopsied. Rectal exam was performed, and colonoscope was advanced to the cecum. Multiple sessile polyps were removed utilizing snare and cauterized. There were two other tiny polyps that were fulgurated due to their size.
45388, 45385-51, 43239
(Both colonoscopy and EGD (esophagogastroduodenoscopy) were performed. The colonoscopy involved fulgurating polyps (45388) and polypectomy by snare (45385-51). The cauterization of the snared polypectomy is not separately reportable to control bleeding created by the excision. An EGD was also performed with biopsy, which would be assigned 43239.) WRONG
A 69-year-old Medicare patient presents for annual mammogram, indicating she is leaving for an extended trip and would like her screening mammogram performed before the one-calendar-year period. Assign the appropriate CPT code(s) for this service.
(It would be appropriate to assign the GA modifier to the claim after obtaining a signed ABN from the patient as the service will be denied. The mammogram will be considered screening 77067-GA since there is no history of a medical problem.)
Any pathological change in skin tissue is called a(n)
(Any pathological change in skin tissue is referred to as a skin lesion. The other answer choices are specific types of skin lesions or skin disorders.) WRONG
Tonsillectomy/adenoidectomy, age 20
(Both tonsils and adenoids were excised; therefore, code 42821, for patients over 12, would be assigned.)
Excision of a local lesion of the epididymis.
(Assign code 54830 found in the male genital section, epididymis, excision section.)
Surgical pathology, oophorectomy, non-neoplastic
(Surgical pathology for oophorectomy is assigned 88305 per surgical pathology examples in CPT.)
Placement of temporary cardiac pacemaker, single chamber
(Temporary pacemaker is assigned code 33210.)
Bilateral L5-S1 transforaminal epidural steroid injections
(Assign code 64483-50 for transforaminal epidural steroid injections found under injection, anesthetic agent, diagnostic, therapeutic somatic nerves.) WRONG
BRCA2 gene analysis, full sequence analysis
(Code 81216 is assigned for an analysis of the BRCA2 gene when full sequence analysis is performed per CPT Pathology guidelines.)
Office visit for 24-year-old patient with acute bronchitis. Expanded problem-focused history and exam are performed.
(Expanded history and exam qualify for 99213; therefore, the two minimum components needed for a 99213 level are met.)
What body movement involves a straightening of a body part by increasing the angle of a joint?
(Extension is the movement that straightens a body part. Dorsiflexion is movement in an upward direction. Flexion is the act of bending. Abduction is movement of a limb or body part away from the midline of the body.) WRONG
Diagnostic cystourethroscopy is performed, which reveals 2 cm ureter stone.
(Only diagnostic cystourethroscopy was performed, therefore, 52000 would be assigned.)
Office visit for follow-up for stable diabetes mellitus. Patient has multiple medical problems; however, all appear stable at this time. No complaints of diplopia, excessive thirst. She has been symptom-free except for some lower back pain in the past few weeks. Exam completed for back, heart, and lungs. Glucose level normal. Assessment: diabetes type II stable.
(For an established patient, only 99213 and 99214 would be correct. Since documentation does not include a detailed exam of the affected system or a detailed history beyond the affected system, the history and exam would be considered expanded problem focused, and therefore, 99213 would be assigned.)
ERCP with removal of obstructed biliary stent, balloon of CBD stones and sludge, placement of biliary stent. Duodenoscopy was advanced through the esophagus, stomach, and pylorus into the duodenum. An obstructed biliary stent was snared and removed. Selective cannulation of the CBD was performed. Balloon of the CBD was performed, removing soft stones and sludge followed by a new 10 French biliary stent placed across the strictures.
(Exchange of stent was performed, 43276, as well as removal of stones and sludge, 43264. Therefore, code 43276 is assigned, followed by 43264-51.)
Migraine headache with aura
(Code needs to incorporate "with aura" as well as "migraine." Therefore, codes for headache or without sixth digit would not be appropriate.)
Comprehensive ophthalmological exam, new patient
(Code 92004 is assigned for comprehensive ophthalmological exam performed for a new patient.)
Arthroscopy, left knee with open lateral retinacular release. Arthroscope cannula was introduced, and the anatomy was examined and appears normal. There was a tight lateral retinaculum noted through range of motion of the knee. A longitudinal skin incision was made, incision carried down to the subcutaneous tissue. Nick was made in the lateral patellar retinaculum and lateral patellar release was accomplished. Arthroscopic portal as well as the lateral release incision was closed.
(Attempted arthroscopic lateral release; however, completed open. Therefore, only the definitive procedure (open) is coded. Assign 27425-LT only.)
Which of the following is NOT a part of the computer planning service for intensity-modulated radiation therapy (IMRT)?
Verification of treatment setup and interpretation of verification methodology
Creating highly conformal radiation dose distribution
Inverse treatment planning
Verification of positional accuracy
Creating highly conformal radiation dose distribution
Dr. Smith spent 1 hour and 30 minutes delivering critical care to a 48-year-old patient. Over the course of this time, Dr. Smith provided interpretation of cardiac output measurements and withdrawal of arterial blood. Dr. Smith did not attend other patients during this time.
99291, 99292 x 1
(According to the time grid in the critical care section, critical care from 75 to 104 minutes qualifies for 99291 and 99292 x 1.)
Evaluation under anesthesia, hysteroscopy, dilation and curettage, and endometrial ablation. Using a Storz hysteroscope, a hysteroscopy was performed, which revealed uterus consistent with menorrhagia. Then, using an Ethicon endometrial ablation apparatus, endometrial ablation of the cavity for 8 minutes at 87 degrees Celsius.
(Hysteroscopic ablation was performed, which is assigned code 58563. Code found in laparoscopy/hysteroscopic procedures, corpus uteri section.)
Abnormal chest x-ray
(Located under Abnormal Radiological Findings, Chest) WRONG
Cystourethroscopy with placement of urethral stent
(When cystoscopy is performed and urethral stent is placed, assign 52282 (note this is urethral NOT ureteral).)
The outer layer of the skin is referred to as
("Epi" means "outside, outer," and "dermis" means "skin." Therefore, the word for the outer layer of the skin would be "epidermis.")
Anesthesia services for emergency C-section on a 29-year-old normally healthy female with eclampsia
(Anesthesia code 01961 is for Cesarean delivery, and physical status modifier is P1 (normally healthy documented), with qualifying circumstance code 99140 as stated as emergency.)
A patient with severe mental retardation and cerumen impactions in both ears was unable to be cleared in the office. Using surgical instrumentation, the canal was cleared of impacted cerumen bilaterally.
(Assign code 69210-50 for bilateral removal of impacted cerumen. Cerumen was cleared with surgical instrumentation and therefore was assigned code 69210.)
X-rays taken and interpreted, bilateral standing knees, AP
(CPT code 73565 is assigned for bilateral standing needs, therefore, there is no need to assign modifier -50.)
Patient presents for status post pin removal following ORIF bimalleolar ankle fracture 2 years ago. One of the pins has apparently dislodged and can be manipulated right under the skin. The pin is removed and area closed with sutures.
(Assign code for removal of implant. Since implant is under the skin, would be considered superficial, therefore, 20670 would be appropriate.)
A 67-year-old patient with known CAD and a history of MI was admitted for CABG. A portion of the right radial artery was procured for bypass grafting, and then proceeded to perform two arterial grafts. Then a portion of femoropopliteal vein for graft was harvested.
(Assign one code for the artery grafting (code 33534), as well as a code for harvesting the femoropopliteal vein for graft (code 35572).) WRONG
Level II surgical pathology codes are utilized for specimens that are not removed for suspected malignant, but other reasons.
Internal derangement of the left knee with operative arthroscopy of the left knee with chondroplasty of the patellofemoral joint and the medial compartment with partial medial meniscectomy of the left knee
(Arthroscopic medial meniscectomy performed; therefore, 29881-LT would be appropriate.)
Child presents to physician due to exposure to chickenpox.
(Code Z20.820 can be found under "Exposure to.")
Utilizing a 5" sinuscope and microdebrider, the right concha bullosa was resected in its lateral portion. Subsequently, the anterior wall of both ethmoids was removed with the microdebrider, and the hypertrophic mucosa and anterior ethmoid cells were cleared with the microdebrider. The maxillary sinus ostia were cleared of hypertrophic mucosa on the right side followed by the same procedures on the left.
(Bilateral endoscopic maxillary antrostomies were performed (31267-50) as well as bilateral ethmoidectomies (31254-50), which would also need modifier -51 appended for multiple surgical procedures.)
When locating an open wound in ICD10 in the alphabetic section, the coder would look under
(Lacerations and open wounds are now distinguished by separate codes in ICD10. Coder should look under "wound, open.")
Extracapsular right cataract extraction on a 72-year-old that requires an iris expansion device. Upon completion of phacoemulsification of the opacified lens, an intraocular lens is inserted.
(When extracapsular cataract extraction with lens implant is performed that requires more than the usual services performed, assign code 66982-RT per CPT.)
When a sigmoidoscopy is performed, what areas are included in the examination?
Entire rectum, sigmoid colon, portion of descending colon (WRONG)
What modifier is appended when multiple procedures are performed during the same operative session, through the same approach, and in the same anatomical site, and when all are appropriate to code/bill?
(Modifier -51 is appended for multiple procedures through the same approach and same anatomical site when appropriate.)
Reticulocyte count, automated
Antinuclear antibody titer
CT-guided lung biopsy. An appropriate area was cleansed and an 18-gauge spring-loaded needle was inserted into a 6 × 5 cm mass in the right base. Three cores of tissue were removed into the biopsy needle.
(When a lung biopsy is performed via needle, code 32405 would be assigned.)
Arthro pertains to which anatomical system?
(Artho, which means "joint," would refer to the joints, which are part of the musculoskeletal systems. The integumentary system would be skin; digestive would be the stomach and other digestive organs; and the nervous system would involve the nerves, spine, and brain. Therefore, the correct answer would be the musculoskeletal system.)
Anesthesia services for septoplasty on a healthy 24-year-old male
(Anesthesia code 00160 for procedures on nose and accessory sinuses, and physical status modifier -P1)
Blood pressure check, done by the physician's nurse.
(Service performed by nurse 99211.)
Injection, ceftazidime, 750 mg
J0713 X 2 units
(J0713 per 500 mg. Since total of 750 mg administered, J0713 x 2 would be appropriate.) WRONG
Anesthesia coding and billing always require the following elements:
CPT code, physical status modifier, and time units
(A CPT code, physical status modifier, and time will always be reported.) WRONG
Treatment of molluscum contagiosum by cryotherapy. Patient was given light sedation and the two lesions were exposed. Curettage was attempted, but the lesions were not easily removed; therefore, cryotherapy was used to treat each of the lesions through two freeze/thaw cycles.
(Cryotherapy for lesions was the definitive treatment; therefore, 17000 would be appropriate for the first lesion, and 17003 for the second lesion. As 17003 is an add-on code, no modifier -51 would be appropriate.)
Dermatological ultraviolet light treatment
(UV light treatment is assigned 96900.)
Mass in the left flank at its widest measuring 4 x 2 cm. Incision was extended into the subcutaneous and fascial layers and the lesion was removed in toto.
(A code from the musculoskeletal section would be utilized for excision of a lesion/tumor that extends into the subcutaenous/fascial layers (musculokeletal area). Therefore, code 21931 would be appropriate in this case.)
An artificial opening through the abdominal wall into the colon is referred to as a(n)
(An artificial opening is termed as an ostomy. Therefore, an artificial opening into the colon would be a "colo/stomy.")
An established patient presents with diagnosis of allergic sinusitis. The physician performs an expanded problem-focused history, exam, and low MDM. Following the completion of the visit, 12 percutaneous scratch tests were performed to determine the origin of the allergens.
99213-25, 95004 x12
(As history, exam, and MDM were performed and decision was made to perform allergy tests, as a result, both an E/M would be assigned 99213-25 as well as 12 scratch tests were also performed; therefore, 95004 x12 would also be appropriate.)
URI determined to be the cause of pharyngitis
(Not necessary to assign code for pharyngitis as inflammation of throat would be sign/symptom of the URI) WRONG
What is one factor of the federal guidelines for compliance programs?
The organization has communicated standards and procedures to employees and agents.
(The organization must communicate the standards and procedures to their employees and any agents of the practice.)
Extensive basal cell carcinoma (BCC) of the left retroauricular area. Wide excision of BCC. Skin graft was obtained from the left thigh and placed at the excision site.
(Two codes would be appropriate: one for the malignant lesion on the face, code 11640 (no size stated), and the other for split-thickness skin graft (not stated as full thickness), code 15120.)
EGD. Scope was passed and visually guided into the esophagus, the stomach, and advanced all the way to the third part of the duodenum. A couple of biopsies were taken from the small bowel mucosa. An esophageal ulcer was examined and biopsy taken as well.
(EGD (esophagogastroduodenoscopy) was performed with biopsies. Code 43239 indicates biopsy, single or multiple, and is only coded once regardless of the number of specimens/locations.)
Allergy immunotherapy with no provision of extract as well as a problem-focused history, exam, and low MDM
(E/M 99212-25 would be assigned to indicate "significantly, separately identifiable" E/M has been performed. Also assign 95115 for allergy immunotherapy with no provision of extract.)
Inguinal hernia repair, age 4
(Inguinal hernia repair was performed open. As not stated as incarcerated/strangulated, would assign 49500 for patients aged 4.)
Bronchoscopy with washings
Nerve conduction studies, two studies
(Nerve conduction studies of one to two studies are assigned 95907.)
Right breast was prepped, and an incision was made over the breast mass for intended excision. The patient experienced EKG abnormalities and the physician made a decision to discontinue the procedure and schedule it at a later date.
(Intended procedure was excision of breast. However, due to the patient's medical condition, the physician made a decision to discontinue the procedure. Therefore, the intended procedure 19120-RT would be reported with modifier -53, 19120-53-RT.)
A patient was referred by primary care to GI for rectal bleeding. The colonoscope was advanced into the cecum. The patient had a polyp removed by snare, another polyp was hot biopsied, and a separate area of questionable inflammation was also biopsied. The base of the polyps was cauterized to control bleeding.
(One technique is allowed per polyp or lesion; therefore, a code for the polyp removed by snare (45385) would be appropriate as well as a separate code assignment for the biopsy(ies) performed to other sites. The polyp that was hot biopsied was not removed and, therefore, would be included in the 45380 with biopsy code. Cauterization to control bleeding created by the excisions or biopsies is included in the procedures assigned.) WRONG
Encounter due to family history heart disease. Patient experiencing chest pain and chest tightness.
R07.9, R07.89, Z82.49
(Chief reason for encounter are symptoms of chest pain and chest tightness. Family history of heart disease as to complexity of visit and should be coded last.)
Patient scheduled for possible TAH/BSO, however, surgical abdomen is explored and no additional procedures performed.
(Since patient was scheduled for "possible" TAH/BSO following findings from exploratory laparotomy, only exploratory laparotomy would be assigned, code 49000.) WRONG
CABG, venous grafting, three vessels
(CABG (coronary artery bypass graft) was performed with venous grafting, three vessels. Therefore, 33512 will be assigned.)
Left diagnostic shoulder arthroscopy was performed which revealed a large rotator cuff tear. Repair of the rotator cuff tear was attempted arthropically; however, it was necessary to perform a mini-arthrotomy to complete the repair of the tear.
(Only definitive procedure performed; therefore, only open rotator cuff repair performed, code 23410-LT.)
Scope advanced into cecum. There were multiple diverticula seen in the sigmoid and descending colon, some were filled showing diverticulitis.
(Diverticula has developed into diverticulitis, therefore, no need to code the diverticula.) WRONG
A 13-year-old presents for removal of tonsils. Tonsils are grasped and removed.
(Tonsils only were excised; therefore, code 42826 would be appropriate for patients over 12.)
Abdominal pain, gastroenteritis, probably viral
("Probably" cannot be coded; therefore, code gastroenteritis only. Abdominal pain is sign/symptom of gastroenteritis and does not need to be coded.) WRONG
Tumor removal from left temporal bone
(Assign code 69970 for removal of tumor from the temporal bone.)
The surgical removal of a gland or gland part is called
(All choices involve the removal/excision of a body part, however, "adeno" refers to gland. Therefore, the correct choice is adenectomy, which is the removal of a gland or part of a gland.)
Laceration to eyelid/eyebrow. Right lower eyelid laceration was sutured using 5-0 Vicryl deep sutures and the eyebrow laceration was sutured utilizing 5-0 Vicryl sutures.
(Stated as deep sutures, however, does not specify repair into deep subcutaneous tissue, therefore, assumed simple. Size also not stated, assumed smallest size, therefore, 12011 would be appropriate.)
A 65-year-old patient was presented for removal of peripheral central venous catheter. Catheter was removed with no problems encountered.
(Only tunneled central venous catheter may be coded for removal; therefore, only an E/M would be appropriate.)
Colonoscope was introduced and advanced to the cecum. Beyond the cecal valve, there was an area with a cauliflower-like appearance. Several biopsies were taken, hot and cold, of the area in question. In the area of the sigmoid colon, an additional polyp was snared in toto.
(Colonoscopy was performed with polypectomy by snare (45385) and biopsy(ies) of other polyps, 45380 with modifier-59 appended to indicate biopsy(ies) of separate sites.)
Portable chest, one view. Cardiac silhouette is prominent, unchanged since prior exams. No superimposed pulmonary edema or infiltrate is evident.
(Portable chest X-ray is considered one view, and, therefore, 71045 should be assigned from Diagnostic Radiology section, Chest.)
Procedure performed: Bilateral nasal endoscopy with cautery. Complete bilateral nasal endoscopy performed with zero-degree endoscope. Only potential bleeding sites on completed endoscopy were located in the anterior septum on each side. These were cauterized under direct visualization.
(Endoscopic repair of nasal hemorrhage was performed bilaterally; therefore, code 31238 with modifier -50 would be appended.) WRONG
Fraud is defined as
making false statement or misrepresentation of facts on claims.
A 38-year-old patient with BPH has his prostate removed via a laser enucleation. During this procedure he also has a vasectomy.
(Laser enucleation of the prostate is assigned code 52649 found in the urinary, vesical neck and prostate section.)
Thyroid uptake imaging, interpretation only
(Thyroid uptake imaging is assigned nuclear medicine code 78012 with modifier -26 for interpretation only.)
Patient with history of colonic polyps presents for colonoscopy with symptoms of bloody stools and abdominal pain.
K92.1, R10.9, Z86.010
(Primary code would be presenting symptoms: bloody stools and abdominal pain. Also code for history of colonic polyps as contributed to reason for colonoscopy.)
The portion of the skull that encloses the brain is called
(The cerebrum and cerebellum are both parts of the brain. The cranium, also referred to as the skull, is the bone that encloses the brain.)
Ca brain mets from the lung
(Primary diagnosis is secondary brain carcinoma, primary carcinoma of lung.)
Prosthetic training, 60 minutes
(Code 97761 should be assigned a total of four units as the code is per 15-minute increments.)
Patient presents for knee arthroscopy after several months of left knee pain. Arthroscope is introduced and the medial joint has some synovium and a torn complex medial meniscus that was repaired.
(Primary reason for encounter is knee arthroscopy for findings of complex torn medial meniscus.)
Intermediate laceration repair, 2.5 cm, right index finger
(Repair/closure, intermediate, hand/finger, 2.5 cm)
Bronchoscopy performed through mouth block. Bilateral BAL performed and transbronchial biopsies taken from the right middle and right lower lobes.
31624-50, 31632-51-RT, 31628-51-RT
(Bronchoscopic alveolar lavage was performed bilaterally, 31624-50, and transbronchial biopsies of two lobes were taken, codes 31628 and 31632 assigned. Modifier -51 is assigned for all subsequent procedures, and codes are placed in the order of significance; therefore, 31624-50 listed first (as bilateral) followed by 31632-51-RT and 31628-51-RT.)
Patient presents with concerns of rectal bleeding and diarrhea. Patient has a past history of colon cancer diagnosed 12 years ago, treated with surgery and has remained cancer free. Patient will undergo colonoscopy. Until that time, patient will refrain from anti-diarrhea medications and use Preparation H for what are believed to be hemorrhoids.
K62.5, R19.7, Z85.038
(Hemorrhoids cannot be coded as "believed to be." Code signs/symptoms for presenting problem: rectal bleeding and diarrhea. Also code history of colon cancer as increased complexity of medical decision making.)
In order for physician supervision requirements to be met for nonprovider staff, what conditions must be met?
Provider must be in the physician suite.
(In the event nonprovider staff, such as an RN provides service, the provider must be in the office suite at the time the services are performed. It is not acceptable for the provider/physician to be only in the same building or available for contact.) WRONG
Tonsillectomy age 8
(Tonsillectomy only was performed; therefore, 42825 would be appropriate for patients under 12.)
(When gallbladder is excised (cholecystectomy) through open technique, assign 47600.)
Vaginal delivery only
(When only vaginal delivery is performed, assign 59409 for delivery only code.)
Hepatomegaly refers to
enlargement of the liver.
(The suffix "megaly" refers to enlargement. In this scenario, "hepato" refers to the liver; therefore, the correct choice would be "hepatomegaly.")
Carpal tunnel release. A thenar incision was made, and dissection was carried down through the palmar fascia. Transverse carpal ligament was identified and the ulnar border of the transverse carpal ligament was released. External neurolysis was performed freeing the scarred fascia.
(Assigned to code 64721 for neuroplasty, medial nerve at carpal tunnel in Nervous System section.)
Thoracentesis with indwelling tube placement
(Thoracentesis was performed with no imaging; however, indwelling catheter was placed, which codes to 32556.)
Breast prosthesis, mastectomy sleeve
(L8010 only code for breast mastectomy sleeve)
Laceration repairs are as follows: 1.5 cm face, intermediate; 2.5 cm arm, simple; and 1.5 cm arm, intermediate
12051, 12031-51, 12001-51
(Each repair/closure requires a separate code as different anatomical grouping and/or different complexity. Therefore, for intermediate face would be most significant, 12051, followed by intermediate arm, 12031-51, followed by simple arm, 12001-51.)
Cytoscopy with urethral dilation with a posterior repair of rectocele. 21 French panendoscope was inserted and the urethra was dilated from 16 to 38 French female sound. The midline of the rectocele was marked and a small triangular tissue of skin was removed. Posterior vaginal wall was then dissected lateral to the lateral pelvic well. At the apex of the vagina, a rectocele was identified and repaired. Posterior vaginal wall was closed at which time extra skin was also removed.
(Posterior colporrhapy was performed and repair of rectocele accomplished. Assign 57250.) WRONG
The RICE protocol is utilized for treating sprains and strains and involves
rest, ice, compression, and elevation.
Contraction of the atria and ventricles is referred to as
A patient has been definitively diagnosed with Meniere's disease. The patient presents for a transcanal chemical labyrinthotomy to the right ear. Dr. Miller visualizes the tympanic membrane with an operating microscope, cleans the ear canal, and makes a small incision into the tympanic membrane. Gentamicin is delivered into the right ear. The perfusion is repeated to achieve the maximum result.
(Assign code 69801 for the labyrinthotomy as well as 69990 as an operating microscope was utilized to visualize and perform the procedure.)
Which of the following drugs, biologicals, or substances would not be reported with chemotherapy administration procedure codes?
IVP of an antibiotic
(An antibiotic is not considered a chemotherapy drug; therefore, code would not be assigned from chemotherapy administration section.)
Emergency department visit for fractured ankle. Detailed history, expanded problem-focused exam, moderate MDM.
(Visit limited by expanded problem-focused exam to level 99283. All three elements, Hx, exam, and MDM must be met for an Emergency Room Visit.)
When repeat pathology services are performed on the same day, what modifier code, if any, would be utilized?
(Modifier -91 is utilized in the Pathology section when the exact same procedure (same CPT code) is performed/repeated on the same day.)
A 28-year-old ESRD patient was seen in an outpatient hospital facility for treatment of an obstructed hemodialysis AV graft by percutaneous transluminal balloon angioplasty of the venous portion of the graft. This procedure lasted 45 minutes. The patient had an excellent result and was released to home after recovery from the treatment. Another physician performed the professional radiological supervision and interpretation for this procedure.
(Code 36902 would be assigned for introduction of dialysis circuit with balloon angioplasty. Other code selections are for stent, thrombectomy, and no angiography.)
The most aggressive form of skin cancer is
(Malignant melanoma is the most aggressive skin cancer. Basal cell and squamous cell carcinoma are also forms of skin cancer, and the most common, but are not considered the most aggressive. Purpura is a purple-colored rash on the skin that is caused by the internal bleeding of small vessels.)
Anesthesia for inguinal hernia repair in normally healthy patient
(Anesthesia code 00830 (lower abdomen hernia), physical status modifier -P1)
When impacted cerumen is removed by surgical instrumentation, what code(s) would be appropriate?
(Impacted cerumen with the use of surgical instrument is assigned code 69210.)
Patient tripped and hit right foot on chair during the evening. Radiological exam found he had fractured his great toe and second toe. Physician strapped the toes and the patient was discharged.
(Strapping only performed; therefore, 29550-RT assigned only.)
Carpal tunnel release, left
(Carpal tunnel performed open is assigned a code from the Nervous System, Neuroplasty Code section. Code 64721-LT would be assigned.) WRONG
Anesthesia services for a 82-year-old with severe Parkinson's and hypertension for liver transplant
(Anesthesia code 00796 for procedures on upper abdomen, liver transplant, and physical status modifier -P3 for severe disease. Also assign qualifying circumstance code 99100 for patients over 70 (82 years).)
Hospital bed, with rails and mattress
(Bed is with rails and mattress; therefore, E0250 is appropriate.)
Endoscopic ultrasound for esophageal cyst. Video radial echoendoscope was introduced through the esophagus, stomach, and duodenum. Moderate gastritis was visualized. Rest of exam was unremarkable. Ultrasound images were taken showing two cystic lesions in the esophagus.
(Endoscopic ultrasound of the esophagus, stomach, and duodenum is assigned 43237.)
Patient has burns noted on both hands, blisters intact on left hand as well as right hand. Silvadene and nonadherent dressing applied and wrapped in kling.
(Burns involving blisters are considered second degree. Assign code 16030 as more than one extremity (two hands) was involved.) WRONG
The tailbone is a small triangular-shaped bone consisting of three to five fused vertebrae, also referred to as the
(The coccyx is also known as the tailbone.)
Bilateral screening mammogram
(Screening mammogram, bilateral, no need to assign modifier -50 as code is bilateral.)
Qualifying circumstances code assigned for patients under 1 or over 70
Patient presents with left lower knee pain. An arthrocentesis is performed with the injection of 10 mg of Kenalog. Code the Kenalog (triamcinolone acetonide).
(J3301 covers up to and including 10 mg of Kenalog; therefore, only one unit is reported of J3301.)
(When cystourethroscopy only is performed, assign diagnostic cystoscope code 52000.)
Coronary angiography by catheter placement in the coronary artery, supervision, and interpretation
(Coronary angiography by catheter placement in the coronary artery, supervision, and interpretation is assigned code 93454.)
Exacerbation of COPD
(Code as exacerbation, disease, pulmonary, obstructive, chronic.)
A cardiologist is called to the ED to perform a consultation. The service was coded as follows: 01/01/XX with Place of Service Inpatient Hospital, and CPT Code 99251. Why will the claim be denied?
Place of service and CPT code are incorrect.
(Emergency room services are considered outpatient, and, therefore, the place of service 21 is incorrect as well as the CPT code 99251 that is for inpatient consultations. Outpatient consultation codes 99241-99245 should be reported.)
A semicircular incision was made in the margin of the umbilicus of this 6-year-old. Dissection was carried down to the fascia. Posterior part of the umbilical skin was detached, and exam showed pinpoint opening in which omentum was stuck. Opening was enlarged, and the omentum was adhesed to the umbilical opening. It was released and returned to the abdominal cavity.
(This represented an incarcerated hernia as the omentum was "stuck" and had to be cut and released and returned to the abdominal cavity. Therefore, code 49587 for an incarcerated hernia on a patient over 5 should be assigned.) WRONG
Possible basal cell carcinoma of right upper lid. Area was marked in a wedge shape, and a wedge resection was performed with Mescott scissors. Three sutures were used to close the tarsus, then two silk sutures were passed through the anterior/posterior lid margins to oppose the lid margins together. Vicryl sutures were used to close the orbicularis oculi layer superior to the tarsus.
(Performed on the eyelid and tarsal; therefore, codes from the ocular/eye section are utilized. Modifier -E3 is utilized to specify the right upper lid.)
After general anesthesia, the right ear was cleansed of excess cerumen with cerumen curette and alligator forceps. Ear canal was cleared and the tympanic membrane was retracted with thin effusion in the middle ear space. Myringotomy knife was used to create a radial incision in the anterior inferior quadrant, followed by evacuation of the middle ear fluid with suction. An Armstrong Beveled Grommet ventilation tube was carefully inserted through the myringotomy incision. Similar procedure was performed on the left ear.
(Tympanostomy with tube placement was performed bilaterally; therefore, 69436 would be reported along with modifier -50. The removal of cerumen was not the definitive procedure but necessary to visualize the surgical site and, therefore, is not separately reportable.)
An idiopathic disorder refers to a disease/disorder that is
without known cause
(Idiopathic means "without cause."
An idiopathic disease is not caused by external forces, psychological factors, or self-inflicted. The disease at the time of diagnosis has no known cause.)
STSG from thigh to arm 4 x 4 cm, STSG from thigh to face 3 x 4 cm
(Codes for skin grafts are assigned based on recipient site. Therefore, code 15120 is assigned for skin graft to face, and 15100 for skin graft to arm.)
Arthroscopic meniscectomy, right knee
(Meniscectomy performed arthroscopically would be assigned 29881-RT because not stated as medial and lateral, and, therefore, assumed to be one compartment only.)
When CRNAs (certified registered nurse anesthetists) provide anesthesia services under the direction of the anesthesiologist, how will these services be coded/billed?
Same anesthesia code with modifier to designate CRNA
(CRNAs utilize the same anesthesia CPT codes with a modifier to designate CRNA.)
How are three transbronchial biopsies of the lower right and two of the left lobe reported?
(Transbronchial biopsies are assigned codes based on each lobe; therefore, 31628 should be assigned for the first lobe, and 31632 for the additional lobe.)
Pair of forearm crutches with tips and handgrips was provided during the patient's visit.
(E0110 is the only code for forearm crutches.)
X-ray, knee, 3 V, right
(Diagnostic X-ray, knee, 3 views, assigned 73562-RT)
Arthroscopic TMJ repair
(Code 29804, located under Arthroscopy, temporomandibular joint.)
Lumpectomy. Incision was made over the palpable breast mass and underlying breast tissue was excised, approximately 6 x 4, constituting a partial mastectomy in the lower right quadrant. This contained the palpable abnormality.
(Stated as lumpectomy; therefore, 19301 would be appropriate.)
Cardiac stress testing, complete, including performance of test, supervision, interpretation, and report
(Cardiac stress test should be assigned 93015 for complete service, which, according to CPT guidelines, includes performance of the test, supervision, interpretation, and report.)
Screening colonoscopy. Colonoscope was inserted and passed through all flexures to the cecum. The patient had a few diverticuloses in the sigmoid colon, and a small sessile polyp in the distal sigmoid was removed by snare.
(Screening colonoscopy was performed. However, a polyp was removed by snare polypectomy. The screening colonoscopy is included, and only 45385 is assigned.)
Cervical epidural steroid injection and epidurogram were performed under fluoroscopic guidance. Would the epidurogram be codeable in conjunction with the cervical epidural steroid injection?
(No, the epidurogram is performed for identification and verification of the site only and, therefore, is not separately reportable.) WRONG
IV infusion for a total of 3 hours
96365, 96366 x2
(Three hours of IV infusion should be assigned 96365 for the first hour and 96366 x2 for two additional hours.)
Anesthesia services for arthroscopic carpal tunnel repair, left, normally healthy 26-year-old male
(Anesthesia code 01830 for open/arthroscopic surgical procedures wrist/hand and physical status modifier -P1)
Laparoscopic ventral herniorrhaphy with patch. A small incision was made, and the trocar was introduced. In the left lower quadrant, two trocars were placed, and the hernia was easily visualized. The herniated area was removed, and the area was covered with an oval mesh patch measuring approximately 8 X 10. Trocars were removed, and the excess CO2 was allowed to escape, and the skin was closed.
(When trocars are introduced, the procedure is intended to be performed laparoscopically. In this scenario, a ventral hernia repair (orrhaphy) was performed. Therefore, codes from the laparoscopic section of the hernia repairs (GI section) should be assigned. In this case, 49659 would be appropriate.) WRONG
Specific E & M guidelines utilized by Medicare/CMS may be found where?
(The CMS website provides specific guidelines regarding E/M service for Medicare.)
A 16-year-old patient for initial visit, referred by physical therapist at school. Injured foot in track practice and has been complaining of right ankle pain for about a month. Detailed history, detailed exam, and low MDM were performed.
(Detailed Hx, detailed exam, and low MDM would be assigned 99203.)
The study of the causes of disease is known as
(Etiology, "study of" "cause." While other choices also contain the suffix "ology" study of, histology is the study of the cells, psychology is the study of the mind, and endocrinology is the study of the endocrine system.)
X-ray of left knee for pain following fall. History of TKA 2 years ago. AP and lateral views of left knee demonstrate left knee replacement in satisfactory position. No fracture, subluxation seen.
M25.562, W19.XXXA, Z96.652
(No definitive diagnosis on x-ray; therefore, utilize left knee pain. Total knee replacement is significant for additional complexity for encounter and is evaluated. Fall not coded as external cause codes assigned for current event only.)
General anesthesia for a 75-year-old male with hypertension and Parkinson's disease for transurethral resection of prostate
(Anesthesia code 00914 for transurethral procedures, that is, transurethral resection of prostate, physical status modifier-P2 as condition of HTN. Qualifying circumstance 99100 for patients over 70 (age 75))
3 V of right knee. There is a 0.3 cm calcification over the central knee portion. Could be an avulsion fracture. Recommend AP view be repeated with notch view.
(Code 73562 for 3 view knee with modifier -RT appended to indicate right)
Anesthesia services for excision of malignant lesion of the arm, 2.5 cm on a 35-year-old normally healthy female
(Assign code 00400 for integumentary procedures and physical status modifier -P1)
Right frontal ventriculoperitoneal shunt placement with Codman programmable valve
(Placement of a ventriculoperitoneal shunt is assigned 62223.) WRONG
After general anesthesia, the right knee was flexed about 85 degrees. It was then gently manipulated so it flexed to about 125 degrees. Scar tissue bands were heard popping with gentle manipulation. Full extension was achieved and the knee was then injected with 80 mg of Kenalog and Marcaine.
(Manipulation of knee under anesthesia is assigned 27570-RT. Injection for postoperative pain is included in procedure and not separately reportable.) WRONG
Excision of a 2 cm lesion on the lower back with 0.5 cm margins with simple repair. Another lesion was excised from the face, 0.5 cm. Two additional lesions on the arm; both lesions, approximately 1.2 cm, were also excised and closed. Surgical pathology indicated that the lower back and both arms lesions were malignant.
11603, 11602, 11602-59, 11440-51
(Four lesions were excised; therefore, four separate codes must be assigned. Three of the lesions were malignant. Lower back, total 3.0 cm, codes to 11603. The two lesions of the arm both code to 11602; therefore, it is listed twice, with modifier -59 on the subsequent code to indicate distinct from other lesion with same code. The remaining lesion of the face would be assigned 11440-51 as subsequent skin procedures performed during the same surgical session are assigned modifier -51.)
Austin bunionectomy. Hallux abducto valvgus of right foot treated with Austin bunionectomy and metatarsal osteotomy of the right foot.
(Bunion was excised and distal metatarsal osteotomy performed, described in 28296-RT.)
Cervix was dilated and a #10 suction cannula introduced. The anterior, posterior, and lateral walls of the endometrial cavity were curetted, yielding moderate amounts of retained products of conception, which were removed.
(An incomplete abortion is a spontaneous abortion with retained products of conception. Therefore, this procedure would be coded as 59812.)
Anterior laryngoscope was entered and passed to the level of the vocal cords. Polyps were identified on the left false and right true vocal cords. CO2 laser was used to excise the polyps, identified as papillomas.
(Laryngoscopic excision of lesions was performed, which is coded to 31540.)
Supervision and interpretation aortography thoracic
(Supervision and interpretation for thoracic aortography is assigned 75600.)
Neurosurgeon and otolaryngologist both participate in performing a cochlear implant on a 6-year-old female. Neurosurgeon codes and submits 69930-RT and is paid 100% of the fee schedule allowance. Otolaryngologist submits code 69930-RT and is denied payment for "services paid to another provider." What was incorrect in regard to the coding for these services?
Both providers must append modifier -62 for both providers to be paid appropriately.
(Both physicians (two surgeons) performed a portion of the same service and, therefore, share in the code/reimbursement for the service. A modifier -62 should be assigned to the claims for both physicians to be reimbursed appropriately.)
Partial hand prosthesis, thumb remaining
(L6000 only code for partial hand, thumb remaining)
Code 29880 was performed in the medial compartment as well as 29875. What modifier(s), if any, would be appropriate for 29875?
(No modifier would be appropriate because 29875 is designated as a "separate procedure", and therefore is not codable with 29880.) WRONG
The suffix indicating inflammation is
(Itis is the suffix for conditions that involve inflammation. The other choice that involves a condition is osis which refers to an abnormal condition. The remaining suffixes refer to procedures, centesis being a surgical puncture to aspiration/inject, and ectomy being an excisional procedure.)
C7-C8 were identified and 0.25% bupivacaine was injected as a test dose. Forty mg of Depo-Medrol was injected into the epidural space and needle removed.
(When cervical epidural injection is performed, assign 62320.)
An intravenous push injection that takes place while the nurse is present the entire time is known as
intravenous push injection (IVP)
(An intravenous push injection or IVP is assigned for administration of medication that is pushed into the IV line by the nurse who is usually present for the 3-5-minute injection.)
Nerve block, by anesthetic, facial nerve
(Code 64402 for facial nerve block located in the Nervous System section, Surgical Procedures on Extracranial Nerves and Autonomic Nervous System.)
The surgical creation of an opening is called
(All the choices refer to procedures; however, only one, ostomy, refers to creating an artificial opening, such as a colosotomy, where an artificial opening is created between the abdomen and colon when a portion of the colon has been removed, usually for disease.)
Ultrasound probe was placed in the rectum and prostatic lengths were determined. Six conventional cryoprobes were placed, eight right and left apical thermal sensors and external sphincter thermal sensors were placed. The warming catheter was advanced into the bladder. Freezing probes 1 and 2 anteriorly continuing posteriorly injecting saline to separate the fascia from the anterior rectal wall. Excellent freezing of the prostate tissue was achieved after which a passive thaw was induced.
(55873 is assigned for cryosurgical ablation of the prostate. Code includes ultrasonic guidance and monitoring, therefore, no additional codes would be assigned.)
Antibody for Epstein-Barr virus, nuclear antigen
(Antibodies for Epstein-Barr by nuclear antigen is assigned code 86664.)
Ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also had an ectropion of the left lower lid that was repaired by suture repair.
(Two ectropions were repaired, one of the right lower eyelid with tarsal wedge to repair, code 67916-E4, and one with suture of the lower left, code 67914-E2.)
Patient suffers from a frozen shoulder. The patient was taken to the OR and the right shoulder was manipulated using first abduction. With this abduction, there were multiple fibrous brands, scarred tissue that was felt to be released. Rotation and abduction was performed and the patient appeared to have full motion of her shoulder.
(Code found under Shoulder, Manipulation. Assign code 23700-52. Modifier -52 should be appended as no application of fixator device was performed.)
An established patient is seen in the hospital for subsequent visit. Detailed history and exam are performed and medical decision-making is of high complexity.
(All three elements qualify for 99233.)
Carbon dioxide, chloride, potassium, sodium
82374, 82435, 84132, 84295
(As carbon dioxide, chloride, potassium, and sodium are not a disease-oriented panel, each service must be assigned individually as 82374, 82435, 84132, and 84295, respectively.)
Right diagnostic arthroscopy was carried out and revealed the rotator cuff and labrum to be intact. There was extensive bursitis in the subacromial space, and although attempted to maintain the CA ligament in its origin from the distal acromion, it was largely released in the process of performing the acromioplasty and a subacromial decompression.
(Per CPT when subacromial decompression is performed without other procedures, assign 29826-RT.) WRONG
The word part meaning excessive or increased is
(The prefix "hyper" refers to excessive, increased, or above the normal. The other choices are also prefixes, however, intra refers to within, hypo refers to the opposite of excessive or increased, and dys is used to indicate bad, difficult, or painful.)
Treatment with manipulation of a nasal septal fracture
(Repair of a nasal septal fracture with manipulation is assigned 21337.)
A patient presents with diagnosis of allergic sinusitis from his or her PCP for allergy testing. Twelve percutaneous scratch allergy tests with allergenic extracts are performed.
(Percutaneous scratch testing with allergenic extracts is assigned per test; therefore, 95004 should be assigned with 12 units.)
Chronic wound requiring STSG. Graft was obtained from the left thigh and placed on a 2 x 4 cm chronic wound of the right hand.
(Split-thickness skin graft assigned for recipient site. In this instance, code 15120, 8 sq cm hand, would be appropriate.)
Circumcision of 1 day old infant. Base of the penis was cleansed. Incision was made down to the apex. The foreskin was then retracted and the foreskin attachment was cross-clamped and removed with scissors.
(Circumcision performed utilizing clamp, assign 54150.) WRONG
Endoscopic partial left ethmoidectomy, bilateral maxillary antrostomy
(Bilateral procedures should be assigned before unilateral procedures. In this instance, bilateral maxillary antrostomy was performed endoscopically, 31256-50, and left ethmoidectomy, 31254-51-LT.)
When patient brings his or her own allergy medication and the only service provided is the injection of the allergan.
(Code 95115 is assigned for allergy immunotherapy when administration performed only.) WRONG
Mesothelioma is a type of cancer specifically caused by
exposure to asbestos
(Mesothelioma is a specific type of cancer caused by excessive exposure to asbestos.)
Right knee diagnostic arthroscopy, partial medial and lateral meniscectomy, chondroplasty with microfracture, medical femoral condyle, chondromalacia patellar chondroplasty, right knee
(Arthroscopic microfracture was performed (29879-RT) as well as medial/lateral meniscectomy (29880-RT). Meniscectomy considered more significant and, therefore, listed first. Diagnostic arthroscopy and chondroplasty included in meniscectomy and not separately reportable.)
EGD with biopsy of gastric polyp. Gastroscope was advanced into the duodenum. Biopsies of the antrum are taken, and a small polyp in the stomach is removed with biopsy forceps.
(Multiple biopsies were obtained during the course of the EGD, however, only assigned once regardless of the number of polyps/locations to 43239. When polyps are removed by biopsy forceps, CPT assistant directs to code an EKG with biopsy as well.)
A patient with a large colonic tumor, identified by CT, presented for surgical resection. During the surgery, the physician also excised a soft tissue mass from the abdomen. The pathologist performed a gross and microscopic examination of the following specimens: (a) colon, terminal ileum, submitted in two cassettes and (b) mass, soft tissue, submitted in one cassette.
(Two specimens were separately identified, one malignant tumor of the colon, assigned 88309, and one soft tissue mass of the abdomen, assigned code 88307.) WRONG
A patient had an open acromioplasty of her shoulder approximately 9 days ago. The incision is healing well and sutures were removed today. She is going to start physical therapy and was given a prescription for ibuprofen 800 mg tid to be taken as needed. Today's visit consisted of an expanded problem-focused history, expanded problem-focused exam, and low MDM.
(Regular postoperative evaluation. No E/M service is assigned, only 99024 to track visit.)
Placement of suprapubic catheter. Approached the site suprapublically through the skin and fascia until the bladder was accessed. Then a stab incision was made, the bladder was aspirated, and a suprapubic catheter was placed which was sewn into place.
(Code 51102 would be assigned for aspirating the bladder and then placing a suprapubic catheter.)
Anesthesia services for radical prostatectomy on a 75-year-old with severe CAD, HTN, COPD
(Anesthesia code 00904 for radical perineal procedure, that is, prostatectomy. Physical status modifier-P3 for severe CAD, HTN, COPD, and qualifying circumstance code 99100 for patients over 70 (aged 75))
What additional criteria for a Medicare claim should be considered in the final assignment of E/M codes that are not contained in the CPT manual?
overarching medically necessary criteria as defined by CMS
(The overarching criteria was developed specifically by CMS/Medicare and should be utilized in determining the E/M codes for services for the carriers that utilized CMS/Medicare guidelines. Time criteria is already part of the original E/M guidelines in the CPT manual.)
Hemostasis refers to
the control of bleeding
(Hemostasis refers to the control of ("stasis") blood ("hemo").)
The degenerative motor system disorder that is the slow progression of the deterioration of neurons in the substantia nigra area of the brain is known as
(Parkinson's disease is a degenerative motor disorder that deteriorates the neurons.)
Per NCCI guidelines, when multiple lesions are excised through the same incision, how many lesion codes are reportable?
(Only one code is assigned if more than one lesion is removed through the same incision/excisional site.)
Comprehensive metabolic panel, CBC, automated differential WBC, and TSH (thyroid stimulating hormone)
80053, 85025, 84443
(A comprehensive metabolic profile is performed and coded to 80053. In addition, CBC with automated differential WBC is performed and coded to 85025 as well as TSH (thyroid stimulating hormone) codable to 84443.)
Septoplasty. Columella reconstruction with cartilage graft. Utilizing a right hemitransfixion incision, bilateral mucoperichondrial and mucoperiosteal flaps were elevated. Remnants of the cartilaginous septum were removed as well as portions of the bony septum and spurs off the maxillary crest. Tears in the mucoperichondrium were reapproximated as best as possible, and then attention was focused on the columella. Excise tissue at the base was excised as well as scar tissue. Tip support was reconstructed with cartilaginous graft obtained from removed cartilaginous septum remnants.
(Nasal septum perforations were performed, which is coded to 30630. In addition, septoplasty was also performed, for which 30520-51 would be assigned.) WRONG
New patient arrives for detailed history and exam and moderate MDM.
(Visit limited by history and exam to 99203.)
Cystoscopy with ureteroscopy with balloon treatment of ureteral stricture
(Cystoscopic with treatment of ureteral stricture by balloon dilation is assigned 52341.)
Patient presented for cystourethroscopy due to lower abdominal pain and possible bladder tumor. Cystoscope was inserted and tumor identified and excised. Surgical path verified the mass was malignant.
(Documentation prior to conclusion of encounter indicates signs/symptoms and tumor diagnosed as malignant neoplasm, bladder. Coded as primary as not stated otherwise.) WRONG
(Cholecystectomy (excision of gallbladder) was performed laparoscopically; therefore, code 47562 is appropriate.)
A patient is diagnosed with a bladder tumor. The physician performs a cystourethroscopy with fulguration and resects a 7 cm bladder tumor.
(Cystourethroscopic resection of 7 cm bladder tumor is assigned code 52240.)
Anesthesia services for a normally healthy 75-year-old for emergency laparoscopic cholecystectomy for ruptured gallbladder
(Anesthesia code 00790 for upper abdomen, intraperitoneal procedures, and physical status modifier -P1. Also addition of 99140 as procedure was performed as emergency.)
Laminectomy performed on L1-L2, L2-L3
(Lumbar laminectomy performed on one to two levels is assigned 63005.)
Anesthesia services for repair of cleft palate on a normally healthy 6-month-old female
(Anesthesia code 00172 intraoral procedures, cleft palate and physical status modifier -P1. Also assign 99100 for patients under 1 year (6 months).)
What is one advantage of implementing a compliance program?
identification of potential problems before identified by third-party carriers
(Compliance programs will assist in identifying potential problems before they are identified as the result of a third-party audit.)
A newborn baby underwent a procedure to slit the prepuce to relieve constriction that prevented retraction of the foreskin over the head of the penis. The slit tissue was sutured at the divided skin to control bleeding.
(Procedure to slit the prepuce of the penis is assigned 54000 found in the male genital section, Penis, incision section.)
A patient with uncontrolled low back pain presents and has implantation of a nonprogrammable intrathecal morphine pump.
(Implantation of a nonprogrammable intrathecal pump is assigned 62361 for nonprogrammable pump located in the Spine and Spinal Cord section of the Nervous System.)
Patient had a temporary ventricular pacemaker placed at the start of a procedure. This temporary system was used as support during the procedure only. How would you report the temporary system?
(Insertion of a temporary pacemaker is assigned 33210.)
Annual preventive medicine exam for a 38-year-old established male patient.
(Preventive medicine visit for established 38-year-old is 99395.)
When a bilateral 2 V tibia/fibula x-ray is performed, how should it be reported?
(Bilateral procedures for purposes of the CPC exam should be assigned once with the modifier -50.)
How should you report a deep biopsy of soft tissue of the thigh or knee area?
(Coded to 27324, Femur/Thigh, biopsy, soft tissue, deep.)
Allergy immunotherapy, administration of antigens requiring three injections
(Code 95117 is assigned for administration of more than two injections.) WRONG
A 78-year-old female with decreased visual acuity. Diagnosis of macular degeneration made approximately 1 year ago. Patient presents for next macular degeneration treatment. Gave IV 7 cc selenium with additional 5 cc bacteriostatic water. Will repeat again in 1 week.
(Patient scheduled for procedure, therefore, procedure only assigned.)
The primary internal female reproductive organs are
(The ovaries are considered the primary internal female reproductive organs.)
Laparoscopy, lysis of adhesions and right ovarian cystectomy. A subumbilical incision was made and cannula and ports were inserted. Adhesions from the omentum to the anterior abdominal wall were taken down, and, after freeing up the adhesions, the right ovary was noted to have two ovarian cysts, which were aspirated.
(Code 49322 assigned for laparoscopic aspiration of ovarian cyst(s), found in abdomen, laparoscopy section.)
ORIF left distal radius, short arm splinting. Standard volar approach was made and the fracture site was identified. Fracture was reduced and T plate was used to hold the fracture on the volar surface. The hardware was placed and visualized fluoroscopically to make certain in good anatomical position.
(Open reduction with internal fixation (ORIF) of distal radius is assigned 25607-LT because number of fragments was not identified; therefore, assumed one. Splinting is included in surgical procedure and not separately reportable.) WRONG
The sense of smell is also referred to as
(Olfaction refers to the sense of smell. Inhalation refers to the drawing of air or other substances into the lungs. Gustation refers to the act of tasting. Sinusitis refers to an inflammatory process that affects the lining of the sinuses/nose.)
Drug screening, three drug classes, ELISA method
(Code 80307 is assigned for drug screening by ELISA method regardless of the number of drug classes tested.)
Modified radical mastoidectomy, left
(When a mastoidectomy is performed that is specified as modified radical, assign code 69505-LT.)
CT abdomen with oral contrast
(Would assign 74150 for CT abdomen performed without contrast. Per Radiology guidelines in CPT, oral contrast does not constitute "with contrast.")
The surgeon finds an enlarged ovarian cyst on the left and an attempt is made to remove the cyst. However, multiple attempts failed to remove the cyst, and the surgeon proceeded with a left salpingo-oophorectomy.
(Only the definitive procedure is reported, therefore, salpingo-oophorectomy is reported with code 58720-LT.) WRONG
This is a 22-year-old female who presents today with sacroilitis. On the physical exam, there was pain on palpation of the left sacroiliac joint and imaging confirmation was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left sacroiliac joint with a 22 gauge needle.
(Code found under Pelvis/Hip, Introduction/Removal, Injection sacroiliac (SI) joint.)
Portable chest x-ray for history of shortness of breath, R/O cardiomegaly. Cardiac silhouette is prominent, unchanged since prior exams. No superimposed pulmonary edema or infiltrate is evident.
(No definitive diagnosis on x-ray; therefore, utilize shortness of breath. Cardiomegaly stated as "rule out"; therefore, cannot be assigned per ICD10 guidelines.)
(Code 53200 for urethral biopsy located under urinary, urethra section under excision, biopsy.)
IV push, antineoplasm (chemotherapy) drug
(Assign code 96409 for intravenous push, injection from the Chemotherapy Administration section.)
L1 refers to which anatomical part?
first lumbar vertebrae
(The levels of the vertebrae are referred to by the section (i.e., lumbar (L), thoracic (T), and cervical (C)) followed by the number of the vertebrae (1, 2, 3, etc.). Therefore, the first vertebrae of the lumbar region would be referred to as L1. The first thoracic vertebrae would be referred to as T1, while the first cervical vertebrae would be labeled as C1. Thereofre, L1 is the first lumbar vertebrae.)
(No additional information documentation; therefore, assigned code for "Headache" only, R51.)
Skin ulceration caused by prolonged pressure, usually experienced by someone who is bedridden, is called
(The only choice that is a skin ulceration is the decubitus ulcer and is usually due to prolonged pressure. It is often referred to as a "pressure ulcer.")
Pneumonia, probably streptococcal
("Probably" cannot be coded, therefore, code only pneumonia.)
Procedure Performed: Resection of 3 cm left posterior neck lesion/mass. A natural skin crease incision was made. Care was taken to resect the entire mass, however, taking care to avoid the underlying cranial nerve. Once the entire mass was resected free, the wound was closed in layers, using 3-0 chromic for the deep subcutaneous and 4-0 Prolene for the skin.
(Two codes are appropriate, one for the excision of the lesion (not stated as malignant, therefore assumed benign). Per CPT, repair/closure may be assigned when more than simple is required. Therefore, also assign code 12041 for intermediate repair.)
Physical therapy evaluation, low complexity
(Assign 97161 for physical therapy evaluation when low complexity.)
ER visit, detailed history, detailed exam, low MDM
(Three of three elements needed, low MDM makes visit 99282.)
Anesthesia services for multiple laceration repairs of the left leg, 2.5 cm knee, 2.5 cm tibia, 1.5 cm ankle on a 37-year-old normally healthy patient
(Anesthesia code 00400 for integumentary procedures, extremities, and physical status modifier -P1)
Radial keratotomy bilateral for elective vision correction
(Radial keratotomy, assigned code 65771-50, as performed bilaterally is found in the Eye, Anterior Segment, Keratoplasty section.)
Left heart catheterization for PTCA of right coronary and intracoronary stent
(Heart catheterization performed for purpose of angioplasty and stent to right coronary. Only successful intervention is assigned; therefore, only stent, 92928-RC is assigned.) WRONG
The longest portion of the small intestine, and the final region, is the
(The ileum is the longest portion of the small intestine. The duodenum and jejunum are also portions of the small intestine but are not the longest portions. The ileocecal valve refers to the valve that guards the opening between the ileum and the cecum.)
Surgical pathology, needle biopsy, liver
(Surgical pathology for liver needle biopsy is assigned 88307 per surgical pathology listing in CPT.)
A 52-year-old female has recurrent lymphoma in the axilla. Ultrasound was used to localize the lymph node in question for needle guidance. An 11 blade scalpel was used to perform a small dermatotomy. An 18 × 10 cm BioPince needle was advanced through the dermatotomy to the periphery of the lymph node. A total of four biopsy specimens were obtained. Two specimens were placed in RPMI and two were placed in formalin and sent to laboratory.
(When lymph nodes are biopsied/excised by needle, code 38505 is assigned.)
Cardiomegaly refers to
enlargement of the heart.
(All choices refer to conditions of the heart or cardiovascular system. However, cardiomegaly would only refer to enlargement ("megaly") of the heart ("cardio").)
Cardiovascular stress test, technical, tracing only
(Assign 93017 for cardiovascular stress test, tracing only from Cardiovascular section.)
Breast prosthesis (implanted) following mastectomy
(Assign C1789. Other codes listed are for implantation of other devices.)
A 62-year-old female has a mass growing on her right flank for several years. It has finally gotten significantly larger and is beginning to bother her. She is brought to the operating room for definitive excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous tissue and the surgeon encountered a well-encapsulated lipoma approximately 4 cm. This was excised primarily bluntly with a few attachments divided with electrocautery.
(Coded to the musculoskeletal section as incision was done into subcutaneous. Found under Femur/Thigh, Excision, Excision Tumor, Subcutaneous, > 3 cm. Code 27337-RT would be appropriate.)
Breast biopsy, percutaneous needle
(Assigned code from Integumentary Section, Excision, biopy, breast, percutaneous needle, code 19100)
ED visit, expanded problem-focused history, detailed exam, low MDM
(Visit limited by expanded problem-focused Hx to 99282.)
Squamous cell carcinoma in situ, floor of mouth
(Code as neoplasm, mouth, floor, and utilizing in situ column of neoplasm table
The inflammation of diverticula in the intestines is known as
(Inflammation ("itis") of the diverticula is known as diverticulitis. Colitis and appendicitis are inflammation of the colon and appendix, respectively, while diverticulosis is the abnormal condition or formation of diverticula in the colon.)
Chemotherapy infusion therapy, 9:00-10:45
(Code 96413 is assigned for first hour; code 96415 for additional hour (minimum 30 minutes needed).)
MRI brain without contrast
(Assign 70551 for MRI brain w/out contrast from Diagnostic Radiology, head/brain section.)
Metastatic neoplasm of the spine
(Primary diagnosis coded as secondary spine. Since no primary site is listed, assign C80.1, unspecified site.) WRONG
Debridement of devitalized epidermis, open wound, selective, 20 sq cm
(20 sq cm of selective active wound therapy is assigned code 97597.)
Laceration repair of the left ring finger
(Coded as smallest size and simple complexity as no additional information. Code 12001 is assigned.)
Open procedure replacement of cranial nerve neurostimulator. The pulse generator was connected to the neurostimulator array inserted previously, tested, and repositioned to ensure maximum effectiveness. The pulse generator was placed and sutured into a created subcutaneous pocket. Again, the system is tested to ensure proper functionality.
(Assign 61885 only for pulse generator replacement of the neurostimulator. Array was previously placed and, therefore, not separately reportable for this surgical procedure.) WRONG
Right kidney mass
(No code for mass, kidney. Therefore, code to other conditions/diseases of kidney/ureter.) WRONG
Drug confirmation, benzodiazepines, 10 analytes
(Drug confirmation for 10 analytes of benzodiazepines is assigned 80346 that is for 1-12 analytes.)
Infectious agent antigen detection, herpes simplex virus type 2, by immunofluorescent technique
(Herpes simplex virus type 2 antigen detection by immunofluorescent technique is assigned 87273.)
Injection, diazepam 7.5 mg
J3360 X 2 units
(Code J3360 is per 5 mg; therefore, two units must be assigned. Correct code is J3360 x 2.)
Infected scalp laceration from fall 3 weeks ago
L08.9, S01.01XA, W19.XXXA
(Active treatment of the laceration necessitates the seventh character "A" even though the initial injury was three weeks prior.)
After adequate anesthesia was obtained, the patient was turned prone in a kneeling position on the spinal table. A lower midline cervical incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and laminectomies were then carried out at C3-4, C4-5, and C5-6. Interbody fusions were set up for the lower three levels using structural autogenous bone from the iliac crest. The posterior instrumentation of dual titanium rods with hooks were then cut to the appropriate length and bent to confirm to the normal curve. It was then slid immediately onto the bone screws, and at each level, compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible.
22551, 22552 X 2, 22842, 20938
(Assign code 22551 for first level (C3-4), and assign 22552 x 2 for two additional levels (C4-5 and C5-6). In addition, assign 22842 for posterior segmental dual rods and 20938 for structural autograft. As both 22842 and 20938 are add-on procedures, modifier -51 is not necessary in this instance.)
A 36-year-old female presents for laparoscopic bilateral inguinal hernia repair with open umbilical hernia repair also was performed.
(Bilateral laparoscopic inguinal hernia on a 36 year old, codes to 49650-50. An open umbilical hernia was also repaired, which codes to 49585.) WRONG
Removal of foreign body from esophagus by scope through guidewire following EGD.
(EGD (esophagogastroduodenoscopy) was performed at which time removal of foreign body through guidewire is assigned 43248.)
Esophagoscopy with FB removal
(When only esophagoscopy is intended and foreign body is removed, assign 43215.)
Surgical pathology, carpal tunnel
(Surgical pathology for carpal tunnel is assigned 88304 per surgical pathology listing in CPT.)
Prescription and fitting of contact lenses
(For the prescription and fitting of contact lenses, assign 92310.)
At the patient's bedside in the hospital, a PICC line is inserted. Using xylocaine local anesthesia, aseptic technique, and ultrasound guidance, a 21-gauge needle was used to aspirate the right cephalic vein of a 72-year-old patient. When blood was obtained, a 0.018-inch platinum tip guide wire was advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6 French peel-away sheath to the SVA RA junction, and after removal of the sheath, the catheter was attached to the skin with a STATLOCK device and flushed with 500 units of heparin in each lumen.
(When a central venous catheter is inserted peripherally, code 36569 is assigned. PICC stands for peripherally inserted central venous catheter.) WRONG