RHIA- CH 9-CPT coding - Flashcards

question

Clotting factor VII

answer

85230

question

Blood transfusion of three units of packed red blood cells. 36430 Transfusion, blood or blood components 36455 Exchange transfusion; blood, other than newborn 36460 Transfusion, intrauterine, fetal

answer

36430

question

Patient presents to the operating room where a 3.2-cm malignant lesion of the shoulder was excised and repaired with simple sutures. A 2-cm benign lesion of the cheek was excised and was repaired with a rotation skin graft.

answer

14040, 11604

question

Scrotal wall abscess drainage.

answer

55100

question

Administration of initial oral radionuclide therapy for hyperthyroidism.

answer

79005

question

Lagophthalmos correction with implantation using gold weight.

answer

67912

question

Transesophageal echocardiography (TEE) with probe placement, image, and interpretation and report.

answer

93312

question

Cytopathology of cervical Pap smear with automated thin-layer preparation utilizing computer screening and manual rescreening under physician supervision

answer

88175

question

Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5 cm and 2.7 cm.

answer

12034

question

Patient has been on the bone marrow transplant recipient list for 3 months. A perfect match was made and the patient came in and received a peripheral stem cell transplant.

answer

38240

question

Left carotid artery excision for tumor of carotid body.

answer

60605

question

Laparoscopic tubal ligation utilizing Endoloop.

answer

58671

question

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and 10 minutes providing critical care for this patient.

answer

99291

question

A physician orders a lipid panel on a 54-year-old male with hypercholesterolemia, hypertension, and a family history of heart disease. The lab employee in his office performs and reports the total cholesterol and HDL cholesterol only. 80061 Lipid panel; this panel must include the following: Cholesterol, serum, total (82465); Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718); Triglycerides (84478) 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 84478 Triglycerides -52 Reduced services

answer

82465, 83718

question

Laser destruction of extensive herpetic lesions of the vulva.

answer

56515

question

Patient with chronic otitis media requiring eustachian tube catheterization.

answer

69799

question

Obstetric patient comes in for a pelvimetry with placental placement.

answer

74710

question

Patient comes into the office for removal of impacted earwax

answer

69210

question

Huhner test and semen analysis.

answer

89300

question

Patient is at a fertility clinic and undergoes intrauterine embryo transplant

answer

58974

question

Cardioversion of cardiac arrhythmia by external forces.

answer

92960

question

Patient presents to the surgical unit and undergoes unilateral nasal endoscopy, partial ethmoidectomy, and maxillary antrostomy.

answer

31254, 31256-51

question

A physician performs a PTCA with drug-eluting stent placement in the left anterior descending artery and angioplasty only in the right coronary artery.

answer

92928-LD, 92920-RC

question

Patient returns to the operating room following open-heart bypass for exploration of blood vessel to control postoperative bleeding in the chest.

answer

35820

question

Code anesthesia for vaginal hysterectomy.

answer

00944

question

Patient undergoes total thyroidectomy with parathyroid autotransplantation.

answer

60240, 60512

question

Decompression internal auditory canal

answer

69960

question

Patient presents to the operating room for excision of a 4.5-cm malignant melanoma of the left forearm. A 6 cm x 6 cm rotation flap was created for closure.

answer

14301 14301 - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

question

Patient was admitted with hemoptysis and underwent a bronchoscopy with transbronchial lung biopsy. Following the bronchoscopy, the patient was taken to the operating room where a left lower lobe lobectomy was performed without complications. Pathology reported large cell carcinoma of the left lower lobe. 31625 Bronchoscopy with bronchial or endobronchial biopsy, with or without fluoroscopic guidance 31628 Bronchoscopy with transbronchial lung biopsy, with or without fluoroscopic guidance 32405 Biopsy, lung or mediastinum, percutaneous needle 32440 Removal of lung, total pneumonectomy 32480 Removal of lung, other than total pneumonectomy, single lobe (lobectomy) 32484 Removal of lung, other than total pneumonectomy, single segment (segmentectomy)

answer

31628, 32480

question

Closure of ureterocutaneous fistula.

answer

50920

question

Male with urinary incontinence. Sling procedure was performed 6 months ago and now the patient has returned for a revision of the sling procedure.

answer

53442

question

Code anesthesia for total shoulder replacement.

answer

01638

question

Patient is admitted for a blepharoplasty of the left lower eyelid and a repair for a tarsal strip of the left upper lid.

answer

67917-E1, 15820-E2

question

Upper lobectomy of the right lung with repair of the bronchus.

answer

32480, 32501

question

Tracheostoma revision with flap rotation. 31613 Tracheostoma revision; simple, without flap rotation 31614 Tracheostoma revision; complex, with flap rotation 31750 Tracheoplasty; cervical 31830 Revision of tracheostomy scar

answer

31614

question

Patient has metastatic brain lesions. Patient undergoes stereotactic radiosurgery gamma knife of two lesions.

answer

61796, 61797

question

Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life-threatening injuries due to a multiple car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient.

answer

99291, 99292

question

Ultrasonic guidance for the needle biopsy of the liver. Code the complete procedure.

answer

47000, 76942

question

Priapism operation with spongiosum shunt.

answer

54430

question

Code anesthesia for placement of vascular shunt in forearm.

answer

01844

question

Injection snoreplasty for treatment of palatal snoring.

answer

42299

question

Patient returns to the physician's office complaining of obscured vision. Patient has had cataract surgery 6 months prior. Patient requires laser discission of secondary cataract.

answer

66821

question

Patient presents to the hospital with ulcer of the right foot. Patient is taken to the operating room where a revision of the right metatarsal head is performed.

answer

28899-RT

question

The physician punctures the left common femoral to examine the right common iliac.

answer

36245

question

One-half hour of IV chemotherapy by infusion followed by IV push of a different drug.

answer

96413, 96411

question

Patient in late stages of labor arrives at the hospital. Her OB physician is not able to make the delivery and the house physician delivers the baby vaginally. Primary care physician resumes care after delivery. Code the delivery.

answer

59409

question

Patient has a bronchoscopy with endobronchial biopsies of three sites.

answer

31625

question

Laparoscopy with multiple biopsies of retroperitoneal lymph nodes.

answer

38570

question

Patient has recurrent spontaneous pneumothorax, which has resulted in a chemical pleurodesis by thoracoscopy.

answer

32650

question

Patient comes in through the emergency room with a laceration of the posterior tibial nerve. Patient is taken to the operating room where the nerve requires transposition and suture.

answer

64840, 64874

question

A pregnant patient has an incompetent cervix, which was repaired using a vaginal cerclage.

answer

59320

question

Patient underwent anoscopy followed by colonoscopy. The physician examined the colon to 60 cm.

answer

45378

question

Patient presents to the emergency room following an assault. Examination of the patient reveals blunt trauma to the face. Radiology reports that the patient suffers from a fracture to the frontal skull and a blow-out fracture of the orbital floor. Patient is admitted and taken to the operating room where a periorbital approach to the orbital fracture is employed and an implant is inserted.

answer

21390

question

Removal of nephrostomy tube with fluoroscopic guidance.

answer

50389

question

An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient's last three glucose tests. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient's insulin. An expanded history was taken and a physical examination was performed.

answer

99213

question

Open I&D of a deep abscess of the cervical spine.

answer

22010

question

Patient was involved in an accident and has been sent to the hospital. During transport the patient develops breathing problems and, upon arrival at the hospital, an emergency transtracheal tracheostomy was performed. Following various x-rays, the patient was diagnosed with traumatic pneumothorax. A thoracentesis with insertion of tube was performed.

answer

31603, 32555

question

Myringoplasty

answer

69620

question

Patient has a history of chronic alcohol abuse with portal hypertension. Patient has been vomiting blood for the past 3 days and presented to his physician's office. Patient was sent to the hospital for evaluation and an EGD was performed. Biopsy findings showed gastritis, esophagitis, and bleeding esophageal varices, which were injected with sclerosing solution.

answer

43239, 43243

question

anesthesia for procedures on bony pelvis

answer

01120

question

Cannulation of the thoracic duct

answer

38794

question

An office consultation is performed for a postmenopausal woman who is complaining of spotting in the past 6 months with right lower-quadrant tenderness. A detailed history and physical examination were performed with a low-complexity medical decision.

answer

99243

question

Pathologist performs a postmortem examination, including the brain, of an adult. Tissue is sent to the lab for microscopic examination.

answer

88025

question

Patient presents to the hospital with right ureteral calculus. Patient is taken to the operating room where a cystoscopy with ureteroscopy is performed to remove the calculus

answer

52352

question

Patient presents to the emergency room complaining of right forearm/elbow pain after racquetball last night. Patient states that he did not fall, but overworked his arm. Past medical history is negative and the physical examination reveals the patient is unable to supinate. A four- view x-ray of the right elbow is performed and is negative. The physician signs the patient out with right elbow sprain. Prescription of Motrin is given to the patient.

answer

99281-25, 73080

question

Patient has been diagnosed with uterine fibroids and undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy.

answer

58150

question

Laparoscopic gastric banding.

answer

43770

question

Patient presents to the hospital for skin grafts due to previous third-degree burns. The burn eschar of the back was removed. Once the eschar was removed, the defect size measured 10 cm x 10 cm. A skin graft from a donor bank was placed onto the defect and sewn into place as a temporary wound closure

answer

15002, 15273

question

Male presented to operating room for sterilization by bilateral vasectomy.

answer

55250

question

Laminectomy and excision of intradural lumbar lesion.

answer

63272

question

Patient is admitted with alcohol cirrhosis and has a TIPS procedure performed.

answer

37182 transvenous intrahepatic portosystemic shunt(s) (TIPS)

question

Caloric vestibular test using air.

answer

92700 unlisted procedure code because of the use of air

question

Patient is admitted to the hospital following an ultrasound at 25 weeks, which revealed fetal pleural effusion. A fetal thoracentesis was performed.

answer

59074

question

Chronic nontraumatic rotator cuff tear. Arthroscopic subacromial decompression with coracoacromial ligament release, and open rotator cuff repair.

answer

23412, 29826-59

question

Cesarean delivery with antepartum and postpartum care.

answer

59510

question

An out-of-town patient presents to a walk-in clinic to have a prescription refilled for a nonsteroidal anti-inflammatory drug. The physician performs a problem-focused history and physical examination with a straightforward decision.

answer

99201

question

Patient came in for excision of a middle ear lesion.

answer

69540

question

Patient has breast carcinoma and is now undergoing sentinel node biopsy. Patient was injected for sentinel node identification and two deep axillary lymph nodes showed up intensely. These two lymph nodes were completely excised. Path report was positive for metastatic carcinoma.

answer

38525, 38792

question

An established patient was seen in her primary physician's office. The patient fell at home and came to the physician's office for an examination. Due to a possible concussion, the patient was sent to the hospital to be admitted as an observation patient. A detailed history and physical examination were performed and the medical decision was low complexity. The patient stayed overnight and was discharged the next afternoon.

answer

99218, 99217

question

Hysterotomy for hydatidifom mole and tubal ligation.

answer

59100, 58611

question

Code anesthesia for upper abdominal ventral hernia repair.

answer

00752

question

Patient has a history of PVD for many years and experiences chest pains. The patient underwent Doppler evaluation, which showed a common femoral DVT. Patient is now admitted for thromboendarterectomy.

answer

35371

question

Laparoscopic repair of umbilical hernia. 49580 Repair umbilical hernia, under age 5 years, reducible 49585 Repair umbilical hernia, age 5 years or over, reducible 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion when performed); reducible 49654 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion when performed); reducible

answer

49652

question

Patient presents to the operating room for excision of three lesions. The 1.5-cm and 2-cm lesions of the back were excised with one excision. The 0.5-cm lesion of the hand was excised. The pathology report identified both back lesions as squamous cell carcinoma. The hand lesion was identified as seborrheic keratosis.

answer

11604, 11420

question

Which code listed below would be used to report an esophageal electrogram during an EPS?

answer

93615

question

Patient undergoes hysteroscopy with excision uterine fibroids.

answer

58561 uterine fibroids - leiomyomata

question

Code anesthesia for cesarean section

answer

01961

question

Patient presents to the operating room and undergoes an endovascular repair of an infrarenal abdominal aortic aneurysm utilizing a unibody bifurcated prosthesis.

answer

34804

question

Young child presents with cleft lip and cleft palate. This is the first attempt of repair, which includes major revision of the cleft palate and unilateral cleft lip repair.

answer

42215, 40700

question

Hydrocelectomy of spermatic cord.

answer

55500

question

Aphakia penetrating corneal transplant.

answer

65750

question

A D;C is performed for postpartum hemorrhage.

answer

59160

question

Laparoscopic adrenalectomy, complete.

answer

60650

question

Patient with hematochromatosis had a therapeutic phlebotomy performed on an outpatient basis.

answer

99195

question

Patient presents to the Respiratory Therapy Department and undergoes a pulmonary stress test. CO2 production with O2 uptake with recordings was also performed.

answer

94621

question

Patient has rhinorrhea, which requires repair of the CSF leak with craniotomy.

answer

62100

question

Patient undergoes enucleation of left eye, and muscles were reattached to an implant.

answer

65105-LT

question

Patient suffers from strabismus and requires surgery. Recession of the lateral rectus (horizontal) muscle with adjustable sutures was performed.

answer

67311, 67335

question

Patient presents to the operating room for fulguration of bladder tumors. The cystoscope was inserted and entered the urethra, which was normal. Bladder tumors measuring approximately 1.5 cm were removed.

answer

52234

question

Patient is 24 weeks pregnant and arrives in the emergency room following an automobile accident. No fetal movement or heartbeat noted. Patient is taken to the OB ward where prostaglandin is given to induce abortion.

answer

59855

question

Chlamydia culture

answer

87110

question

Patient comes into his physician's office complaining of wrist pain. Physician gives the patient an injection and sends the patient to the hospital for an arthrography. Code the complete procedure.

answer

25246, 73115

question

Patient had been diagnosed with a bunion. Patient was taken to the operating room where a simple resection of the base of the proximal phalanx along with the medial eminence was performed. Kirschner wire was placed to hold the joint in place.

answer

28292

question

Patient has been diagnosed with carcinoma of the vagina, and she has a radical vaginectomy with complete removal of the vaginal wall.

answer

57111

question

Patient comes in for a percutaneous needle biopsy of the thyroid gland

answer

60100

question

Patient was admitted for right upper quadrant pain. Workup included various x-rays that showed cholelithiasis. Patient was taken to the operating room where a laparoscopic cholecystectomy was performed. During the procedure, the physician was unable to visualize through the ports and an open cholecystectomy was elected to be performed. An intraoperative cholangiogram was performed. Pathology report states acute and chronic cholecystitis with cholelithiasis.

answer

47605

question

Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a comprehensive history and physical examination. To rule out pancreatitis, the physician orders lab work, along with an ultrasound of the gallbladder and an abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.

answer

99254

question

Modified radical mastoidectomy.

answer

69505

question

Patient arrives to the hospital and has a Nissen fundoplasty done laparoscopically.

answer

43280

question

Patient was admitted to the hospital for removal of excessive tissue due to massive weight loss. Liposuction of the abdomen and bilateral thighs was performed.

answer

15877, 15879-50

question

Patient has a Bartholin's gland cyst that was marsupialized.

answer

56440

question

Nonhuman graft for temporary wound closure. Patient has a 5-cm defect on the scalp.

answer

15275

question

Laparoscopic retroperitoneal lymph node biopsy.

answer

38570

question

Lacrimal fistula closure.

answer

68770

question

Excision of mediastinal cyst.

answer

39200

question

Patient presents with a history of upper abdominal pain. Cholangiogram was negative and patient was sent to the hospital for ERCP. During the procedure the sphincter was incised and a stent was placed for drainage.

answer

43274

question

Excision of 2.5-cm bladder tumor with cystoscopy.

answer

52235

question

Lye burn of the larynx repaired by laryngoplasty.

answer

31588

question

Nephrectomy with resection of half of the ureter

answer

50220

question

Correction of trichiasis by incision of lid margin

answer

67830

question

Partial thromboplastin time utilizing whole blood

answer

85730

question

Patient diagnosed with cystic hygroma of the axilla, which was excised.

answer

38550

question

Code anesthesia for corneal transplant.

answer

00144

question

Patient presents with a traumatic partial amputation of the second, third, and fourth fingers on the right hand. Patient was taken to the operating room where completion of the amputation of three fingers was performed with direct closure.

answer

26951-F6, 26951-F7, 26951-F8

question

Patient undergoes laparoscopic orchiopexy for intra-abdominal testes.

answer

54692

question

Patient undergoes percutaneous transluminal iliac artery balloon angioplasty.

answer

37220

question

Patient with Bell's palsy requiring a total facial nerve decompression.

answer

69955

question

A 10-square-centimeter epidermal autograft to the face from the back.

answer

15115

question

Established 42-year-old patient comes into your office to obtain vaccines required for his trip to Sri Lanka. The nurse injects intramuscularly the following vaccines: hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As the coding specialist, what would you report on the CMS 1500 form?

answer

administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever

question

Patient presents to the emergency room with chest pains. The patient is admitted as a 23-hour observation. The cardiologist orders cardiac workup and the patient undergoes left heart catheterization via the left femoral artery with visualization of the coronary arteries and left ventriculography. The physician interprets the report. Code the heart catheterization.

answer

93458

question

Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy.

answer

53852

question

Patient presents to the emergency room with right lower abdominal pains. Emergency room physician suspects possible appendicitis. Patient was taken to the operating room where a laparoscopic appendectomy was performed. Pathology report was negative for appendicitis.

answer

44970

question

Patient presents to the hospital for debridement of a diabetic ulcer of the left ankle. The patient has a history of recurrent ulcers. Medication taken by the patient includes Diabeta and the patient was covered in the hospital with insulin sliding scales. The decubitus ulcer was debrided down to the bone.

answer

11044

question

Ureterolithotomy completed laparoscopically. 50600 Ureterotomy with exploration or drainage (separate procedure) 50945 Laparoscopy, surgical ureterolithotomy 52325 Cystourethroscopy; with fragmentation of ureteral calculus 52352 Cystourethroscopy, with urethroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

answer

50945

question

Patient has a bone marrow aspiration of the iliac crest and of the tibia.

answer

38220, 38220-59

question

Patient comes into the outpatient department at the local hospital for an MRI of the cervical spine with contrast. Patient status post automobile accident.

answer

72142

question

Patient has been diagnosed with prostate cancer. Patient arrived in the operating room where a therapeutic orchiectomy is performed.

answer

54520

question

Patient complains of recurrent syncope following carotid thromboendarterectomy. Patient returns 2 weeks after initial surgery and undergoes repeat carotid thromboendarterectomy.

answer

35301

question

Tonsillectomy on a 14-year-old. 42820 Tonsillectomy and adenoidectomy; under age 12 42821 Tonsillectomy and adenoidectomy; age 12 or over 42825 Tonsillectomy, primary or secondary; under age 12 42826 Tonsillectomy, primary or secondary; age 12 or over

answer

42826

question

Patient undergoes construction of apical aortic conduit with an insertion of a single-ventricle ventricular assist device.

answer

33975

question

A 69-year-old established female patient presents to the office with chronic obstructive lung disease, congestive heart failure, and hypertension. The physician conducts a comprehensive history and physical examination and makes a medical decision of moderate complexity. Physician admits the patient from the office to the hospital for acute exacerbation of CHF

answer

99222

question

Patient is admitted for contact laser vaporization of the prostate. The physician performed a TURP and transurethral resection of the bladder neck at the same time.

answer

52648

question

Drainage of simple external ear abscess.

answer

69000

question

CT scan of the head with contrast.

answer

70460

question

Patient presents to the emergency room following a fall. X-rays were ordered for the lower leg and results showed a fracture of the proximal left tibia. The emergency room physician performed a closed manipulation of the fracture with skeletal traction.

answer

27532-LT

question

Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered x-rays of the ankle, which came back negative for a fracture. A problem-focused history and physical examination were performed and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only.

answer

99281

question

Patient presents to the radiology department where a fine-needle aspiration of the breast is performed utilizing computed tomography.

answer

10022, 77012

question

Code anesthesia for decortication of left lung.

answer

00542

question

Patient comes in through the emergency room with a wound that was caused by an electric saw. Patient is taken to the operating room where two ulna nerves are sutured.

answer

64836, 64837

question

Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion.

answer

19120-LT

question

Pathologist bills for gross and microscopic examination of medial meniscus.

answer

88304

question

Patient undergoes x-ray of the foot with three views.

answer

73630

question

Patient comes to the hospital with a history of right flank pain. Urine tests are negative. Radiology examination reveals that the patient has renal cysts. Patient is now admitted for laparoscopic ablation of the cysts.

answer

50541

question

Patient presents to the operating room where a CABG x 3 is performed using the mammary artery and two sections of the saphenous vein.

answer

33533, 33518

question

Patient with laryngeal cancer has a tracheoesophageal fistula created and has a voicebox inserted.

answer

31611

question

Patient presents to the hospital with a right index trigger finger. Release of the trigger finger was performed.

answer

26055-F6

question

Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician's office 2 weeks ago and the final pathology was positive for carcinoma. Patient is admitted for prostatectomy. The frozen section of the prostate and one lymph node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectomy became a radical perineal with bilateral pelvic lymphadenectomy.

answer

55815

question

Two-year-old patient returns to the hospital for cleft palate repair where a secondary lengthening procedure takes place. 40720 Plastic repair of cleft lip/nasal deformity; secondary, by re-creation of defect and reclosure 42145 Palatopharyngoplasty 42220 Palatoplasty for cleft palate; secondary lengthening procedure 42226 Lengthening of palate and pharyngeal flap

answer

42220

question

Patient presents to the emergency room following a fall from a tree. X-rays were ordered for the left upper arm, which showed a fracture of the humerus shaft. The emergency room physician performed a closed reduction of the fracture and placed the patient in a long arm spica cast. Code the diagnoses and procedures, excluding the x-ray.

answer

24505-LT

question

Trauma patient is rushed to the operating room with multiple injuries. The patient had his spleen removed due to a massive rupture, with repair of the lacerated diaphragm.

answer

38100, 39501

question

Facelift utilizing the superficial musculoaponeurotic system (SMAS) flap technique. 15788 Chemical peel, facial; epidermal 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; SMAS flap

answer

15829

question

Patient undergoes partial nephrectomy for carcinoma of the kidney. 50220 Nephrectomy, including partial ureterectomy, any open approach including rib resection 50234 Nephrectomy with total ureterectomy and bladder cuff; through same incision 50240 Nephrectomy, partial 50340 Recipient nephrectomy (separate procedure)

answer

50240

question

Insertion of cochlear device inner ear.

answer

69930

question

Patient with a traumatic rupture of the eardrum. Repaired with tympanoplasty with incision of the mastoid. Repair of ossicular chain not required.

answer

69635

question

IV push of one antineoplastic drug.

answer

96409

question

First-stage repair for hypospadias with skin flaps.

answer

54304

question

Code anesthesia for total hip replacement.

answer

01214

question

Patient is brought to the emergency room following a shark attack. The paramedics have the patient's amputated foot. The patient is taken directly to the operating room to reattach the patient's foot.

answer

20838

question

D;C performed for patient with a diagnosis of incomplete abortion at 8 weeks.

answer

59812

question

Patient with Parkinson's disease is admitted for insertion of a brain neurostimulator pulse generator with one electrode array.

answer

61885

question

Patient undergoes ocular resurfacing construction utilizing stem cell allograft from a cadaver.

answer

65781

question

Basic metabolic panel (calcium, total) and total bilirubin.

answer

80048, 82247

question

Laryngoscopic stripping of vocal cords for leukoplakia of the vocal cords.

answer

31540

question

Female with 6 months of stress incontinence. Outpatient therapies are not working and the patient decides to have the problem fixed. Laparoscopic urethral suspension was completed.

answer

51990

question

Patient is 6 weeks pregnant and complains of left-sided abdominal pains. Patient is suspected of having an ectopic pregnancy. Patient has a laparoscopic salpingectomy with removal of the ectopic tubal pregnancy.

answer

59151

question

Patient was admitted to the hospital with sharp pelvic pains. A pelvic ultrasound was ordered and the results showed a possible ovarian cyst. The patient was taken to the operating room where a laparoscopic destruction of two corpus luteum cysts was performed.

answer

58662

question

Patient presents to the operating room where the physician performed, using imaging guidance, a percutaneous breast biopsy utilizing a rotating biopsy device.

answer

19081

question

Trauma patient was rushed to the operating room with multiple injuries. Open reduction with internal fixation of intertrochanteric femoral fracture, and open reduction of the tibial and fibula shaft with internal fixation was performed.

answer

27244, 27758

question

What code is used for a culture of embryos less than 4 days old?

answer

89250

question

Patient presents to the emergency room with lacerations sustained in an automobile accident. Repairs of the 3.3-cm skin laceration of the left leg that involved the fascia, 2.5-cm and 3-cm lacerations of the left arm involving the fascia, and 2.7 cm of the left foot, which required simple sutures, were performed. Sterile dressings were applied.

answer

12034, 12002-59

question

Patient has been diagnosed with metastatic laryngeal carcinoma. Patient underwent subtotal supraglottic laryngectomy with radical neck dissection.

answer

31368

question

Patient comes in for steroid injection for lumbar herniated disk. Marcaine and Aristocort were injected into the L2-L3 space.

answer

62311

question

Bronchoscopy with multiple transbronchial right upper and right lower lobe lung biopsy with fluoroscopic guidance.

answer

31628-RT, 31632-RT

question

Patient was admitted with a cystocele and rectocele. An anterior colporrhaphy was performed.

answer

57240

question

Laser destruction of penile condylomas.

answer

54057

question

Osteopathic manipulative treatment to three body regions.

answer

98926

question

The patient is on vacation and presents to a physician's office with a lacerated finger. The physician repairs the laceration and gives a prescription for pain control and has the patient follow up with his primary physician when he returns home. The physician fills out the superbill as a problem-focused history and physical examination with straightforward medical decision making. Also checked is a laceration repair for a 1.5-cm finger wound.

answer

99201, 12001

question

Morbidly obese patient comes in for vertical banding of the stomach.

answer

43842

question

Pregnant female comes in for a complete fetal and maternal evaluation via ultrasound.

answer

76811

question

Radial keratotomy

answer

65771

question

Unilateral mammogram with computer-aided detection with further physician review and interpretation.

answer

77055, 77051

question

Eighty-year-old patient has carcinoma and presents to the operating room for placement of a tunneled implantable centrally inserted venous access port.

answer

36561

question

Attempted vaginal delivery in a previous cesarean section patient, which resulted in a repeat cesarean section.

answer

59620

question

Patient requires repair of a 6-cm meningocele.

answer

63702

question

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made.

answer

99324

question

Patient has ovarian vein syndrome and has ureterolysis performed.

answer

50722

question

Patient has carcinoma of the breast and undergoes proton beam delivery of radiation to the breast with a single port.

answer

77520

question

Patient has extensive bladder cancer. She underwent a complete cystectomy with bilateral pelvic lymphadenectomy and creation of ureteroileal conduit.

answer

51595

question

Unilateral partial thyroidectomy.

answer

60210

question

Hysteroscopy with D;C and polypectomy.

answer

58558

question

Patient has right sacroiliac joint dysfunction and requires a right S2-S3 paravertebral facet joint anesthetic nerve block with image guidance.

answer

64493

question

Patient with a deviated nasal septum that was repaired by septoplasty.

answer

30520

question

Patient has a history of hiatal hernia for many years, which has progressively gotten worse. The decision to repair the hernia was made and the patient was sent to the operating room where the repair took place via the thorax and abdomen.

answer

43336

question

injection of contrast for a knee arthropathy

answer

27370

question

dr. performs a knee arthrotomy with meniscus repair

answer

27403

question

femur legthening osteoplasty

answer

27466

question

radical resection of femoral tumor

answer

27365

question

hamstring muscle neurectomy

answer

27325

question

revision if tracheostomy scar

answer

31830

question

doctor performs a simple tracheostoma revision without flap rotation

answer

31613

question

nasotracheal catherter aspiration

answer

31720

question

tracheobronchoscopy through an establishes tracheostomy incision

answer

31615

question

bronchoscopy with removal of foreign body

answer

31635

question

open treatment of an ulnar styloid fracture

answer

25652

question

excision of a bone cyst of the carpal bones with auto graft

answer

25135

question

krukenburg procedure

answer

25915

question

osteotomy of the radius and ulna

answer

25365

question

excision of lesion of the tendon sheath of the forearm

answer

25110

question

stomal colonscopy with removal of foreign bodies

answer

44390

question

physician performs an intestinal allotransplanation from a living donor.

answer

44136

question

excision of two lesions of the large intestine with a single enterotomy

answer

44110

question

small intestinal endoscopy via enteroscopy beyond the second portion of duodenum including the ilium with control of bleeding

answer

44378

question

total abdominal colectomy with proctectomy and ileostomy.

answer

44155

question

radiological supervision and interpretation of a lumbar discography

answer

72295

question

MRI of the pelvis with contrast materials

answer

72196

question

CT of the cervical spine without contrast material.

answer

72125

question

radiologic examination of the spine for a scoliosis study, including supine and erect studies

answer

72090

question

MRI of the lumbar spinal canal and contents without contrast material

answer

72148

question

marsupialization of a cyst of the liver

answer

47300

question

percutaneous cryoablation of two liver tumors

answer

47383

question

hepatectomy with a total left lobectomy

answer

47125

question

backbench reconstruction of a living donor liver graft prior to allotransplantation with venous anastomosis

answer

47146

question

hepatectomy from a cadaver donor, including the graft and cold preservation

answer

47133

question

closure of a vesicouterine fistula

answer

51920

question

tranvesical ureterolithotomy

answer

51060

question

complicated change of a cystostomy tube

answer

51710

question

simple cystometrogram

answer

51725

question

complete cystectomy with ureterosigmoidostomy

answer

51580

question

re-exploration of the parathyroids

answer

60502

question

thyroidectomy, including the substernal thyroid, by cervical approach

answer

60271

question

unilateral partial thyroid lobectomy.

answer

60210

question

complete thyroidectomy

answer

60240

question

excision of a carotid body tumor with excision of the carotid artery

answer

60605

question

osteotomy of the femoral neck

answer

27161

question

open tenotomy of the hip adductor.

answer

27001

question

Girdlestone procedure

answer

27122

question

open treatment of a coccygeal fracture.

answer

27202

question

primary coccygectomy

answer

27080

question

parathyroid planar imaging

answer

78070

question

bone marrow imaging of the whole body

answer

78104

question

diagnostic tomographic bone imaging.

answer

78320

question

cardiac shunt detection

answer

78428

question

pulmonary ventilation and perfusion imaging

answer

78582

question

open drainage of a retroperitoneal abscess

answer

49060

question

physician removes a peritoneal-venous shunt

answer

49429

question

repair of a spigelian hernia

answer

49590

question

peritoneal lavage with imaging guidance

answer

49084

question

physician repairs a lumbar hernia

answer

49540

question

surgical thorascopy with control of a traumatic hemorrhage

answer

32654

question

percutaneous pleural drainage with insertion of an indwelling catheter with imaging guidance

answer

32557

question

thoracotomy for postoperative complications

answer

32120

question

removal of an indwelling tunneled pleural catheter with cuff

answer

32552

question

unilateral thoracotomy with diagnostic biopsies of lung infiltrates

answer

32096

question

closed treatment of proximal tibiofibular joint dislocation requiring anesthesia

answer

27831

question

proximal fibula fracture without manipulation.

answer

27780

question

radical resection of a tumor of the calcaneus

answer

27647

question

incision and drainage of an infect bursa on the ankle

answer

27604

question

physician excises a 3.2 cm subcutaneous tumor from the soft tissue of the leg.

answer

27632

question

Gross Exam

answer

88300

question

Appendix (incidental) (gross exam)

answer

88302

question

Fallopian Tube (sterilization)-(gross exam)

answer

88302

question

Vas deferens (sterilization)-(gross exam)

answer

88302

question

Hernia sac-(gross exam)

answer

88302

question

Finger/toe amputation (traumatic)-(gross exam)

answer

88302

question

Nerve-(gross exam)

answer

88302

question

Foreskin (newborn)-(gross exam)

answer

88302

question

Thymus (incidental)-(gross exam)

answer

88302

question

Arterial/Ventricular (aneurysm)-(gross exam)

answer

88304

question

Appendix (other then incidental)-(gross exam)

answer

88304

question

Bone fragments (other than Path fracture)-(gross exam)

answer

88304

question

Carpal Tunnel Tissue-(gross exam)

answer

88304

question

Cartilage shavings-(gross exam)

answer

88304

question

Cornea-(gross exam)

answer

88304

question

Femoral head (other than fracture)-(gross exam)

answer

88304

question

Femoral head (fracture)-(gross exam)

answer

88305

question

Foreskin (other than newborn)-(gross exam)

answer

88304

question

Gallbladder(gross exam)

answer

88304

question

Ganglion cyst(gross exam)

answer

88304

question

Hematoma (gross exam)

answer

88304

question

Hemorrhoids (gross exam)

answer

88304

question

Intervertebral disc (gross exam)

answer

88304

question

Nasal/sinusoidal Polyp (inflammatory) (gross exam)

answer

88304

question

CHART NOTE CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration. OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted. ASSESSMENT: Hemorrhoid. PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity. CPT Code:

answer

CPT CODE 99212

question

IALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Gloria Baxter ATTENDING PHYSICIAN: Ronald Green, MD This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized. The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient's intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response. The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better. This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.) CPT Code

answer

99233

question

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol. PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC. Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward). Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones

answer

99242

question

The level of E/M service is based on: -Documentation -Key components -Contributing factors -All of the above

answer

all of the above

question

According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam. Problem-focused Expanded problem focused Detailed Comprehensive

answer

Comprehensive

question

What are the four levels of medical decision making complexity?

answer

Low Complexity High Complexity Moderate Complexity Straightforward

question

What are the four levels of history type?

answer

problem-focused, expanded problem-focused, detailed, comprehensive

question

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM? 99284 99291 99283 99220

answer

99284

question

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused Expanded problem focused Detailed Comprehensive

answer

detailed

question

An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity

answer

99253

question

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination? Problem-focused Expanded problem focused Detailed Comprehensive

answer

detailed

question

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)

answer

99291, 99292

question

Counseling, coordination of care, nature of presenting problem, and time are considered: Levels of E/M service Key components Contributory factors Medical decision-making process

answer

Contributory factors

question

These elements would be part of the ________ history: employment, education, use of drugs. Past Social Family Any of above

answer

Social

question

The HPI must be documented in the medical record by: The physician Any office staff member The patient Any of the above

answer

The physician

question

The definition of low birth weight can be found in the notes for subheading ________.

answer

Continuing intensive care

question

When a physician performs a preventive care service, the extent of the exam is determined by the: Age Gender Gender and age Length of time elapsed since last exam

answer

Age

question

LOCATION: Emergency Room SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage. OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced. ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above. PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems. CPT Code:

answer

99281

question

The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.

answer

outpatient

question

The ________ is a statement describing the reason for the encounter and is a history element.

answer

Chief Complaint

question

Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.

answer

-25

question

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. CPT Code:

answer

99341

question

CHART NOTE CC: Dizziness SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49. OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9. ASSESSMENT: Hypothyroidism (MDM was low). PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months. CPT Code:

answer

99213

question

CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Mandy Horton ATTENDING PHYSICIAN: Ronald Green, MD This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out. The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.) CPT Code:

answer

99232

question

Is examination of the back an organ system or body area examination?

answer

Body Area

question

What are the four types of patient status?

answer

New, Established, Outpatient and Inpatient

question

The first outpatient visit is called the ________ visit, and the second visit is called the ________ visit.

answer

Initial, subsequent

question

The first three factors a coder must consider when coding are patient? .

answer

Patient status, type of service, place of service

question

Which history is more complex: the problem focused history or the expanded problem focused history?

answer

Expaneded Problem Focused

question

The examination that is limited to the affected body area is the ________.

answer

Problem Focused

question

What does VLBW stand for?

answer

very low birth weight

question

What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity that must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?

answer

Straightforward

question

What term is used to describe a patient who has been formally admitted to a hospital?

answer

Inpatient

question

The physician provides initial intensive care service for the evaluation and management of a critically ill newborn (5 days old) inpatient for one day. CPT Code: ________.

answer

99468

question

A 55-year-old man is seen by the dermatologist for the first time and complains of two cystic lesions on his back. Considering that the patient is otherwise healthy and has a primary care physician caring for him, the dermatologist focuses the history of the present illness on the skin lesions (problem focused history) and focuses the problem focused physical examination on the patient's trunk. The physician concludes with straightforward decision making that the lesions are sebaceous cysts. The physician advises the patient that the lesions should be monitored for any changes, but that no surgical intervention is warranted at this time. CPT Code: ________.

answer

99201

question

A 68-year-old woman visits her internist again complaining of angina that seems to have worsened over the past 3 days. The patient had had an acute anterior wall myocardial infarction (MI) 2 months earlier. One month after the acute MI, she began to have angina pectoris. The patient also states that she thinks the medications are causing her to have gastrointestinal problems while not relieving her symptoms. She had refused a cardiac catheterization after her MI to evaluate the extent of her coronary artery disease. The physician performs a detailed history and a detailed physical examination of her cardiovascular, respiratory, and gastrointestinal systems. The physician indicates that the decision making process is moderately complex, given the number of conditions it is necessary to consider. CPT Code: ________.

answer

99214

question

A 22-year-old woman visits the gynecologist for the first time since relocating from another state last year. The patient wants a gynecologic examination and wants to discuss contraceptive options with the physician (think Preventive Medicine Services!). The physician collects pertinent past and social history related to the patient's reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history of her present physical state. A physical examination includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient's history of not tolerating certain types of oral contraceptives in the past, the physician's decision making involves a limited number of management options, all with low risk of morbidity to the patient. CPT Code: ________.

answer

99385

question

An established patient is admitted on observation status for influenza symptoms and extreme nausea and vomiting. The patient is severely dehydrated and has been experiencing dizziness and mental confusion for the past 2 days. Prior to this episode the patient was well but became acutely ill overnight with these symptoms. Given the abrupt onset of these symptoms, the physician has to consider multiple possible causes and orders a variety of laboratory tests to be performed. The patient is at risk for a moderate number of complications. The MDM complexity is moderate. A comprehensive history is collected, and a comprehensive head-to-toe physical examination is performed. CPT Code: ________.

answer

99219

question

A physician visits another patient on observation status who has severe influenza. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical examination to reflect the patient's current status. The patient's problem is of low severity but requires ongoing active management, with possible surgical consultation. The MDM complexity is low. CPT Code: ________.

answer

99221

question

An 8-month-old infant, who is a new patient, is brought in by her mother for diaper rash. The physician focuses on the problem of the diaper rash for the problem focused history and examination. The MDM complexity is straightforward. CPT Code: ________.

answer

99201

question

A 33-year-old man is brought to his private physician's office by his wife. The man, who is an established patient, has been experiencing severe leg pain of 2 weeks' duration. In the past 2 days, the patient has experienced fainting spells, nausea, and vomiting. The patient has had multiple other vague complaints over the past month that he dismissed as unimportant, but his wife is not so sure, and she describes his general health as deteriorating. The physician performs a comprehensive multisystem physical examination after performing a complete review of systems and a complete past medical, family, and social history, with an extended history of the present illness (comprehensive history). The physician has to consider an extensive number of diagnoses, orders a variety of tests to be performed immediately, and indicates the MDM complexity to be high. CPT Code: ________.

answer

99215

question

A 42-year-old woman, who is an established patient, visits her family practitioner with the chief complaint of a self-discovered breast lump. She describes a feeling of fullness and tenderness over the mass that has become more pronounced in the past 2 weeks. Because the patient is otherwise healthy and has had a physical within the past 6 months, the physician focuses his attention on the breast lump during the taking of a problem focused history and the performance of a problem focused physical examination. The physician orders an immediate mammography to be performed and a follow-up appointment in 5 days. The physician has given the patient no other options and indicates that the MDM complexity is straightforward. CPT Code: ________

answer

99212

question

Surgeries which are prolonged or extremely difficult are coded with the modifier _________? a) -62 b) -59 c) -22 d) -52

answer

C

question

A code used to indicate that a physician assisted the primary surgeon in a major procedure is __________? a) -81 b) -80 c) -54 d) -51

answer

B

question

The following are subsections of the surgery section of the CPT manual EXCEPT __________? a) musculoskeletal b) cardiovascular c) radiology d) female genital

answer

radiology

question

For coding purposes, information about the size of a lesion should come from __________? a) the physician report b) the medical assistant's measurements c) radiology report d) pathology report

answer

the physicial report

question

Free skin grafts are coded by _________? a) degree of burn b) type of wound c) recipient site and size of defect d) length of grafted area

answer

recipient site and size of defect

question

For a breast biopsy, the placement of a wire marker is ___________. a) coded separately b) included in the excision code c) coded by size of the wire guage d) coded by the depth the marker is placed

answer

coded separately

question

Fractures are coded by _____________? a) application of casts and strapping procedures b) cast material and type c) site and treatment d) cause of injury

answer

site and treatment

question

To code diagnostic endoscopy procedures _________? a) code each area that is passed with the scope b) never code more than one procedure in an operative setting c) select the code that refects the farthest extent of the procedure d) ignore the approach

answer

select the code that reflects the farthest extent of the procedure

question

Code groupings for arteries and veins vary according to ___________? a) procedure b) surgical intstruments c) functions d) directional flow

answer

procedure

question

Codes for the digestive system are arranged by site, beginning with the mouuth and ending with the __________? a) feet b) anus c) rectum d) sigmoid

answer

anus

question

When coding ostomies, it is critical to _______? a) indicate the anatomosis b) use a medical dictionary c) identify the site from which it originated d) determine the type of material used

answer

identify the site from which it originated

question

When an exploratory laparotomy is used as surgical approach for another procedure, it is ____________ ? a) always coded separately b) not coded separately c) considered the most definitive procedure d) considered the primary procedure

answer

not coded separately

question

In the CPT index, hernia codes are listed __________? a) by anatomic site of hernia b) by type of repair c) by patients gender d) under 'Protrusion"

answer

by anatomic site of hernia

question

The code for a total hysterectomy includes removal of the ________? a) uterus b) ovaries c) fallopian tubes d) all answers are correct

answer

all answers are correct

question

Codes for the nervous system subsection of the CPT manual are divided __________? a) by the specific names of nerves b) by body region c) by anatomic site and type of procedure d) alphabetically by nerve type

answer

by anatomic site and type of procedure

question

When coding spinal procedures, consider all of the following EXCEPT __________? a) the segmens involved b) unilateral or bliateral orientation c) approach d) condition

answer

unilateral or bilateral orientation

question

If a radiologist is reading films taken at another facility ________? a) use a modifier to indicate the technical component b) use a modifier to indicate the professional component c) a global code is used d) an outpatient code is used

answer

use a modifier to indicate tha technical component

question

When contrast material is injected by a radiologist, the injection procedure code is taken from the __________? a) surgery section b) radiology section c) anesthesiology section d) E/M section

answer

surgery section

question

Codes in the Diagnostic Radiology subsection are arrange __________. a) by amount of radiation given b) by anatomic site c) alphabetically d) technologically

answer

by anatomic site

question

When coding the radiation oncology, consider all of the following EXCEPT __________? a) treatment type b) level of treatment planning c) age of the patient d) number of ports and blocks

answer

age of the patient

question

Considerations when coding urinalysis and chemistry laboratory procedures include all of the following EXCEPT __________? a) names of specific tests b) number of tests done c) specification of qualitative or quantitative results d) brand names for lab equipment

answer

brand names for lab equipment

question

Level I pathology code 88300 identifies specimens that normally do not need to be viewed under a microscope such as __________? a) tooth b) malignant uterus tissue c) fluid from a breas biopsy d) neoplastic tissue

answer

a tooth

question

If a physician spends 50 minutes with a patient after he or she has been admitted for a suicide attemt in connection with depression, the psychotherapy coding would be _________? a) bundled b) separate from initial care c) considered outpatient d) disregarded

answer

separate from initial care

question

The major factor for coding psychiatry is _______? a) time b) physician credentials c) inpatient outpatient status d) counseling

answer

time

question

The Physical Medicine codes are indications of type of modalities and ____________? a) temperature b) location c) time d) method

answer

time

question

When coding trauma cases, the most severe injury is _________? a) bundled with all other injuries b) th eonly one coded c) coded first d) coded last

answer

coded first

question

The code for a simple drainage of a finger abcess is ________? a) 26011 b) 26010 c) 26951 d) 26034

answer

26010

question

The appropriate code for an indirect laryngoscopy with removal of foreign body is __________? a) 31505 b) 31530 c) 31511 d) 31512

answer

31511

question

The code for the complicated removal of a subcutaneous foreign body of the foot is ________? a) 28190 b) 28192 c) 28193 d) 11010

answer

28193

question

The code for a percutaneous needle core breast biopsy (without imaging) is _________? a) 19100 b) 76095 c) 19101 d) 19102

answer

19100

question

The appropriate code for a gastrojejunostomy without vagotomy is _________? a) 43820 b) 43810 c) 43860 d) 48547

answer

43820

question

The code for a complex arthotomy of the knee (lateral) with menisectomy is ________? a) 27332 b) 27332-22 c) 27333 d) 27333-22

answer

27332-22

question

The code for Subsequent Hospital Care which indicates physician visits for a patient in stable condition is ___________? a) 99231 b) 99232 c) 99233 d) 99238

answer

99231

question

Which Emergency Department Services code indicates a need for immediate attention without the presence of a life-theatening condition? a) 99285 b) 99284 c) 99283 d) 99282

answer

99284

question

The code for harvesting a small bone graft when the graft is not already listed as a part of the procedure is _________? a) 27170 b) 20930 c) 20936 d) 20900

answer

20900

question

The code for a simple repair of superficial scalp would not exceeding 2.5 cm in length is ___________? a) 120011 b) 12011 c) 12031 d) 13100

answer

12001

question

The code for repair of a flexor tendon of the leg is _______? a) 27650 b) 27658 c) 27658 x2 d) 27659

answer

27658

question

The preoperative placement of a needle localization wire in the breast is coded _________? a) 19100 b) 19291 c) 19290 d) 19295

answer

19290

question

If an arthroplasty is performed for reasons of a fractured ankle, is is called __________? a) 20605 b) 27700 c) 27870 d) 29891

answer

27700

question

Which code describes a surgical thoracoscopy with excision-plication of bullae as well as pleural procedures? a) 32650 b) 32601 c) 32655 d) 32656

answer

32655

question

The code for a coronary artery bypass graft using three arterial grafts is _______? a) 33535 b) 33534 c) 33533 d) 33510

answer

33535

question

The code for a partial colectomy with anastomosis is __________? a) 44140 b) 44141 c) 44140 -52 d) 44150

answer

44140

question

Which code describes a laparoscopic vaginal hysterectomy with the removal of the ovaries? a) 58150 b) 58260 c) 58262 d) 58552

answer

58262

question

The CPT that appropriately describes a set of obstetric laboratory test for the first obstetric visit is _______? a) 59409 b) 80050 c) 80055 d) 86762

answer

80055

question

A surgical endoscopy always includes ______? a) an x-ray b) a diagnostic endoscopy c) a -51 modifier d) a sigmoidoscopy

answer

a diagnostic endoscopy

question

The highest level of pathology coding which would include examination of neoplastic tissue or very involved specimens is __________? a) 90703 b) 90698 c) 90700 d) 90715

answer

88309

question

Which code indicates an immunization for tetanus toxoid? a) 90703 b) 90698 c) 90700 d) 90715

answer

90703

question

Which of the following is an example of unethical or illegal coding? a) Dividing services provided into separate codes when a single code is available b) Inclusion of all relevant complications as documented in the patients medical record c) Using code numbers for the minimum payment allowed d) strict adherence to coding for only procedures performed at your facility

answer

Dividing services provided into separate codes when a single code is available

question

The transformation of verbal descriptions of diseases, injuries, and procedures into numbers is called ________? a) indexing b) posting c) tabulation d) coding

answer

coding

question

Two coding systems are used by phsicians offices. One is for diagnoses and the other is for ___________? a) symtoms b) computer directories c) services and procedures d) appointments

answer

services and procedures

question

Physicians Current Procedural Terminology (CPT) is revised ________? a) annually b) when necessary c) every 6 months d) every 2 years

answer

annually

question

Basic CPT codes use ___________? a) 3 to 5 digits b) 5 digits c) 2 digits d) 3 digits

answer

5 digits

question

Add-on modifier - 26 indicates the _______? a) service is significant and separately identifiable b) unusual nature of the service or procedure c) technical component d) professional component

answer

professional component

question

In some billing cases it is necessary to add a 2 digit modifier in order to __________? a) indicate usual charges b) prevent miscoding c) give a more accurate description d) meet carrier criteria

answer

give a more accurate description

question

CPT codes, descriptions and two digit modifiers are copyrighted by the _______? a) American Medical Association b) Blue Cross and Blue Shield Organization c) CPT Assistant d) World Hospital Organizaiton

answer

American Medical Association

question

When transferring codes to claim forms he careful to __________? a) include descriptions b) write out all abbreviations c) keep from transposing numbers d) write neatly

answer

keep from transposing numbers

question

Unbundling, exploding, or a la carte coding are __________? a) common b) fraudulent c) necessary d) complex

answer

fraudulent

question

If multiple lacerations are repaired under the same classification and in the same group of anatomic parts a billing and coding specialist should _______? a) add the sum of lengths and report one code b) report a code for each laceration c) include a printed report d) report only the longest laceration

answer

add the sum of lengths and report one code

question

Modifier code - 66 indicates ________? a) procedure performed on infants b) surgical team c) assistant physician d) two surgeons

answer

surgical team

question

Modifier code - 99 indicates ________? a) laboratory work b) surgical tray c) universal application d) multiple modifiers

answer

multiple modifiers

question

Which of the following is NOT needed when coding a laceration repair ________? a) depth of wound b) size of wound c) location of wound d) cause of wound

answer

cause of wound

question

The modifier for a repeat procedure by the same physician is ______? a) -79 b) -78 c) -77 d) -76

answer

-76

question

The purpose of CPT is to ________? a) revise technologic advances b) simplify the CMS-1500 form c) convert medical descriptions into 5 digit codes d) organize insurance billers work

answer

convert medical descriptions into 5 digit codes

question

The CPT coding system is used by all of the following EXCEPT ___________? a) doctors offices and clinics b) outpatient departments c) third party payers d) patients

answer

patients

question

The CPT coding system was developed by the ______? a) American Medical Association b) federal government c) state government d) Social Security Administration

answer

Amerian Medical Association

question

In the CPT manual, a round bullet symbol indicates a ________? a) bundled code b) new code c) revised code d) deleted code

answer

new code

question

A triangle symbol in the CPT manual indicates a _______? a) minor surgical procedure b) decision for surgery c) new code d) revised description

answer

revised description

question

In the CPT manual, where is a complete summary of additions, deletions and revisions located? a) In Appendix B b) In Appendix A c) In the Index d) In the Table of Contents

answer

In Appendix B

question

Which of the following is NOT one of the sections in the CPT manual? a) Evalution and management b) Integumentary system c) Surgery d) Medicine

answer

Integumentary system

question

There are two types of CPT codes: stand-alone and __________? a) sub codes b) parent codes c) stand aside codes d) add on or indeted codes

answer

add on or indented codes

question

In CPT coding, the words following the semicolon may indicate all of the following EXCEPT ___________? a) alternative anatomic site b) alternative procedure c) lesser important procedures d) extent of procedures

answer

lesser important procedures

question

CPT surgical packages are used only by _________? a) third party payers b) physicians c) anethesiologists d) radiologist

answer

third party payers

question

Which of the following is NOT included in the CPT surgery package ___________? a) The operation b) the surgery c) Normal follow-up care d) General anethesia

answer

General anesthesia

question

Which of the following indicates a co-surgeon? a) -80 b) -81 c) -66 d) -62

answer

-62

question

When using CPT codes to indicate an unlisted procedure, the last digit will usually be a _______? a) 9 b) 2 c) 3 d) 4

answer

9

question

Claims including codes for an unusual,new,seldom performed or unlisted procedure should include a _________? a) duplicate copy b) written medical report c) written description by the code number d) numerical summary

answer

written medical report

question

In the CPT index, main terms are listed by _____? a) procedure or service b) organ or anatomic site c) condition, synonym, or abbreviation d) all answers are correct

answer

all answers are correct

question

At the beginning of the CPT index are ________? a) diagrams b) instructions c) definitions d) anatomical listings

answer

instructions

question

Even if only one code is listed for the desired procedure in the index of the CPT manual, the user ____________? a) can select that code b) must refer to the main text c) can expect across references d) notes that code on the claim form

answer

must refer to the main text

question

The CPT manual is divided into how mayn sections? a) 6 b) 5 c) 4 d) 8

answer

6

question

The Evaluation and Management section is organized by type of service, place of service, and __________? a) nature of presenting problem b) time c) patient status d) coordination of care

answer

patient status

question

The key components of documentation that support levels of E?M codes includes the following EXCEPT __________? a) history b) examination c) counseling and coordination of care d) medical decision-making

answer

counseling and coordination of care

question

Components of a medical history inlude all of the following except __________? a) medical decision making b) chief complaint c) family history d) review of systems

answer

medical decision making

question

A key component in coding medical decision-making is _____________? a) patient childhood diseases b) level of complexity c) the physician's level of education d) the amount of time the physician spends with the patient

answer

level of complexity

question

Physician counseling is considered a key component for selecting the level of code assignment for Evaluation and Management services only when ____________? a) the physician is a psychiatrist b) counseling exceeds 50% of the time spent c) the physician does not take a history or perform a physical examination d) the physician is a physchologist

answer

counseling exceeds 50% of the time spent

question

Critical care is coded _____________. a) in quarter hours units b) each time the patient is seen in a 24 hours period c) the minute the patient is determined to have a life threatening emergency d) in minutes starting with 30-74 minutes

answer

in minutes starting with 30-74 minutes

question

In a case requiring critical care coding __________. a) the coder is expected to unbundle b) no other services are included c) ventilator management is not included d) ventilator management is included

answer

ventilator management is included

question

A code indicating a vaginal delivery only, not including obstetric care, is _____________? a) 59409 b) 59410 c) 59610 d) 59561

answer

59409

question

Physicians telephone calls are usually __________? a) coded according to area codes b) not paid by third party payers c) paid by third party payers d) coded using HCPCS Level II codes

answer

not paid by third party payers

question

Care Plan Oversight Sevices for hospice and homebound patients _____________? a) require vast documentation and are typically not paid by third party payers b) are usually paid by the third party payers c) are not listed services in CPT d) are coded once for every 24 hours period the patient is seen

answer

require vast documentation and are typically not paid by third party payers

question

Which of the following conditions would not require critical care? a) Cardiac arrest b) Labor leading to childbirth c) Shock d) Respiratiory failure

answer

Labor leading to childbirth

question

Anesthesia codes are divided by ___________? a) medication b) anatomical site c) drug name d) number of anethesiologists

answer

anatomical site

question

For anesthesia coding purposes, physical status modifiers are used to indicate ________? a) age of patients at time of surgery b) patient's status upon admittance c) patient's status at the time of anesthesia d) patient's status at the time of completion of surgery

answer

patient's status at the time of anesthesia

question

Where in the CPT manual are codes for anethesia provided under difficult circumtances? a) Anesthesia guidelines b) Medicine c) Surgery d) Both anesthesia guidelines and medicine are correct answers

answer

Both anesthesia guidelines and medicine are correct answers

question

Which section of the CPT manual is the largest? a) Medicine b) Evaluation and Management c) Surgery d) Radiolgy

answer

Surgery

question

When one fee is used for a surgical procedure and uncomplicated follow-up care, this is called a __________? a) surgical unit b) global surgical package c) general procedure d) cluster

answer

global surgical package

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