(The physician performs adiagnostic ERCPof the common bile duct with insertion of astentinto the biliary duct. What CPT® coding is reported?)
(A patient is in the operating room for a planned partial meniscectomy of the temporomandibular joint. However, after general anesthesia was administered and the oral surgeon made the incision, the patient experienced respiratory distress. The oral surgeon decides tocancel the procedure. What CPT® coding is reported for the oral surgeon?)
A woman with vulvar intraepithelial neoplasia (VIN II) undergoes a partial vulvectomy ( < 80%) with removal of skin and deep subcutaneous tissue.
What CPT® and ICD-10-CM codes are reported?
According to the ICD-10-CM Guidelines, what code is reported as an additional code when the blood pressure of a patient with hypertension remains above goal in spite of the use of antihypertensive medications?
A patient was in a car accident as the driver and suffered a concussion with brief loss of consciousness (15 minutes). What ICD-10-CM codes are reported?
Provider performs staged procedures for gender reassignment surgery converting female anatomy to male anatomy.
What CPT® code is reported?
Multiple laceration repairs were performed:
Simple: cheek (2.5 cm), nose (3 cm)
Intermediate: left leg (9 cm), right leg (11.5 cm)
Complex: left upper arm (4 cm)
What CPT® codes are reported?
A 45-year-old patient comes In with chronic sinusitis that has not responded to medication. The physician decides to use a sinus stent implant to help alleviate the patients symptoms.
The physician inserts the implant into the ethmoid sinus using a delivery system. This implant is designed to keep the surgical opening clear, prop open the sinus, and gradually release a corticosteroid with anti-inflammatory properties directly to the sinus lining. The implant is not permanent and will dissolve over time.
What HCPCS Level II code is reported?
A patient with severe diverticulitis in the sigmoid colon presents to surgery for a partial colectomy. The physician performs an exploratory laparoscopic laparotomy to verify the location of the diverticulitis. Once identified, it was noted that there was bleeding from the diverticulitis. The physician transects the descending colon and then transects at the line of the rectum.
The physician mobilizes the splenic flexure in order to create a colostomy with the proximal portion of the remaining colon. The distal portion of the colon is closed. The physician washes the patient ' s abdomen with saline, removes all trocars and instruments, and then closes the abdomen with sutures.
What CPT® and ICD-10-CM codes are reported?
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?
In rhinoplasty:
A patient has five biopsies performed on the duodenum.
What CPT® coding is reported?
According to the Repair (Closure) CPT® guidelines, what type of repair is reported when a single layer closure includes copious irrigation and extensive cleaning to remove particulate matter?
(A pathologist performs an analysis usingfluorescent microscopyto evaluate a specimen for inherited or acquiredchromosomal abnormalities. No specific CPT® code accurately describes this service. Which unlisted CPT® code is reported?)
(Which of the following is classified ascoronary arteries?)
A 20-year-old female is being seen for the first time by a primary care physician to have a yearly physical. During the examination for the physical, the provider discovers non-inflammed lesions on her legs and arms. The physician performs a complete physical and additional separate documentation for the treatment of the lesions on the bilateral upper and lower extremities. The provider has the patient buy an over-the-counter ointment and will continue to watch them.
What CPT® coding is reported for this visit?
A patient with end-stage renal disease (ESRD) receives hemodialysis 3x weekly in the office for one month. The nephrologist performs a comprehensive exam and supervises dialysis.
What CPT® and ICD-10-CM codes are reported?
A pediatric patient with a congenital double inlet ventricle undergoes corrective cardiac surgery. The surgeon performs a modified Fontan procedure to redirect systemic venous blood flow directly to the pulmonary arteries as part of staged repair for a single-ventricle physiology.
What CPT® and ICD-10-CM® codes are reported?
A 47-year-old male recently injured as a passenger in a car accident sustained multiple fractures. The patient now has physical restraints due to pulling out foley catheter, IV catheters and
attempted to pull out NG tube. Emergency department physician is asked to come see patient and injects 0.5 lidocaine into lumbar region of the spine. An indwelling catheter is placed into the
lumbar region for continuous infusion with fluoroscopy for pain management.
What CPT® is reported for the Emergency department physician?
A complete 7-view X-ray of the lumbosacral spine, including bending views, is performed.
What CPT® code is reported?
Repeat three-view imaging of both hips and pelvis is performed on the same day due to a new fall, interpreted by the same radiologist.
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 '
According to the ICD-10-CM coding guidelines, when coding hypertension with heart conditions classified to I50.- or I51.4–I51.7, I51.89, I51.9, what category should be used?
(What does the suffix-graphmean?)
(Miranda is in her provider’s office for follow up of her diabetes. Her blood sugars remain at goal with continuing her prescribed medications. When referring to the MDM Table for number and complexity of problems addressed, what type of problem is this considered?)
An established patient presents with fever and sore throat. Rapid strep test is positive.
What CPT® and ICD-10-CM codes are 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?)
A patient undergoes lumbar puncture with catheter placement under CT guidance to drain CSF.
What CPT® coding is reported?
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 presents with recurrent spontaneous episodes of dizziness of unclear etiology. Caloric vestibular testing is performed irrigating both ears with warm and cold water while evaluating the patient’s eye movements. There is a total of three irrigations.
What CPT® coding is reported?
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 with empyema requires a Schede thoracoplasty.
What CPT® code is reported for this procedure?
(Which place of service code is submitted on the claim for a procedure that is performed in a patient’sprivate residence?)
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 underwent a cystourethroscopy with a pyeloscopy using lithotripsy to break up the ureteral calculus. An indwelling stent was also inserted during the same operative session on the same side. This service was performed in the outpatient hospital surgery center.
What CPT® coding reported?
Which medical term refers to inflammation of the cornea?
(What modifier is appended to indicate that during thepostoperative period, a procedure is performed that wasplanned,more extensivethan the original procedure, or done fortherapeutic reasons?)
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?
(A 58-year-old patient undergoes diagnostic facet joint injections. The physician performsbilateral paravertebral facet joint injectionsat theT2–T3, T3–T4, and T4–T5levels, usingfluoroscopic guidanceat each site. What CPT® coding is reported for this encounter?)
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 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?
A 40-year-old woman with progressive sensory neural hearing loss in the right ear since the age of 13 has not gained benefit from her hearing aid. She has normal hearing in the left ear. A cochlear implant is placed for the right ear. Anesthesia is provided by a CRNA with medical direction by an anesthesiologist who is concurrently directing 5 CRNAs. PS is 3.
What anesthesia CPT® and ICD-10-CM codes are reported by the Anesthesiologist?
The knee joint consists of which three compartments?
A patient is seen at the doctor ' s office for nausea, vomiting, and sharp right lower abdominal pain. CT scan of the abdomen is ordered. Labs come back indicating an increased WBC count with review of the abdominal CT scan. The physician determines the patient has a ruptured appendicitis. The physician schedules an appendectomy and takes the patient to the operating room. The appendix is severed from the intestines and removed via scope inserted through an umbilical incision. What CPT® and diagnosis codes are reported?
A 55-year-old female patient is diagnosed with renal cell carcinoma. She is having a resection of the affected kidney, a portion of the ureter, and rib resection, open aproach. The procedure is complicated due to a prior surgical procedure performed on the same kidney.
What CPT® coding is reported?
The evisceration of ocular contents was performed using a surgical microscope for enhanced visualization. The procedure was performed on the left eye and an implant was not placed in the ocular cavity.
What CPT® coding is reported?
(A patient is diagnosed with agangrenous ulceron theright thighwith thefat layer exposedand is currently being treated. What ICD-10-CM coding is reported?)
(A provider documents “pericarditis with effusion” in the assessment. Based on medical terminology, which structure is inflamed?)
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image
Reason: Screen
Bilateral digital mammography with computer-aided detection (CAD)
No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT® coding is reported for this case?
(A 3-year-old is seen by his primary care physician for anannual exam. His last exam with the primary care physician wastwo years ago. He has no complaints. What CPT® code is reported?)
What does PHI stand for in healthcare privacy regulations?
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?
Dr. Burns sees newborn baby James at the birthing center on the same day after the cesarean delivery. Dr. Burns examined baby James, the maternal and newborn history, ordered appropriate blood test tests and hearing screening. He met with the family at the end of the exam.
How would Dr. Bums report his services?
A patient who has HIV disease presents with loin pain in the clinic today. The patient reports he is having trouble sleeping due to the pain. What ICD-10-CM coding is reported?
An 8-year-old patient is placed under general anesthesia for treatment of a right orbital fracture due to a traumatic fall to the nose and face from a swing set. An on-call otolaryngologist is
asked to perform a general otolaryngologic examination to evaluate the patient. A mild nasal fracture is the diagnosis given by the otolaryngologist.
What is the CPT® and ICD-10-CM coding for the otolaryngologist ' s services?
(What ICD-10-CM coding is reported forType 1 diabeteswithdiabetic chronic kidney disease?)
(A patient has aliver massand presents for apercutaneous needle biopsy of the liver with CT guidance. Four core specimens are taken to rule out benign hepatic adenoma. What CPT® and ICD-10-CM codes are reported?)
A pathologist performs fluorescent microscopy for chromosomal abnormalities, but no specific CPT® code exists.
Which unlisted CPT® code is reported?
(Patient presents to the office for the removal of15 actinic keratoseslesions. The provider destroys these lesions withlaser surgery. What CPT® coding is reported for this visit?)
Which one of the following terms refers to inflammation of the liver?
Refer to the supplemental information when answering this question:
View MR 065174
What E/M code is reported for this encounter?
A patient complains of tarry, black stool, and epigastric tightness. An esophagogastroduodenoscopy is recommended to evaluate the source of the bleeding. The endoscope is inserted orally. The esophagus appears normal on scope insertion. No evidence of bleeding in the stomach. The scope is then passed into the duodenum, where a polyp is found and removed with hot biopsy forceps. No evidence of bleeding post procedure.
What CPT® code is reported?
A patient that delivered her second child vaginally has a history of having a previous cesarean delivery for the first child.
What CPT® code is reported for the delivery of the second child with antepartum care and postpartum care with the same provider?
A physician performs excisional debridement on multiple wounds:
Lower back: 12 cm, involving fascia
Left shoulder: 8 cm, involving subcutaneous tissue
Left lower leg: 16 cm, involving subcutaneous tissue
What CPT® codes are reported?
(Day 1: Provider admits patient toobservation carefor type 2 diabetes with hyperglycemia, orders labs, consults endocrinologist, starts IV insulin drip, keeps overnight. Day 2: orders glucose test, dietitian, documents total time 25 minutes. Day 3: glucose normal, documents 15 minutes, discharges patient. What E/M coding is reported by the physician for the patient in observation care?)
Which statement is FALSE in reporting a personal history ICD-10-CM code?
(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?)
A 65-year-old man had a right axillary block by the anesthesiologist. When the arm was totally numb, the arm was prepped and draped, and the surgeon performed tendon repairs of the right first, second, and third fingers. The anesthesiologist monitored the patient throughout the case.
What anesthesia code is reported?
A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesia. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
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?
(Patient with erectile dysfunction is presenting for a penile implant. Anon-inflatable penile prosthesisis inserted. What CPT® code is reported for this service?)
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 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws were placed at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.
Select the procedure codes for this scenario.
A patient presents with fever, cough, SOB, and a recent history of COVID-19. A PCR test was positive for COVID-19. The provider documents a final diagnosis of “pneumonia with history of COVID-19.”
What ICD-10-CM coding is reported?
Mr. Roland has difficulty breathing and congestion with a productive cough. The physician takes frontal and lateral view chest X-rays in the office (the equipment is owned by the physician group). The physician reads the X-rays and determines a diagnosis of walking pneumonia. The physician’s interpretation is placed in the patient’s chart.
How does the physician bill for the chest X-ray?
(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?)
What modifier is appended to indicate when a service is performed because it was mandated by a third-party payer, government agency, or other regulatory requirement?
(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?)
(Full Case:Chief complaint:Syncope.HPI:68-year-old male arrives to ED inrespiratory distressafter sudden syncope/collapse while shopping; unresponsive; EMS: weak pulse, labored respirations, unresponsive. History:CABG 5 years ago, no chest pain since.ROS:unobtainable (unconscious).Allergies:none.Meds:Coumadin.PMH:HTN.Social:lives with wife.Exam/Vitals:BP 82/62, pulse 79, RR 12 shallow, O2 sat 90% on high flow O2; monitor shows right bundle branch block. Neuro: initially eyes closed, opens to questions, responds to some questions, later unresponsive. HEENT pupils sluggish equal; unable EOM/fundus. Neck supple, no JVD/bruits. Lungs mild rhonchi. Heart regular without murmurs. Abdomen benign. Extremities symmetric, no edema/cyanosis. Skin no rash. Neuro no focal deficits.Hospital course:IV x2; NS 1000 cc bolus with little response; dopamine drip 10 → 20 mcg/kg/min; O2 sat drops, respirations slow; becomes unresponsive; progresses tocardiac arrest; CPR; multiple adrenaline/atropine; defibrillation; ABG pH 7.1 etc; bicarbonate x2; no effect; pronounced dead 13:32.Critical care time:77 minutes continuous.Diagnosis:Cardiorespiratory arrest.Question:What is the E/M coding reported for this encounter?)
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 code is reported?
Patient has undergone open surgery for a left total knee arthroplasty. While in the recovery room, he continued to have severe postoperative pain. The surgeon ordered a femoral block for postoperative pain. The anesthesiologist evaluated the patient and performed a left femoral block, which provided significant post-operative pain relief.
What CPT® coding is reported?
A 53-year-old male arrived at the ER due to severe ocular trauma to the right eye. He was at work on a metal drilling machine and a metallic item penetrates his right eyeball. A foreign body is in
the posterior segment of the eye and corneal laceration with multiple posterior perforated sites were noted. He is brought back to the surgical suite. The surgeon removes the metallic foreign
body using large retinal forceps. The laceration of the cornea is sutured and the provider also performs a pars plana lensectomy.
What is the CPT® and ICD-10-CM codes are reported?
A 49-year-old patient arrives with hearing loss in his left ear. Impedance testing via tympanometry is performed.
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?
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?
What is the medical term for a procedure that creates a connection between the gallbladder and the small intestine?
This 27-year-old male has morbid obesity with a BMI of 45 due to a high calorie diet. He has decided to have an open Roux-en-Y gastric bypass. The patient is brought to the operating room and placed in supine position. A midline abdominal incision is made. The stomach is mobilized, and the proximal stomach is divided and stapled creating a small proximal pouch in continuity with the esophagus. A short limb of the proximal bowel of 155 cm is divided. It is brought up and anastomosed to the gastric pouch. The other end of the divided bowel is connected back into the distal small bowel to the short limb ' s gastric anastomosis to restore intestinal continuity. The abdominal incision is closed.
What are the procedure and diagnosis codes for this encounter?
(A patient presents for an outpatient physical therapy evaluation due to chronic low back pain. The medical record documents that the patient has a current diagnosis oflumbar spine region cancer, which isactively being treatedat the time of therapy. Which lumbar spine associated conditionM codeis reported?)
(A 52-year-old woman has vulvar intraepithelial neoplasia (VIN II). The surgeon performs avulvectomyremovingless than 80%of the vulva, including affected skin and deep subcutaneous tissue. What CPT® and ICD-10-CM codes are reported?)
Which HCPCS Level II codes identify temporary services that would not be assigned a CPT® code, but are needed for claims processing purposes?
Which statement is FALSE in reporting a personal history ICD-10-CM code?
A patient undergoes MRI-guided needle liver biopsy with two core samples taken.
What CPT® codes are reported?
Mr. Woolridge has had a suspicious lesion on his left shoulder for approximately eight weeks that is not healing. On the dermatologist ' s exam of left shoulder blade, there is excoriation and scabbing and the lesion not healing. Patient agrees and wishes to proceed with a punch biopsy of the lesion. A punch biopsy is taken of the lesion and sent to pathology. A simple repair is performed at the biopsy site.
What CPT® and ICD-10-CM codes are reported?
A cystic lesion on the chest is excised with margins totaling 2.5 cm. Simple closure performed.
What CPT® coding is reported?
Refer to the supplemental information when answering this question:
View MR 000281
What anesthesia and diagnosis codes are reported for this case?
View MR 099405
MR 099405
CC: Shortness of breath
HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.
Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.
ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.
PMH: Asthma
SH: Lives with both parents.
FH: Family hx of asthma, paternal side
ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child’s family and no changes reported.
PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.
Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva
Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.
Lymph nodes: normal.
Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.
Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.
GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly
Skin: normal warm and dry. Pink well perfused
Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.
Assessment: Asthma, acute exacerbation
Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.
What E/M code is reported?
A 67-year-old patient has osteomyelitis of the shoulder blade and is in surgery to remove the sequestered section of dead infected fragment bone from surrounding bone.
What CPT® code is reported?
A patient who has colon adenocarcinoma undergoes a laparoscopic 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?
The mediastinum is:
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?
(Regarding the CPT® Surgery Guidelines for a surgical code designated as a“Separate Procedure,”which statement isFALSE?)
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?
(A patient is seen by her podiatrist to treat a painfulleft ingrown toenailon the big toe. The podiatrist performs awedge excisionof the skin of the nail fold at the lateral margin. Local anesthetic is administered, and an elliptical incision is made through subcutaneous tissue of the affected nail groove. A wedge-shaped piece of soft tissue from the nail margins is removed. What CPT® code 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?
A CRNA independently administers MAC anesthesia for ICD replacement.
What CPT® and ICD-10-CM codes are 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?)
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?
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 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 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?)
Which one of the following is a commercial or private payer?
(A patient visits her provider’s office because she is experiencing persistent headaches. Her provider sends her to a radiology facility to do aCT scan of the brain without contrast. The images are sent to the provider, and the providerreads and interpretsthe scan. What CPT® coding of the radiology service is reported by the provider?)
(When a provider’s documentation refers touse, abuse, and dependenceof the same substance (e.g., alcohol), which statement is correct?)
(A 50-year-old patient undergoesflexible bronchoscopy with bronchial biopsies. Five biopsies are taken and sent to the lab. What CPT® coding is reported?)
Which statement is NOT true regarding the ICD-10-CM coding guidelines for burns?
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 presents for planned sterilization via bilateral excisional vasectomy.
What CPT® and ICD-10-CM codes are reported?
(A patient presents to the OR for removal of asubcutaneous cardiac rhythm monitor system14 months after the device was implanted. What is the CPT® code for this service?)
A patient undergoes CABG using the right internal mammary artery anastomosed to three coronary arteries.
What CPT® coding is reported?
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 44-year-old female patient with chest pains had a CT of her chest that identified a mass in her left lower lung. The patient currently has ovarian cancer with metastases to the liver. The radiologist suspects the cancer has spread to her lungs. The physician performed an outpatient bronchoscopic biopsy and the pathology report documents the mass as a tumor of uncertain behavior.
What ICD-10-CM codes are reported for this patient?
An 8-year-old undergoes tonsillectomy with adenoidectomy for chronic tonsillitis and adenoiditis with hypertrophy.
What CPT® and ICD-10-CM codes are 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?
(Full Case:Preoperative diagnosis:Recurrent dysphagia.Postoperative diagnosis:Hiatal hernia with obstruction.Procedure:EGD with dilation.Consent:PAR conference; informed consent signed; premedication given.Position/monitoring:left lateral decubitus; monitored with BP cuff and pulse oximeter throughout.Topical:Hurricaine spray to posterior pharynx.Scope passage:flexible endoscope passed under direct visualization through cricopharyngeus into esophagus; advanced with identification of EG junction into stomach; rugal folds visualized; advanced to antrum/pylorus; pylorus cannulated; duodenal bulb and second portion visualized; retroflexed views of cardia/fundus/lesser curvature.Dilation technique:guidewire placed in antrum; scope removed; wire positioned by markings;#14 French dilatorpassed into stomach area;esophageal dilation performed over guidewire.Findings:tortuous/shortened esophagus; large sliding hiatal hernia; EG junction ~30 cm; stomach abnormal with very large sliding hiatal hernia; duodenum normal.Question:What CPT® coding is reported?)
A patient is diagnosed with a healing pressure ulcer on her left heel that is currently being treated.
What ICD-10-CM coding is reported?
A 25-year-old woman underwent percutaneous breast biopsy on the right breast with placement of a Gelmark clip. The procedure was performed using stereotactic imaging.
What CPT® codes will be reported?
Refer to the supplemental information when answering this question:
View MR 138093
What E/M coding is reported?
(The patient presents to the emergency department with chest pain. EKG showsNSTEMIand troponin is abnormal. The ED provider discusses the case with a cardiologist and the patient is admitted for heart catheterization/PCI. What is the E/M service and ICD-10-CM coding reported for the ED provider?)
A physician sees a patient for the first observation visit, spends 85 minutes, with moderate MDM.
What CPT® code is reported?
A patient in a radiology facility has an X-ray examination of her thoracolumbar junction due to pain while playing golf. The patient also has limited mobility in the hip. A radiologist takes a two view of the thoracolumbar junction.
What CPT® code 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?
Which place of service code is submitted on the claim for a service that is performed in a skilled nursing facility?
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?
Mrs. Wilder presents with right and left leg swelling. Venous thrombosis imaging of each leg is done and shows deep venous embolism and thrombosis in each leg.
What CPT® and ICD-10-CM codes are reported?
(A provider orders a liquid chromatography mass spectrometry (LC-MS) definitive drug test for a patient suspected ofacetaminophen (analgesic) overdose. What CPT® code is reported for the test?)