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NEW QUESTION # 104 
Refer to the supplemental information when answering this question:
View MR 065174
What E/M code is reported for this encounter?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
To determine the correct E/M code, we need to consider the three key components: history, examination, and medical decision making (MDM).
* History:
* The documentation indicates an expanded problem-focused history. This is supported by the detailed history of present illness, including the patient's description of symptoms, family history, and review of systems with pertinent positives and negatives.
* Examination:
* The examination is also expanded problem-focused. The physician focused on the relevant systems (head, neck, throat) and documented specific findings related to the chief complaint (thyromegaly).
* Medical Decision Making:
* The MDM is straightforward. The physician is evaluating a new problem (bilateral thyroid nodules) with a low level of risk. Although further workup is planned, this alone doesn't automatically increase the MDM complexity.
Based on these components, 99213 is the most appropriate code.
Why other options are incorrect:
* 99212: Requires a problem-focused history and examination, which is less comprehensive than what was documented.
* 99214 and 99215: Require a higher level of MDM (low or moderate complexity) and/or a more detailed examination. The documentation doesn't support this level of service.
References:
* CPT Codes 99211-99215: Office or other outpatient visit for the evaluation and management of an established patient
* 1995 and 1997 Documentation Guidelines for Evaluation and Management Services: These guidelines provide detailed criteria for selecting the appropriate E/M code based on history, examination, and MDM.
* AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.
NEW QUESTION # 105
A patient presents to the surgical suite for a planned sterilization procedure via a bilateral excisional vasectomy.
What is the correct CPTcode and diagnosis code for the service?
- A. 55250, Z30.2
- B. 55250-50, Z30.2
- C. 55250, Z30.012
- D. 55250-50, Z30.012
Answer: A
Explanation:
1. Procedure and CPTCode Selection:
The patient underwent a bilateral excisional vasectomy for sterilization.
CPTCode 55250 represents a bilateral vasectomy with excision, which includes postoperative care. The code already implies a bilateral procedure, so it is not necessary to add the -50 modifier for bilateral designation.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code Z30.2 is used for encounter for sterilization and is the correct code to report for a planned sterilization procedure such as a vasectomy.
Code Z30.012 is specific to encounter for sterilization of a female patient, which does not apply in this male patient scenario.
3. Rationale for Excluding Other Options:
55250-50 (in options C and D) is unnecessary because the CPTcode 55250 inherently covers a bilateral vasectomy, and applying the -50 modifier is redundant.
Z30.012 (options B and D) is incorrect as it pertains to female sterilization procedures, not male.
4. AAPC and CPTCoding Guidelines:
According to AAPC guidelines, 55250 is reported without a bilateral modifier, as the procedure inherently covers both sides. Additionally, Z30.2 is the correct ICD-10-CM code for male sterilization procedures.
Thus, the correct answer based on CPTand ICD-10-CM guidelines is A. 55250, Z30.2.
NEW QUESTION # 106
A patient presents to the ER from a nursing home after the patient was found to have foul smelling, large sacral pressure ulcer during daily nursing rounds. The ER provider swabbed the wound for culture (which measured at 7cm in largest diameter); then cleaned the site before painting with povidone around the entire sacrum to reduce cutaneous bacterial load. The provider made an elliptical excision with 3mm margins around the outer edge of the ulcer and removed the lesion in its entirety.
Further examination revealed deep tissue damage, prompting muscle and
segmental bone removal. The wound was then closed using a layered skin flap closure.
What CPTcoding and ICD-10-CM coding is reported?
- A. 15933, L89.153
- B. 15937, L89.156
- C. 15935, L89.156
- D. 15931, L89.153
Answer: B
Explanation:
In this scenario, the procedure involved the excision of a large sacral pressure ulcer with deep tissue damage that required muscle and bone removal and was followed by a layered flap closure. The coding reflects both the extent of the ulcer and the procedure performed:
1. CPTCode 15937: This code describes excision of a pressure ulcer with muscle and bone removal followed by flap closure, which matches the detailed procedure performed on the sacral ulcer.
2. ICD-10-CM Code L89.156: This code is used for a stage 4 sacral pressure ulcer, indicating the presence of deep tissue damage down to muscle and possibly bone, which aligns with the clinical findings.
Explanation of other options:
A: 15933, L89.153 and B. 15931, L89.153: These codes do not adequately describe the excision with muscle and bone removal nor the stage 4 severity of the ulcer.
C: 15935, L89.156: Although L89.156 is correct for a stage 4 ulcer, 15935 does not account for both muscle and bone excision with flap closure.
Therefore, the correct answer is D. 15937, L89.156, accurately capturing the procedure performed and the severity of the ulcer.
NEW QUESTION # 107
A 62-year-old with ventricular fibrillation comes to the outpatient surgery department for the replacement of a pacing cardioverter-defibrillator. The procedure is performed under MAC anesthesia. The Certified Registered Nurse Anesthetist (CRNA), is working independently without medical direction.
What CPTand ICD-10-CM codes are reported for the CRNA?
- A. 00520-QY, 148.91
- B. 00534-QY, 148.91
- C. 00520-QZ-QS, 149.01
- D. 00534-QZ-QS, 149.01
Answer: D
NEW QUESTION # 108
A 55-year-old patient was recently diagnosed with an enlarged goiter. It has been two years since her last visit to the endocrinologist. A new doctor in the exact same specialty group will be examining her. The physician performs a medically appropriate history and exam. The provider reviewed the TSH results and ultrasound. The provider orders a fine needle aspiration biopsy which is a minor procedure.
What E/M code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
NEW QUESTION # 109
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. 11104, D49.2
- B. 11104,12001-51, L98.9
- C. 11102, 12001-51, D49.2
- D. 11102, L98.9
Answer: C
Explanation:
CPT code 11102 is for punch biopsy of skin, including simple closure. CPT code 12001-51 is for simple repair of superficial wounds, with modifier 51 indicating multiple procedures. ICD-10-CM code D49.2 is used for a neoplasm of unspecified behavior of the bone, soft tissue, and skin. This coding accurately reflects the punch biopsy and simple repair performed on the lesion.References: AMA's CPT Professional Edition (current year), ICD-10-CM (current year)
NEW QUESTION # 110
Regarding the CPTSurgery Guidelines for a surgical code designated as a "Separate Procedure", which statement is FALSE?
- A. A service that is commonly carried out as an integral component of a total service or procedure is identified by the inclusion of the term "separate procedure."
- B. To identify a service designated as a "separate procedure" that is reported with an unrelated primary service, append modifier 79 to the code.
- C. When a procedure is designated as a separate procedure and carried out independently or considered to be unrelated from the total primary service, it may be reported.
- D. The codes designated as "separate procedure" should not be reported in addition to the code for the total procedure or service of which it is an integral component.
Answer: B
Explanation:
In CPTSurgery Guidelines, a "separate procedure" code is used to identify a service that is typically performed as part of a larger procedure and should not be coded separately when it is an integral component of that primary service. However, it may be reported independently if it is performed alone or is unrelated to the primary procedure.
A: is true because a separate procedure may be reported if it is performed independently or is unrelated to the primary procedure.
B: is true, as "separate procedure" codes are not reported in addition to the code for the primary procedure when they are part of the total procedure.
C: is correct because "separate procedure" designation indicates that the service is often part of a more comprehensive procedure but can be reported separately when performed alone.
D: is false because modifier 79 is not used for unrelated "separate procedures." Instead, modifier 59 is typically used to indicate a "distinct procedural service" when reporting a separate procedure that is unrelated to the primary service.
Therefore, the correct answer is D. To identify a service designated as a "separate procedure" that is reported with an unrelated primary service, append modifier 79 to the code.
NEW QUESTION # 111
The CPT code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.
What is the full description of CPT code 69644?
- A. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction
- B. Without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
- C. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
- D. With intact or reconstructed canal wall with ossicular chain reconstruction
Answer: A
Explanation:
CPT code 69644 refers to a tympanoplasty with mastoidectomy, which includes canalplasty, middle ear surgery, and tympanic membrane repair. The specific procedure described by this code is performed with an intact or reconstructed canal wall and includes ossicular chain reconstruction. The use of a semicolon in the CPT description helps distinguish between different variations of the procedure.References: AMA's CPT Professional Edition, specific code descriptions and guidelines.
NEW QUESTION # 112
An established patient suffering from migraines without aura, no mention of intractable migraine, and no mention of status migrainosus, is seen by his ophthalmologist who conducts a visual field examination of both eyes. The examination was accomplished plotting four isopters utilizing the Goldmann perimeter testing method. The patient and requesting physician receive the interpretation and report on the same date of service.
What procedure and diagnosis codes are reported for this encounter?
- A. 92083, G43.019
- B. 92082, G43.009
- C. 92081, G43.009
- D. 92082, G43.019
Answer: B
NEW QUESTION # 113
Patient is diagnosed with dacryocystitis, which is the inflammation of?
- A. Fingernail
- B. Eardrum
- C. Cornea
- D. Lacrimal sac
Answer: D
Explanation:
Dacryocystitis is the inflammation of the lacrimal sac, which is part of the tear drainage system located in the inner corner of the eye. The lacrimal sac is connected to the nasolacrimal duct, which drains tears into the nasal cavity. Inflammation in this area can cause pain, redness, and swelling near the inner corner of the eye.
References: ICD-10-CM, medical dictionaries
NEW QUESTION # 114
A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.
How does each surgeon report their portion of the surgery?
- A. 63087-62, 63088-62
- B. 63090-66, 63091-66
- C. 63090-80, 63091-80
- D. 63085-62, 63086-62
Answer: D
NEW QUESTION # 115
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. 0
- B. 1
- C. 2
- D. 3
Answer: A
NEW QUESTION # 116
A cardiologist uses the hospital's equipment for a cardiac stress test as he doesn't own equipment for the test. He supervises the test and provides the interpretation and report of the test.
What CPT codes are reported?
- A. 93016, 93018
- B. 93015, 93016
- C. 93016, 93017, 93018
- D. 93015, 93018
Answer: D
NEW QUESTION # 117
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?
- A. R91.8, C56.9, C78.7
- B. D38.1, C56.9, C78.7
- C. C56.9, C78.7, C78.02
- D. C78.02, C22.9, C79.82
Answer: A
NEW QUESTION # 118
A business requires drug testing for cocaine and methamphetamines prior to hiring a job candidate. A single analysis with direct optical observation is performed, followed by a confirmation for cocaine.
Which codes are used for reporting the testing and confirmation?
- A. 80306 x 2, 80353
- B. 80305 x 2, 80353
- C. 80305, 80353
- D. 80306, 80375
Answer: C
NEW QUESTION # 119
A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting technique was used to repair the eardrum with ossicular chain reconstruction.
What CPTcode is reported for this surgery?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
1. Procedure and CPTCode Selection:
The procedure involves a tympanoplasty with a radical mastoidectomy to remove a cholesteatoma in the middle ear. Additionally, the procedure includes ossicular chain reconstruction and grafting to repair the eardrum.
CPTCode 69646 is appropriate for tympanoplasty with a radical mastoidectomy, including removal of the cholesteatoma and ossicular chain reconstruction. This code accurately describes the combination of tympanoplasty, radical mastoidectomy, and ossicular chain reconstruction, making it the correct choice.
2. Rationale for Excluding Other Options:
Code 69643 describes a tympanoplasty with a simple mastoidectomy, which is not appropriate since a radical mastoidectomy was performed.
Code 69645 covers a tympanoplasty with radical mastoidectomy but does not include ossicular chain reconstruction, which was part of this procedure.
Code 69641 is for a tympanoplasty without mastoidectomy, making it incorrect for this case.
3. AAPC and CPTCoding Guidelines:
According to AAPC and CPTguidelines, 69646 is the appropriate code when a tympanoplasty includes a radical mastoidectomy with ossicular chain reconstruction, as documented in this case.
Therefore, the correct answer based on CPTguidelines is D. 69646.
NEW QUESTION # 120
A 1-year-old is with his mom to have his scheduled vaccinations. The physician provides counseling for routine immunizations and carries out measles, mumps, rubella and varicella (MMRV) subcutaneously and dose 3 of Hepatitis B intramuscularly without difficulty.
What CPTcodes are reported?
- A. 90460 x 2, 90461 x 3, 90710, 90744
- B. 90471, 90472, 90707, 90746
- C. 90471, 90472 x 4, 90707, 90746
- D. 90460, 90461, 90710, 90744
Answer: A
Explanation:
1. Procedure and CPTCode Selection:
The physician administered the MMRV (measles, mumps, rubella, and varicella) vaccine subcutaneously and dose 3 of Hepatitis B vaccine intramuscularly. The physician also provided counseling on routine immunizations.
CPTCode 90460 is used for immunization administration with counseling by the physician for patients 18 years or younger for the first or only component of each vaccine.
CPTCode 90461 is used for each additional component in a vaccine with counseling.
90710 is the code for the MMRV vaccine.
90744 is the code for the Hepatitis B vaccine (pediatric).
2. Application of 90460 and 90461:
For the MMRV vaccine (which has four components: measles, mumps, rubella, and varicella), 90460 is reported once for the first component, and 90461 is reported three times (once for each additional component).
For the Hepatitis B vaccine, 90460 is reported again since it is a separate vaccine with one component.
3. Rationale for Excluding Other Options:
Option A (90471, 90472 x 4, 90707, 90746) uses codes for vaccine administration without counseling and incorrect vaccine codes (90707 for MMR instead of MMRV and 90746 for adult Hepatitis B instead of pediatric).
Option B and Option D also contain incorrect vaccine codes and do not correctly apply the counseling administration codes.
4. AAPC and CPTCoding Guidelines:
According to AAPC guidelines, 90460 and 90461 are the appropriate administration codes for vaccines with counseling provided to pediatric patients, with each component of a multi-component vaccine coded separately.
Therefore, the correct answer is C. 90460 x 2, 90461 x 3, 90710, 90744.
NEW QUESTION # 121
The human shoulder is made of which three bones?
- A. Clavicle, scapula, humerus
- B. Metatarsal, tibia, navicular
- C. Olecranon, radius, ulna
- D. Carpal, radius, humerus
Answer: A
Explanation:
The human shoulder is composed of three main bones: the clavicle (collarbone), scapula (shoulder blade), and humerus (upper arm bone). These bones form the shoulder joint, which is one of the most flexible and mobile joints in the human body, allowing for a wide range of motion.References: AMA's CPT Professional Edition (current year), Musculoskeletal System section.
NEW QUESTION # 122
A patient is diagnosed with diabetic polyneuropathy.
Using ICD-10-CM coding guidelines, what ICD-10-CM coding is reported?
- A. E11.42
- B. E11.9, G62.9
- C. E10.9, G62.9
- D. E10.42
Answer: A
Explanation:
Diabetic polyneuropathy is coded as E11.42, which indicates type 2 diabetes mellitus with diabetic polyneuropathy. The ICD-10-CM guidelines direct that when a patient has both diabetes and polyneuropathy, a single combination code is used to capture both conditions.References: ICD-10-CM (current year), Chapter
4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89), ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.4.a.6.
NEW QUESTION # 123
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
- A. J9312 x 80, 00163 x 2
- B. J9312, J1200
- C. J9312, Q0163
- D. J9312 x 80, J1200 x 2
Answer: B
Explanation:
The patient with malignant lymphoma is administered Rituximab (800 mg) and Benadryl (100 mg) intravenously.
* Procedure Description:
* Administration of Rituximab (800 mg) intravenously.
* Administration of Benadryl (100 mg) intravenously.
* HCPCS Level II Coding:
* J9312: Injection, Rituximab, 10 mg.
* For 800 mg, report 80 units of J9312.
* J1200: Injection, Diphenhydramine HCl, up to 50 mg.
* For 100 mg, report 2 units of J1200.
References:
* HCPCS Level II Code Book (current year).
* HCPCS Level II coding guidelines for intravenous drug administration.
NEW QUESTION # 124
A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.
What CPT coding is reported?
- A. 0
- B. 1
- C. 36253, 75625-26
- D. 36252, 75625-26
Answer: B
NEW QUESTION # 125
A 5-year-old who has an allergy history experienced a possible reaction to peanuts. A quantitative, high-sensitive fluorescent enzyme immunoassay was used to measure specific IgE for recombinant peanut components. Results showed there was no reaction indicating the child has a peanut allergy.
What lab test is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
Explanation:
For the quantitative, high-sensitive fluorescent enzyme immunoassay used to measure specific IgE for recombinant peanut components, the correct lab test code is 86003. This code is specific to quantitative allergen-specific IgE testing.
References:
* AMA's CPT Professional Edition (current year)
NEW QUESTION # 126
A 57-year-old woman with a physical status of 3 received general endotracheal anesthesia for a panniculectomy. The anesthesiologist personally performed the entire anesthesia service.
What CPT@ coding is reported for the anesthesia?
- A. 00800-AA-P3
- B. 00802-AA-P3
- C. 00800-P3, 99140-P3
- D. 00802, 99140-AA-P3
Answer: A
Explanation:
To code for anesthesia services, we select the correct CPTanesthesia code based on the procedure, modifiers, and physical status of the patient:
00800 represents "Anesthesia for procedures on the lower abdomen not otherwise specified," which includes procedures like a panniculectomy. The code 00802 is not appropriate here because it is used for lower abdominal procedures involving "major lower abdominal vessels," which does not apply to a panniculectomy.
AA Modifier indicates that the anesthesia services were personally performed by the anesthesiologist, as stated in the scenario.
P3 Modifier reflects a physical status of 3, which indicates a patient with a "severe systemic disease," matching the patient's documented condition.
The emergency modifier 99140 is not appropriate here, as there is no indication that the procedure was performed under emergency conditions.
Thus, the correct answer is 00800-AA-P3.
NEW QUESTION # 127
A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.
That lab test is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
Explanation:
* Procedure: Albumin Cobalt Binding (ACB) test to determine ischemic nature of chest pain.
* CPT Code:
* 83857: This code is used for the Albumin Cobalt Binding test.
* Code Selection Justification: The ACB test specifically measures ischemia-modified albumin, making
83857 the appropriate code for this laboratory test.
References:
* AMA CPT Professional Edition (current year)
* ICD-10-CM (current year)
* HCPCS Level II (current year)
NEW QUESTION # 128
The mediastinum is:
- A. A small endocrine organ behind the heart
- B. A location in the chest, bounded by the sternum, diaphragm, and lungs
- C. A part of the lymphatic system
- D. Both the heart and lungs
Answer: B
Explanation:
The mediastinum is an anatomical region located in the thoracic cavity. It is bounded by the sternum in front, the vertebral column at the back, and is situated between the lungs. It contains the heart, trachea, esophagus, thymus, and other structures, but it is not itself an organ. Therefore, the correct answer is that it is a location in the chest.References: ICD-10-CM, Medical Anatomy and Physiology textbooks
NEW QUESTION # 129
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