AAPC CPC Certified Professional Coder (CPC) Exam Exam Practice Test
Certified Professional Coder (CPC) Exam Questions and Answers
(Patient with erectile dysfunction is presenting for a penile implant. Anon-inflatable penile prosthesisis inserted. What CPT® code is reported for this service?)
The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.
What CPT® code is reported?
An established patient presents with fever and sore throat. Rapid strep test is positive.
What CPT® and ICD-10-CM codes are reported?
A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.
What CPT® coding is reported?
(A 42-year-old female is in the operative room to repair azone 2 flexor digitorum profundus (FDP) tendonlaceration involving her index finger with an associatedradial digital nerveinjury. The dorsal side of the FDP tendon was sutured. Next, themicroscopewas brought into place and the radial digital nerve was repaired using epineural sutures. What CPT® codes are reported?)
A pediatrician is requested to attend a high-risk delivery and performs initial stabilization of the newborn after cesarean delivery.
What E/M service is reported?
Patient has esotropia of the right eye and presents to operating suite for strabismus surgery. The physician resects the medial rectus horizontal and lateral rectus muscles of the eye and secures them with adjustable sutures. Extensive scar tissue is noted, due to a previous surgery involving an extraocular muscle. Extraocular muscle is isolated, and the muscle is freed from surrounding scar tissues.
What CPT® codes are reported for this surgery?
(What CPT® coding is reported for the insertion ofHeyman capsulesfor clinical brachytherapy?)
A patient comes to the gynecologist's office to check if she is pregnant. A urine sample is taken and tested. The visual result is positive that she is pregnant.
What CPT® code is reported'
(A patient with age-related osteoporosis is hospitalized after a slip and fall resulting in fractures to both hips. The physician ordersthree-view imaging of both hips and the pelvis, interpreted by the hospital radiologist. Later the same day, the patient falls from bed and the doctor ordersthree additional viewsof both hips and pelvis, interpreted by thesame radiologist. What CPT® coding is reported?)
A mother brings her 2-year-old son to the pediatrician's office because he stuck a bead up his left nostril. The pediatrician uses a nasal decongestant to open the blocked nostril and removes the bead with nasal forceps.
What CPT® coding is reported?
Which one of the following is correct to report an intermediate repair code (12031–12037)?
A patient who has colon adenocarcinoma undergoes an open partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and
remaining colon.
What procedure and diagnosis codes are reported?
An 8-day-old newborn (3 kg) undergoes circumcision using a scalpel (no clamp).
What CPT® coding is reported?
An inpatient, suffering from hypertension and chronic kidney disease, is administered continuous venovenous hemofiltration. The on-duty nephrologist performs a series repeated low-level evaluation and management services to monitor the patient's status.
What is the CPT® and ICD-10-CM coding'
Dr. Meredith sees Mr. Hollis (new patient) for the first time In the Community Rest Home. She documents a visit with medical decision making of moderate complexity. She spends 20 minutes of additional time discussing physical therapy and going over medications. Dr. Meredith spends a total of 90 minutes on that patient that day.
What CPT® coding does Dr. Meredith report?
A patient who was training for a marathon collapsed due to heat exhaustion on a very hot day. The patient is driven by his wife to a non-facility urgent care center for him to be treated. On
examination, the physician diagnoses heat exhaustion and dehydration. The physician began IV therapy of normal saline that consists of pre-packaged fluid and electrolytes. The hydration lasts
for 1 and 30 minutes.
What CPT® coding is reported?
A patient has suspicious lesions on his feet. Biopsies confirm squamous cell carcinoma. The patient elects to destroy a 0.6 cm lesion on the right dorsal foot and a 2.0 cm lesion on the left dorsal foot using cryosurgery.
What CPT® coding is reported?
(What is the medical term for the study of the kidney?)
A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesia. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots. Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT® coding is reported for this procedure?
A complete 7-view X-ray of the lumbosacral spine, including bending views, is performed.
What CPT® code is reported?
A cardiologist attempted to perform a percutaneous transluminal coronary angioplasty of a totally occluded blood vessel. The surgeon stopped the procedure because of an anatomical problem creating risk for the patient and preventing performance of the catheterization.
What modifier is appended to the procedure code?
Adenoids, tonsils, appendix, and spleen belong to which organ system?
A cardiologist uses the hospital's equipment for a cardiac stress test as he doesn't own equipment for the test. He supervises the test and provides the interpretation and report of the test.
What CPT® codes are reported?
A 23-year-old receives MMR and Hepatitis B vaccines without counseling.
What CPT® codes are reported?
A physician orders a CT scan of the abdomen without contrast.
What CPT® coding is reported?
A 26-year-old male presents with a deep laceration from a kitchen knife to his right hand. The surgeon washes the open wound with sterile saline. Clamps are applied. The provider cleans the
vessel and prepares the edges of thee wound. She then repairs the bleeding vessel with sutures. The clamps are removed and the provider uses a Doppler probe to check the blood flow pattern
through the repaired vessel.
What CPT® code is reported?
The outermost protective layer of skin is called the:
A 50-year-old patient presented with a persistent cough has not responded to standard treatments. The patient's physician decides to perform a flexible bronchoscopy with bronchial biopsies to further investigate the cause. A flexible bronchoscope is inserted through the patient's mouth and into the bronchial tubes. Five biopsies are taken for further testing. The biopsies were sent to the lab for analysis to determine the next steps in the patient's treatment plan.
What CPT® coding is reported?
A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT® code is reported?
A patient has swelling in both arms and lymphangitis is suspected. She is in the outpatient radiology department for a lymphangiography of both arms.
What CPT® coding is correct?
(A patient suffering fromlateral epicondylitisin the left elbow is sent to the operating room tomanipulate the elbow. The patient is placed undergeneral anesthesiaby the anesthesiologist. The physician manipulates the elbow through stretching and rotation to restore motion. What CPT® coding is reported for the physician?)
A therapeutic colonoscopy is performed, where the scope goes beyond the splenic flexure, but not to the cecum. Using the Colonoscopy Decision Tree illustrated in the CPT® code book, what coding is reported?
(A patient has nausea with several episodes of emesis and severe stomach pain due to dehydration. Normal saline is infused in the same bag with2 mg ondansetron. Then15 mg ketorolac tromethamineis given for stomach pain. What J codes are reported for these services?)
(Full Case:Preoperative diagnosis:Low back pain; possible spinal stenosis L3–4.Postoperative diagnosis:No evidence of discogenic pathology or spinal stenosis at L3–4; normal discography L3–4.Procedure:Awake discography and injection, L3–4.Anesthesia:IV narcotic with reversal and local; propofol given transiently, then patient alert/responsive for pain response during injection.Technique:Patient to OR; right decubitus; sterile prep/drape; C-arm used to mark entry; local ethyl chloride + 1% Xylocaine; docking needle placed posterolateral at L3–4 under AP/lateral; inner needle advanced to disc nucleus center; contrast injected while monitoring patient response; normal bilocular pattern; 1.5 cc volume; no pain with pressurization.Documentation:No videotape; plain films available; post-discography CT planned/reviewed for other causes.Question:What CPT® and ICD-10-CM coding is reported?)
(A patient’s left eye is damaged beyond repair due to a work injury. The provider fabricates aprosthesisfromsilicon materialsand makes modifications to restore the patient’s cosmetic appearance. What CPT® code is reported?)
(A patient is in her dermatologist’s office for treatment of recurring psoriatic plaques on the upper back and neck resistant to topical therapy. The dermatologist performsExcimer laser therapyon the upper back (300 sq cm) and neck (100 sq cm), total surface area400 sq cm. What CPT® codes are reported?)
A 56-year-old female patient with a history of degenerative disc disease at levels T2-T3 and T4-T5 underwent a surgical repair procedure. Two surgeons will be working together as primary surgeons
Surgeon X: Carried out the anterior exposure of the spine and mobilized the great vessels, assisted Dr. Z. and performed the closure.
Surgeon Z: Performed a minimal anterior discectomy and fusion at T2-T3 and T4-T5 levels using an anterior interbody technique and solely performed utilizing a structural allograft.
What is the CPT® coding for the two surgeons?
A planned partial meniscectomy of the temporomandibular joint is cancelled after anesthesia and incision due to respiratory distress.
What CPT® coding is reported for the oral surgeon?
Refer to the supplemental information when answering this question:
View MR 005271
What CPT® coding is reported?
Which is an anesthesia physical status modifier?
The provider performs a radical resection of a 4.5 cm sarcoma in the upper arm.
What CPT® coding is reported?
The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.
What CPT® and ICD-10CM codes are reported?
The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger’s lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
Which statement is FALSE in reporting a personal history ICD-10-CM code?
A 44-year-old female patient came in for a planned laparoscopic total abdominal hysterectomy for endometriosis of the uterus. The surgeon attached the trocars, a scope is inserted examining
the uterus, abdominal wall, bilateral ovaries, and fallopian tubes. The surgeon decided to convert the laparoscopic procedure to an open total hysterectomy because of the extensive amount of
adhesions that need to be removed. A total hysterectomy was performed and due to removal of the extensive adhesions the surgery took longer than normal of 2 hours.
What CPT® and diagnosis codes are reported?
A patient arrives with stridor and in respiratory distress. The provider performs a micro laryngoscopy using a Parson's laryngoscope and magnifying telescope. A bronchoscopy was also
performed using a 2.5 Stortz bronchoscope. The findings include subglottic web and stenosis with laryngeal edema suggestive of reflux. There was also significant collapse of the trachea at
the carina and into the main bronchi bilaterally.
What CPT® coding is reported?
A patient who was experiencing severe abdominal pain underwent abdominal imaging and results showed several peritoneal tumors of various sizes.
The patient elected to have the tumors removed. An incision was made to access the intra-abdominal peritoneal cavity, where four tumors were identified, measured, and excised.
The largest was 2 cm, two were 1 cm each, and the smallest was 0.5 cm. Pathology report indicated the tumors were malignant.
What CPT® and ICD-10-CM coding is reported7
A patient presents to the pulmonologist's office for the first time with coughing and shortness of breath. The patient has a history of asthma. The physician performs a medically appropriate
history and exam. The following labs are ordered: CBC, arterial blood gas, and sputum culture. The pulmonologist assesses the patient with a new diagnosis of COPD. The patient is given a
prescription for the inhaler Breo Ellipta.
What E/M code is reported?
The pulmonologist performs a bronchoscopy with fluoroscopic guidance. The scope is introduced into the right nostril and advanced to the vocal cords and into the trachea. The scope is advanced to the right upper lobe and a lung nodule is noted. An endobronchial biopsy is performed.
What CPT® code is reported for the procedure?
A comatose patient is seen in the ER. The patient has a history of depression. Drug testing confirm she overdosed on tricyclic antidepressant drugs doxepin, amoxapine, and clomipramine.
What CPT® code is reported?
When a provider's documentation refers to use, abuse, and dependence of the same substance (e.g. alcohol), which statement is correct?
A child returns for stage 2 surgical repair of double outlet right ventricle, including removal of pulmonary artery band, arterial switch repair, and ECMO cannulation.
What CPT® codes are reported?
An 8-year-old undergoes tonsillectomy with adenoidectomy for chronic tonsillitis and adenoiditis with hypertrophy.
What CPT® and ICD-10-CM codes are reported?
(A wheelchair-bound resident of a skilled nursing facility is seen in the physician’s office. The physician’s office makes arrangements with a social worker to take the patient back to the skilled nursing facility. What is the HCPCS Level II transportation service code?)
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general
anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What CPT® and ICD-10-CM codes are reported?
The patient, who is at 32 weeks pregnant, has been hospitalized due to an infection of COVID-19.
What ICD-10-CM codes are reported?
(A 1-year-old patient was born with twosupernumerary digits, one extending from the right pinky and one extending from the left pinky. The digit from his left pinky is larger and includes themetacarpal bone with a jointand is amputated. The one on the right is anubbinand containsno bony structure. The hand surgeon removes the extra digit containingsoft tissueby a simple excision. What is the CPT® coding for the procedures performed?)
Patient with erectile dysfunction is presenting for same day surgery in removal and replacement of an inflatable penile prosthesis.
What CPT® code is reported for this service?
An interventional radiologist performs an abdominal paracentesis in his office utilizing ultrasonic imaging guidance to remove excess fluid. What CPT® coding is reported?
A physician prescribes carbamazepine to treat a patient with epileptic seizures. After six months, the physician performs a therapeutic drug test to monitor the total level of the drug in the patient.
What CPT® and ICD-10-CM coding is used for the six month-evaluation?
A patient who is 37 weeks' gestation is admitted to labor and delivery for a cesarean delivery. An external cephalic version was performed successfully several days ago and she now presents in labor, fully dilated, and the fetus has returned to a footling presentation.
What anesthesia code is reported?
A 58-year-old male suffered an acute STEMI of the inferolateral wall while running a marathon on June 15 and had received treatment. Three weeks later, the patient presents to the ED complaining of SOB and left arm pain. An EKG is performed as well as blood tests. Patient is admitted for further evaluation.
What diagnosis code is reported for this encounter?
(A patient presents with fatigue and unexplained weight gain. To evaluate possible thyroid dysfunction, the provider orders a single laboratory test to measurethyroid-stimulating hormone (TSH). A routine venous blood sample is collected and sent to the laboratory.Which CPT® and ICD-10-CM® codes are reported?)
A 5-year-old is brought to the QuickCare in the ED to repair two lacerations: a 3 cm laceration on her right arm and 2 cm laceration on her nose. Her arm is repaired with a simple one-layer closure with sutures. Her nose is repaired with a simple repair using tissue adhesive, 2-cyanoacrylate.
How are the repairs reported?
(A 55-year-old female with severe coronary arteriosclerosis with angina is admitted for elective coronary artery bypass. The surgeon performed a coronary artery bypass using asaphenous vein harvested endoscopically. The vein graft was anastomosed to theobtuse marginaland theleft circumflex. What CPT® coding is reported for this procedure?)
What is the medical term for a procedure that creates a connection between the gallbladder and the small intestine?
What is the HCPCS Level II code for a standard wheelchair?
A patient with abnormal growth had a suppression study that included five glucose tests and five human growth hormone tests.
What CPT@ coding is reported?
An air bag deployed when a driver lost control of the car and crashed into a guardrail on the side of the highway. The driver suffers partial impact resulting in a skull fracture of the anterior
cranial base. The fracture is diagnosed using the MRI scanner and cerebrospinal fluid is noted dripping via the sphenoid sinus into the right nasal passage. The patient requires a surgical nasal
sinus endoscopy to assess and repair the injury.
What is the correct procedure and diagnosis coding combination to report this service?
A surgeon removes the right and left fallopian tubes and the left ovary via an abdominal incision. How is this reported?
A 5-year-old who has an allergy history experienced a possible reaction to peanuts. A quantitative, high-sensitive fluorescent enzyme immunoassay was used to measure specific IgE for recombinant peanut components. Results showed there was no reaction indicating the child has a peanut allergy.
What lab test is reported?
A patient with lateral epicondylitis of the left elbow is taken to the operating room for manipulation under general anesthesia. The physician performs stretching and rotation to restore motion.
What CPT® coding is reported for the physician?
A patient has a bone infection being treated with vancomycin. A therapeutic drug assay is performed to measure the concentration of vancomycin in the patient's blood.
What lab test is reported?
(Full Case:Pre/Post-op diagnosis:Grade 1 endometrial cancer.Procedure:Radical hysterectomy and pelvic lymph node sampling.Anesthesia:General.EBL:400 mL.Complications:None.Specimens:pelvic washings; uterus; tubes; ovaries; pelvic lymph nodes.Fluids:2 L crystalloid.Operative details:frog-leg position; perineum prepped sterile; Foley placed; midline vertical incision umbilicus to symphysis; exploration shows normal upper abdomen and bowel; no paraaortic adenopathy; pelvis/perineum normal; washings collected; round ligaments transected; retroperitoneal spaces opened; ureters visualized; ovarian vessels isolated/ligated; bladder flap taken down; uterine arteries, uterosacral and cardinal ligaments clamped/ligated; uterus removed; vagina closed; lymph node sampling left then right with removal of lymphatic tissue from external/internal iliac bifurcation to circumflex iliac vein and down to obturator nerve; tumor ~40% endometrial surface with <50% myometrial invasion; closure in layers; patient tolerated well.Question:What CPT® codes are reported?)
(An 8-day-old newborn, weighing 3 kilograms, is seen for a circumcision. A numbing cream is applied. A circumferential incision is made and the foreskin is excised with a scalpel. What CPT® coding is reported?)
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT® coding is reported for this case?
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT® coding is reported for this case?
A patient has five biopsies performed on the duodenum.
What CPT® coding is reported?
What does NCCI stand for, and what is its purpose?
(A 7-year-old child presents with third-degree circumferential burns of his chest, resulting in restricted chest expansion and concern for respiratory compromise. To relieve pressure caused by the eschar, the surgeon performs anescharotomy. During the procedure,two incisionsare made through the eschar down to the subcutaneous tissue to release the constrictive effects. The burns are full-thickness and involve10% TBSA, resulting in all third-degree burns. What CPT® and ICD-10-CM codes are reported for this service?)
Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?
Ten-year-old boy has a painful felon abscess of the deep tissues of the palmar surface of his right thumb. The provider makes an incision on one side of the nail and then across the fingertip parallel to the end of the nail. He identifies the area of abscess and drains it. A drainage tube is inserted.
What CPT® and ICD-10-CM is reported?
Which one of the following activities, when performed, is NOT considered when selecting an E/M service level based on time?
A physician conducts a 15-minute phone call discussing medication management.
How is this reported?
Patient is admitted in observation care on 12/2/20XX in the morning for acute asthma exacerbation. The ED physician requires the patient to stay overnight. Next day, 12/3/20XX the patient is
discharged from observation care in the afternoon. Patient's total stay in observation was 16 hours.
What E/M categories and code ranges are appropriate to report?
A patient with three thyroid nodules is seen for an FNA biopsy. Using ultrasonic guidance, the provider inserts a 25-gauge needle into each nodule. Nodular tissue is aspirated and sent to pathology.
What CPT® coding reported?
A provider orders LC-MS definitive drug testing for suspected acetaminophen overdose.
What CPT® code is reported?
(A 14-month-old male with a unilateral complete cleft lip and alveolar cleft palate had prior repair of the cleft lip. He now presents forreconstruction of the palatewith closing the fissure in the soft tissue of thealveolar ridge with bone graft. What CPT® coding is reported?)
An anesthesiologist medically directs two cases during EGD and colonoscopy in a PS III patient with severe bleeding risk.
What CPT® codes are reported?
A complete cardiac MRI for morphology and function without contrast, followed by contrast with four additional sequences and stress imaging, is performed on a patient with systolic left ventricular congestive heart failure and premature ventricular contractions.
What CPT® and ICD-10-CM codes are reported?
A patient is having a thyroidectomy for malignancy on the right lobe. During the procedure, a lesion was found on the left lower side of the parathyroid gland and is suspected for malignancy.
The total right lobe of the thyroid and the parathyroid gland are removed.
What is the CPT® codes are reported for this encounter?
(An orthopedic surgeon evaluated a patient in the emergency room two months after a surgical repair of a right radius and ulnar shaft fracture. After reinjury, imaging shows a displaced proximal fixation screw andmalunion of only the radial shaft. The same surgeon performs surgery to repair the malunion using a graft from the hip. What CPT® and diagnosis codes are reported?)
The human shoulder is made of which three bones?
A 55-year-old patient with suspected liver cancer was seen by the physician to obtain a biopsy. The special biopsy needle was placed using ultrasonic guidance. The physician obtained a small tissue sample from the liver, which was then sent to pathology.
What CPT® codes are reported?
A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins. The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.
What CPT® coding is reported for the twin delivery?
A male patient passes out while jogging in the park. Upon examination at the hospital, he is found to have a wide complex tachycardia and undergoes an electrophysiologic study and radiofrequency ablation. For this procedure he is placed under general anesthesia.
What is the anesthesia coding for this otherwise healthy 35-year-old?
(Which one of the following isNOTa cardiac valve?)
(A 78-year-old patient withintermittent asthma with exacerbationis in her pulmonologist’s office for pulmonary function testing. The pulmonologist performs spirometry with flow volume loops, measuring before and after administering a bronchodilator. What CPT® and ICD-10-CM codes are reported?)
A healthy 35-year-old undergoes EP study and ablation under general anesthesia.
What anesthesia coding is correct?
The procedure is performed at an outpatient radiology department. From a left femoral access, the catheter is placed in the abdominal aorta and is then selectively placed in the celiac trunk and manipulated up into the common hepatic artery for an abdominal angiography. Dye is injected, and imaging is obtained. The provider performs the supervision and interpretation.
What CPT® codes are reported?
A 65-year-old gentleman presents for refill of medications and follow-up for his chronic conditions. The patient indicates good medicine compliance. No new symptoms or complaints.
Appropriate history and exam are obtained. Labs that were ordered from previous visit were reviewed and discussed with patient. The following are the diagnoses and treatment:
Hypokalemia - stable. Refill Potassium 20 MEQ
Hypertension - blood pressure remaining stable. Patient states home readings have been in line with goals. Refill prescription Lisinopril.
Esophageal Reflux - Patient denies any new symptoms. Stable condition. Continue taking over the counter Prevacid oral capsules, 1 every day.
Patient is instructed to follow up in 3 months. Labs will be obtained prior to visit.
What CPT® code is reported?
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
An interventional radiologist performs an abdominal paracentesis using fluoroscopic guidance to remove excess fluid. The procedure is performed in the hospital. What CPT® coding is reported?
A patient has squamous cell carcinoma lesions destroyed with cryosurgery:
0.6 cm right dorsal foot
2.0 cm left dorsal foot
What CPT® coding is reported?
A surgeon performed Mohs micrographic surgery on a lesion on the right arm. This required one stage with six tissue blocks.
What CPT@ codes are reported for the Mohs surgery?
(Which place of service code is submitted on the claim for a procedure that is performed in a patient’sprivate residence?)
A 63-year-old is seen by his. primary care physician for an annual exam. His last exam with the primary care physician was four years ago. He has no complaints.
What CPT code is reported?
A patient comes in complaining of pain in the lower left back, which is accompanied by a numbing sensation that extends into the leg. Attempts to alleviate the pain with home treatments have been unsuccessful. The provider orders an MRI of the lumbar spine initially without, and then with, contrast material. The images are interpreted by the physician, the final diagnosis is left-sided low back pain with sciatica.
What CPT® and ICD-10-CM codes are reported?
A patient is diagnosed with compression fractures of the C6, C7 and T1 vertebrae. The patient agrees to have vertebroplasty. Bone cement is injected in the vertebral space until each of the two whole vertebral body is filled. The procedure is performed bilaterally.
What CPT® coding is reported?
View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See Nurses Notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Have been reviewed-tachycardic.
Eyes: Pupils equal, round and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardia. Heart sounds normal. Pulses normal.
E D. Course: Insulin IV drip per protocol, at 10 units/hr.
Zofran 8 mg 01:33 Jul 13 2008 IVP.
Phenergan 25 mg IVP. 07:52.Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.
Total critical care time: 45 min.
Disposition: Admitted to Intensive Care Unit. Condition: stable.
Admit decision based on need for monitoring and IV hydration and medications.
CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.
What E/M code is reported for this encounter?
Two weeks after removal of a 4 cm subcutaneous lipoma, the patient presents with extensive internal wound dehiscence requiring multi-layer closure in the OR.
What CPT® coding is reported by the surgeon?
Which statement is NOT true regarding the ICD-10-CM coding guidelines for burns?
A 42-year-old male is diagnosed with a left renal mass. An abdominal incision along with rib resection is made to expose and access the kidney. The left kidney is removed, along with surrounding fat, adrenal gland, lymph nodes in the area, and the incision site is sutured. What CPT ® code is reported for this procedure?
A retinal specialist diagnoses type 2 diabetic mild nonproliferative retinopathy with macular edema, bilateral. Diabetes is secondary to Cushing’s syndrome and controlled with oral hypoglycemics. What ICD-10-CM codes are reported?
A patient presents with fever, cough, SOB, and fatigue. PCR test is positive for COVID-19. Final diagnosis: pneumonia due to COVID-19. What ICD-10-CM coding is reported?
A patient undergoes lumbar puncture with catheter placement under CT guidance to drain CSF.
What CPT® coding is reported?
A patient in a radiology facility has an X-ray examination of her lumbosacral spine due to pain while playing golf. The radiologist takes a complete 7-view of the lumbosacral spine, including
bending views.
What CPT® code is reported?
A catheter is placed from the femoral artery into the right common carotid, with imaging of the ipsilateral extracranial carotid and bilateral external carotids.
Which CPT® codes are reported?
The surgeon performs Roux-en-Y anastomosis of the extrahepatic biliary duct to the gastrointestinal tract on a 45-year-old patient.
What CPT® code is reported?
A suppression study includes five glucose tests and five growth hormone tests.
What CPT® coding is reported?
A 16-year-old female just moved to the area and is living in a campground with her parents. She has several medical conditions and the parents are unable to take her to a physician's office. A physician sees the patient in the campground and documents a medical decision making of moderate complexity. After the visit, the physician spends an additional 25 minutes in a prolonged discussion with the patient's parents; he reviews complex and detailed medical records from her previous physicians and completes a comprehensive treatment plan. A care plan with the local hearth agency and a dietician is initiated.
What E/M coding is reported for this visit?
A patient arrives for a PEG placement. The patient requires tube feeds for nutrition but frequently pulls out the dobhoffs tube. An EGD was performed. Several attempts were made to place the
PEG tube without success so the procedure was aborted. During the withdraw of the scope, a small hiatal hernia was noted in the stomach. The scope was removed the the patient transferred
to recovery.
What CPT and ICD-10-CM coding is reported?
When a provider’s documentation refers to use, abuse, and dependence of the same substance (e.g., alcohol), which statement is correct?
A patient with suspected gynecologic malignancy undergoes laparoscopic staging including bilateral pelvic lymphadenectomy, periaortic lymph node sampling, peritoneal washings, peritoneal and diaphragmatic biopsies, and omentectomy.
What CPT® coding is reported?
(A patient with abnormal growth had asuppression studythat includedfive glucose testsandfive human growth hormone tests. What CPT® coding is reported?)
An 87-year-old male with a history of atrioventricular block and prior dual-chamber pacemaker implantation presents to the cardiology clinic for an in-person device evaluation. The physician performs a full electronic analysis of the pacemaker system, assessing atrial and ventricular lead function, battery status, sensing thresholds, and pacing thresholds. After the assessment, the pacemaker settings are adjusted to optimize heart rate response. The patient tolerates the procedure well and is advised to return for routine follow-up.
What CPT® code is reported?
An MRI guided cisternal puncture with diagnostic contrast injection is performed at the C2 level for cervical discography, with imaging supervision and interpretation.
What CPT® coding is reported?
Which circumstance supports medical necessity for a payment by the insurance company?
The gallbladder is in which organ system?
A patient with a history of a right-hand mass presents for outpatient surgical excision. The surgeon excises the 1.5 cm mass with margins using a scalpel with dissection extending through the dermis into the subcutaneous tissue. Hemostasis is achieved with electrocautery, and the wound is closed. Final pathology confirms the mass is a subcutaneous arteriovenous hemangioma.
Which CPT® and ICD-10-CM codes are reported?
(A patient is in her otolaryngologist’s office to receive therapeutic treatment forasthmatic bronchitis with status asthmaticus. A subcutaneous injection ofomalizumab (150 mg)is given in her left upper arm. What is the CPT® and ICD-10-CM coding?)
A 1-year-old patient has bilateral supernumerary digits:
Left digit contains bone and joint → amputated
Right digit is a soft-tissue nubbin → simple excision
What CPT® coding is reported?
A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting
technique was used to repair the eardrum with ossicular chain reconstruction.
What CPT® code is reported for this surgery?