COC 2020 - FINAL EXAM STUDY QUESTIONS (SET 3)
A patient presented to the ED with an apparent acute MI. He is immediately taken to the cardiac cath lab where diagnostic coronary angiography with left ventriculography was performed. There was an acute total occlusion of the first diagonal of the LAD, and 80% stenosis of the left main coronary artery and 75% stenosis of the proximal left anterior descending coronary artery. The decision was made to stent the left main coronary artery, and the proximal LD. Aspiration thrombectomy was performed in the first diagonal of the LD and a stent was placed. IVUS was used in the diagonal to confirm adequate stent expansion. What CPT ® codes are reported?
93458-59, 92941-LD, 92928-LM, 92978
A patient presents to the outpatient hospital facility. A physician performs a complete bilateral transcranial Doppler study of the intracranial arteries, with a copied analysis placed in the patient's medical records. The patient has a seizure disorder due to a severe head injury he suffered six months ago. The physician supervises the procedure and interprets the results in the local hospital. What CPT® and ICD-10-CM codes are reported by the facility?
93886, R56.1, S09.90XS
A patient is referred to the hospital radiology clinic for numbness and tingling in the arms. The radiologist performs a Doppler analog waveform analysis, a volume plethysmography and a flow velocity signal of the arteries of both arms. What procedure and diagnosis codes are reported for the facility services?
93922, R20.0, R20.2
A patient was seen in the allergy clinic at the local hospital for follow-up of allergy testing. Three intradermal tests with allergenic extracts (delayed type reaction) were administered and results were interpreted. How are these services reported?
95028 x 3
A patient presented to the hospital outpatient facility for chemotherapy for breast cancer. Report only the infusion services. Do not report the drugs. (Hydratione per protocol/500cc/10:00AM-11:00AM; Taxol 35 mg/11:00AM-12:45PM;Decadron 10 mg;10:45-11:15 IV drip concurrent; Aloxi 250 mcg/10:45-11:15 mixed w/Decadron in concurrent IV drip)
96413, 96415, 96368, 96361-59
A patient was seen in the emergency department after falling down an embankment while hiking at a local park. The patient suffered abrasions on his left lower leg, which needed to be debrided due to rock, grass and soil being embedded into the abrasions. Debridement, using wet to moist dressings, without anesthesia was performed, along with silvadene application, wound assessment and dressings applied to the area. The patient was given instructions for care of the wounded area and released home in good condition. Report the CPT ® and ICD-10-CM for the facility service.
97602, S80.812A, W17.81XA, Y92.830, Y93.01
A patient presents to the ED with puncture wounds on the right forearm from a dog bite. The dog was not wearing a collar. The ED physician cleans the wound, gives a rabies vaccination in the deltoid region (IM), and administers human rabies immunoglobulin (RIg) IM. The ED visit is a mid-level visit. What CPT® and ICD-10-CM codes are reported by the facility?
99283-25, 90675, 90471, 90375, 96372, S51.809A, Z23, W54.0XXA
A patient presents to the local ambulatory surgical center for a scheduled dilation of the esophagus. After being prepped and draped, anesthesia was administered. A bougie dilator is used. The surgeon passes the dilator into the patient's throat down into the esophagus until the end of the dilator passes the stricture. The dilator is withdrawn after it passes the stricture. This is repeated four times with incrementally larger dilators. The surgeon evaluates the esophagus and feels that it is now at an acceptable size. The procedure is terminated and the patient is sent to recovery in stable condition. What CPT® and ICD-10-CM codes are reported?
43450, K22.2
A patient presents to the ASC for a scheduled dilation of the esophagus. After being prepped and draped, anesthesia was administered. An unguided dilator is used. The surgeon passes the dilator into the patient's throat down into the esophagus until the end of the dilator passes the stricture. The dilator is withdrawn after it passes the stricture. As the surgeon prepares to insert the dilator again, the patient begins to seize on the operating table. The procedure is terminated and the patient stabilized before being sent to recovery in stable condition. What are the correct procedure and diagnosis codes for this encounter?
43450-74, K22.2, R56.9
A patient presents to outpatient surgery department for freeing of intestinal adhesions to correct an internal hernia. Documentation states that under anesthesia, the surgeon placed a trocar at the umbilicus into the abdominal cavity and insufflated the area. A laparoscope was placed through the umbilical incision and additional trocars were placed. Intestinal adhesions were identified tangled with a loop of small bowel. Dissection and gentle removal of the adhesions were performed releasing the small internal hernia showing viable pink bowel. The trocars were removed and the incision was closed with sutures. What CPT® code is reported for the procedure?
44180
A patient was referred to Observation from his doctor's office. After workup, it was determined that the patient had appendicitis and three hours later he underwent a laparoscopic appendectomy (44970, status indicator T) and was later discharged. Report the facility services.
44970
A patient underwent a colonoscopy, where the gastroenterologist biopsied three polyps from the colon. Each polyp was sent to pathology as separately identified specimens. The gastroenterologist was requesting a pathology consult while the patient was still on the table. Tissue blocks and frozen sections were then prepared and examined as follows: Specimen 1: First Tissue Block—Three Frozen Sections Second Tissue Block—One Frozen Section Specimen 2: First Tissue Block—Two Frozen Sections Second Tissue Block—One Frozen Section Specimen 3: Single Tissue Block—Three Frozen Sections How should these services be reported?
88331 x 3, 88332 x 2
A patient undergoes an arthrocentesis. The fluid is sent to the lab for analysis . The physician suspects an infection; he orders a cell count of the fluid. What CPI® code is reported?
89050
A patient who underwent a cardiac catheterization last week for CAD and chest pain was subsequently admitted to outpatient surgery. The procedure performed was a PTCA on the left anterior descending coronary artery and stent placement in the left circumflex coronary artery for atherosclerosis. All these services were performed during the same operative session. Report the CPT ® and ICD-10-CM codes.
92928-LC, 92920-LD, I25.10
A patient with a history of coronary artery disease underwent a transesophageal echo study. A transesophageal probe was placed, 2D images acquired and interpretation and report performed by a cardiologist who is not employed by the facility. How are these services reported by the facility?
93312
A patient was seen in the outpatient dermatology clinic at the local hospital. His complaints were moderate itching, which then became severe (pruritus). He also noticed small blisters, redness, and swelling of his lower legs. It was documented the patient had come in contact with poison ivy. The patient was diagnosed with allergic contact dermatitis due to poison ivy. Hydroxyzine HCl 25 mg tablets and Temovate 0.05% cream was prescribed. The patient was instructed to call with any problems. What diagnosis code(s) are reported for this encounter?
L23.7
A patient is diagnosed with pressure ulcers on each heel. Each heel displays bone involvement with evidence of necrosis and is identified as stage 4. Select the diagnosis code(s):
L89.614,L89.624
A patient presents to the hospital-based clinic in her 15th week of pregnancy with cramping, cervix dilated to 2 cm, and a bulging amniotic sac. The physician confirms a spontaneous abortion is inevitable and decides to manage the patient expectantly with monitoring. How is this coded?
An appropriate E/M code
A patient is having a decompression of the nerve root involving two segments of the lumbar spine via transpedicular approach. Report the CPT® code(s).
63056, 63057
A patient presented to outpatient radiology with a 90% lesion of the right iliac, and 85% lesion in the right popliteal artery. From a right femoral artery access, atherectomy was performed in the iliac artery, and angioplasty followed by stent placement was performed in the popliteal artery. What CPT ® codes are reported?
0238T-RT, 37226-RT
A patient with a 4.1 cm infected sebaceous cyst on the back and a 2.5 cm infected sebaceous cyst on the neck undergoes surgical excision in the local hospital's outpatient-surgery department. The patient was placed in the prone position, the back and neck were prepped. Sterile towels were applied, and Marcaine was injected subcutaneously in a linear fashion transversely over each of the cysts asynchronously. Additional local anesthetic was administered. The lower cyst was excised; however, because of recent inflammation that was adherent to the adjacent tissues, the cyst wall was rigorously dissected. The cavity was irrigated, and the skin edges were loosely reapproximated with a suture. An incision was made transversely across the other cyst and it was completely excised as well. The wound was irrigated and packed with Iodoform and dressings applied. The patient tolerated the procedure well. Provide the procedure code(s) and diagnosis code for this encounter.
11406, 11423, L72.3
A patient presents to the hospital-based ambulatory surgery center for skin grafts due to previous third-degree burns on the abdomen. Burn eschar is removed from the abdomen and the defect size at that time measured 10 cm x 10 cm. An acellular dermal allograft from a donor bank was placed on the defect and sewn into place. What are the correct procedure codes for this service?
15002, 15273
A patient was admitted to the ASC for corrective surgery of a keloid scar on the left hand due to a burn experienced in a grass fire one year ago. Radical excision of the scar was carried out and the defect was covered with a full-thickness graft of 40 sq. cm taken from the upper arm. The patient was discharged in good condition, to be seen in the physician's office in two weeks. What codes are reported for this procedure?
15240, 15241, 15004, L91.0, T23.002S, X01.0XXS
A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT code is reported for this service?
20206
A patient is seen in the outpatient clinic for pain and the physician gives a series of 6 injections for the following muscles on the right side of the back: the rhomboid (1), trapezius (3), and latissimus dorsi (2). Report the CPT® code(s) for the trigger point injections.
20553
A patient with a left complete, chronic, nontraumatic rotator cuff tear is in the outpatient surgery department of the hospital. An arthroscopic subacromial decompression is performed along with a mini-open rotator cuff repair. What are the correct CPT ® procedure and ICD-10-CM codes for this service?
23412, M75.122
A patient presented to the emergency department with complaint of left wrist pain due to an imbedded foreign body (thorn entered while trimming bushes, at home, in his backyard). The provider incises the area and dissects the tissue to locate the thorn. The thorn was located deep in the tissues of the wrist. The emergency department physician proceeded to remove the thorn without complication and performs a layered closure. Code this scenario.
25248, S61.542A, W45.8XXA, Y92.017, Y93.H2
A patient presented to the hospital outpatient pulmonary clinic for asthma follow-up. During the encounter, the physician performed an expanded problem focused history and exam with moderate decision making for this established patient. The documentation supported a low-level E/M for the facility. Later in the evening, the patient suffered an acute asthma attack and went to the ER in the same hospital for treatment. What modifier is used to indicate multiple E/M services occurred on the same date?
27
A patient presented with a right ankle fracture. After induction of general anesthesia, the right leg was elevated and draped in the usual manner for surgery. A longitudinal incision was made parallel and posterior to the fibula. It was curved anteriorly to its distal end. The skin flap was developed and retracted anteriorly. The distal fibula fracture was then reduced and held with reduction forceps. A lag screw was inserted from anterior to posterior across the fracture. A 5-hole 1/3 tubular plate was then applied to the lateral contours of the fibula with cortical and cancellous bone screws. Final radiographs showed restoration of the fibula. The wound was irrigated and closed with suture and staples on the skin. Sterile dressing was applied followed by a posterior splint. What CPT code is reported?
27792-RT
A patient suffered from an injury to the lateral plantar nerve of the right foot, which later developed into a Morton's neuroma. The surgeon performs an excision of the neuroma.
28080, G57.61, S94.01XS
A patient was brought into the ED following accident. The Pt suffered a humerus fracture, which required care and is reported with CPT 23620 (APC assignement of 5111 w/a status indictor of T). The Pt also suffered a break to the forearm and a cast was applied to provide support until th ePt could be seen by an orthopedic surgeon for potential surgery. The CPT code reported was 29075 (APC assignment of 5102 with a status indicator of T). How will the procedures be reimbursed under the OPPS?
29075 (status indicator T) will be reimbursed 100%, 23620 (status indictor T) will be reduced by 50%)
A patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. Under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure. What CPT ® and ICD-10-CM codes are reported?
31830, L90.5, Z43.0, Z99.11
A patient was in the emergency room complaining of shortness of breath, and chest pain. The ER physician called in the cardiologist who, after completing a battery of diagnostic tests, determined the patient needed a pacemaker. The patient was taken to the outpatient surgery department where the surgeon inserted a pacemaker with a transvenous electrode in the atrium and ventricle for paroxysmal supraventricular tachycardia.
33208, I47.1
A patient was scheduled for cerebral carotid angiography. The risks, benefits, and alternative of the procedure were explained to the patient. An informed consent was obtained. The risks outlined included, but were not limited to, that of temporary or permanent neurologic sequelae, infection, and hematoma. After the usual sterile preparation of the patient's right arm, a catheter was advanced into the ascending aorta. Its tip was positioned just above the aortic valve and digital run of the arch vessels was performed. The catheter tip was then selectively placed into the proximal left common carotid artery. Digital imaging was performed over the head and neck to complete the angiography. It was decided not to inject on the right side since prior MRI showed significant stenosis on the right side. The catheter was then withdrawn and compres sion was applied until hemostasis was achieved. 45 percent stenosis of the left internal carotid was documented. The intra cerebral vessels were normal. Code for the selective catheterization and cerebral carotid angiography, and the diagnosis.
36223-LT, 165.23
A patient is sent to the hospital for a bone marrow needle biopsy. The specimen is sent to the lab in the hospital for interpretation. The diagnosis is thrombocytopenia. What CPT ® and ICD-10-CM codes are reported by the facility?
38221, 88305, D69.6
A patient returns to the OR five days after a glossectomy and lymph node sampling for oral cancer in the soft palate. The pathology report indicated spread of the neoplasm into lymph nodes in the suprahyoid area. A suprahyoid lymphadenectomy is performed on both sides of the neck. What CPT ® and ICD-10-CM codes are reported?
38700-50, C77.0, Z85.810
A patient presents to the outpatient hospital facility for a diagnostic ERCP. A stone is discovered in the biliary duct. Sphincterotomy is performed before the stone can be removed. This was performed with radiologic supervision and interpretation with images saved for permanent record and report of imaging. Report the CPT® codes for the facility.
43264, 43262, 74328
A patient with a preoperative diagnosis of hematochezia undergoes a colonoscopy in the hospital outpatient surgery department. After bowel prep and IV sedation the patient was placed in the left lateral position. With multiple repositioning, the colonoscope was advanced under direct vision, probably to the upper ascending colon. She had a very tight curve in the sigmoid colon. Despite all our maneuvers we never were able to get to the cecum. Prep was adequate and mucosal surfaces were adequately visualized and appeared entirely unremarkable. In the distance a floppy ileocecal valve versus mass effect was seen. A barium enema will be arranged for follow-up. The postoperative diagnosis is incomplete negative colonoscopy. Provide the procedure code and diagnosis code for this encounter.
45378-74, K92.1
A patient is seen in the outpatient GI lab of the hospital for a screening colonoscopy. A colonoscopy revealed three polyps in the transverse colon. The polyps were removed by snare technique. What are the procedure and diagnosis codes for this procedure?
45385, Z12.11, D12.3
A patient undergoes hemorrhoid tag removal in the hospital outpatient surgery department. Once prepped and draped, the physician identifies two external hemorrhoid tags and makes the incisions around the lesions. The first one is dissected from the sphincter muscle and removed. The same procedure is performed for the second hemorrhoid tag. Incisions are closed. The patient tolerated the procedure well and was discharged after recovery. What CPT® and ICD-10-CM codes are reported?
46230, K64.4
A patient is seen in the hospital outpatient surgery department for anal fistula repair. The surgeon first explores the anal canal and identifies the location of the fistula. The fistula tract is then excised. The perianal skin is incised and a wedge of skin and subcutaneous tissue is mobilized and advanced into the defect that was created by the excision of the fistula. The incisions are closed with sutures. What are the correct procedure and diagnosis codes for this encounter?
46288, K60.3
A patient is seen in the hospital outpatient surgery department for anorectal fistula repair. The surgeon first explores the anal canal and identifies the location of the fistula. The fistula tract is then thoroughly irrigated. A fistula plug was introduced through the fistula tract ensuring that the plug completely occludes the internal fistula opening. The plug was trimmed to insure a flush fit with the mucosal wall and absorbable sutures were used to secure the plug into place. What CPT® code is reported for the procedure?
46707
A patient was taken to the operating room to remove a bladder tumor measuring 1.5 cm. The physician makes an incision into the skin of the lower abdomen to access the bladder. The bladder is incised and the tumor is removed along with the surrounding diseased vesical tissue. A drain tube is inserted and the wound is closed in layers. What CPT ® and ICD-10-CM codes are reported?
51530, D49.4
A patient is scheduled for closure of a cystostomy. The patient has a personal history of bladder carcinoma. After removing the sutures that secured the cystostomy tube to the skin and bladder, the surgeon removed the cystostomy tube and sutured the bladder musculature to repair the opening. The physician placed a drain tube, brought it out through a separate stab incision in the skin, and performed a layered closure. What CPT ® and ICD-10-CM codes are reported?
51880, Z43.5, Z85.51
A patient presents to the ambulatory surgery center at the local hospital with a diagnosis of left ureteral stones. After being prepped and draped, the surgeon examines the urinary collecting system with a cystourethroscope that was passed through the urethra and into bladder. The surgeon inserts a special instrument through the cystourethroscope to manipulate the calculi found in the ureter. The stones are not removed. The surgeon then inserts a ureteral stent and removes the cystourethroscope. No complications were noted. What CPT ® and ICD-10-CM codes are reported?
52330-LT, 52332-LT, N20.1
A patient underwent an orchiopexy by inguinal approach in the ambulatory surgery center. The diagnosis was torsion of appendix testis. What CPT ® and ICD-10-CM codes are reported?
54640, N44.03
A patient receives an abnormal Pap test result and is scheduled for an endometrial biopsy at the ASC. What procedure code describes an endometrial biopsy without dilation?
58100
A patient is in the hospital for a hysterosalpingogram due to her infertility for 10 years. She has no history of pelvic infection or surgery. A 5-F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Contrast was administered through the catheter and multiple images were taken. Findings were possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation. What are the CPT ® and ICD-10-CM codes reported?
58340, 74740, N97.9
A patient with a new onset of headaches, seizures, and gustatory hallucinations undergoes a cisternal (lateral) cervical puncture with fluoroscopic guidance. The radiology and supervision is performed by a radiologist. The surgeon uses a paramedian approach and inserts a needle through the tissue to obtain cerebral spinal fluid. Temporal lobe epilepsy is suspected. Code the procedure and the diagnoses.
61050, 77003, R51, R56.9, R44.2
A patient with a neoplasm of the left eyeball undergoes surgery at the local hospital in the outpatient surgery department. An incision is made in the frontal scalp area and the scalp is retracted posteriorly and the forehead anteriorly. The frontal bone is cut and removed. The forebrain is retracted until the superior margins of the orbit are visualized. The roof of the orbit is decompressed. Once that is accomplished, the dura is closed and the bone is replaced. The forehead and scalp are re-anastomosed and closed in layers. The neoplasm is benign. Provide the procedure code and diagnosis code for this encounter.
61330, D31.92
A patient suffering from lower back pain presents to her family physician, who orders lumbar myelography for a suspected herniated disc following a physical exam. The patient is sent to the hospital where the radiologist injects contrast material into the patient's subarachnoid space through a percutaneously placed spinal needle. Films of the lumbar spine are obtained and interpreted. What CPT® and ICD-10-CM codes are reported by the hospital?
62304, M54.5
A patient with a herniated cervical disc undergoes a cervical laminotomy with a partial facetectomy and excision of the herniated disc for cervical interspace C3-C4. What CPT® and ICD-10-CM codes are reported?
63020, M50.21
A patient underwent a decompression of the spinal cord involving two segments of the thoracic spine via a costovertebral approach. The patient had experienced a closed traumatic fracture of the T9 vertebra 12 years ago along with a spinal cord injury. As a result, she now has displacement of the thoracic intervertebral disc. The physician made an incision 3 inches lateral to the spine through the fascia, muscles, and the 9th rib on the left side. The physician entered anterior to the transverse process and the pedicle using a Kerrington rongeur. The physician removed the transverse process. The spinal nerve root was decompressed by removing the herniated disk of T8-T9. The wound was filled with saline and a radiologic exam of the spine with three views was performed to assure no air was leaking from the lungs. Tissue was closed with layered sutures and the patient tolerated the procedure well with no complications. Provide the correct procedure and diagnosis codes for this encounter.
63064-LT, 72072, M51.24, S22.079S, S24.103S
A patient receives a paravertebral facet joint injection with fluoroscopic guidance at two levels on both sides of the lumbar spine (L1-L2, and L2-L3) for pain. What CPT® and ICD-10-CM codes are reported?
64493-50, 64494-50, M54.5
A patient receives chemodenervation with Botulinum toxin injections to stop blepharospasms of the right eye. Myobloc ® 0.01 cc (50 unit) is injected. What are the procedure and diagnosis codes?
64612-RT, J0587, G24.5
A patient presents to the hospital outpatient pain management clinic for an appointment for Botox injection for migraine headaches that did not respond to more conservative treatment. This is her third episode of migraine this month. The physician performs a Botox injection for chemodenervation to bilateral facial nerves to relieve the intractable migraine pain. Provide the CPT® and ICD-10-CM code(s) for the facility services.
64615, G43.919
A patient was admitted to observation status after losing control and crashing his motorcycle into the guardrail on the highway. The patient was unconscious and a CT scan of the brain without contrast and CT of the chest without contrast is performed. Studies revealed a fracture of the skull base with no hemorrhage in the brain. There was no puncture of the lungs. Three views of the right and left sides of the rib cage reveal fractures of 2 ribs on the left side. What CPT ® and ICD-10-CM codes are reported by the facility?
70450, 71250, 71110, S02.109A, S22.42XA, V27.4XXA, Y92.411
A patient is in the outpatient radiology department of the hospital for an MRI of the brain to rule out stroke. His symptoms are slurred speech and headache. The ventricles and sulci are seen within the brain. There is no evidence of space-occupying lesion or intracranial hemorrhage. No abnormal extra-axial cerebral fluid collections are identified. Diffusion weighting imaging shows no abnormality. Impression is negative. What CPT ® and ICD-10-CM codes are reported by the facility?
70551, R47.81, R51
A patient with a history of colonic perforation undergoes a CT scan of the abdomen and pelvis in the outpatient radiology department of the hospital for a one-month visit after surgery. There is a nonobstructive bowel gas pattern. No free air in the abdomen. There are small bilateral pleural effusions. The liver is mildly enlarged. The gallbladder is not definitely visualized. The spleen and pancreas appear normal. There are no adrenal masses. The kidneys, ureters, and urinary bladder appear normal. The abdominal aorta is normal in size. There is no adenopathy. An ileostomy or colostomy is present. The bowel loops are nondistended. There is mild ascites. Impression: No evidence of perforation; mild ascites. Provide the procedure code and diagnosis code for this encounter.
74176, Z48.815, R18.8, Z93.3, Z87.19
A patient presents with right upper quadrant pain, nausea, and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders blood tests for albumin; bilirubin, both total and direct; alkaline phosphates; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. Report the CPT ® code(s) for the facility.
80076, 82565
A patient with a history of drug abuse presents to the ED in a coma. Drug screens are ordered for amphetamines, cocaine metabolite, opiates, barbiturates, and synthetic cannabinoids. The laboratory performs single drug class screening for each analyte by multiple analyte rapid test immunoassay kit. Provide the procedure code for this encounter for the facility.
80307
A patient with abnormal growth is given a growth hormone suppression test to determine whether growth hormone (GH) production is suppressed by high blood sugar. He has 4 glucose tests and 4 human growth hormone tests taken before, during, and after drinking glucose solution. What CPT ® code(s) is/are reported by the facility?
80430, 82947
A patient with a sudden weight loss, rapid heartbeat, and nervousness is suspected of having hyperthyroidism. The provider sends the patient to the hospital for TSH and T4 Total lab work. What CPT® and lCD-10-CM codes are reported for the lab work?
84436, 84443, R63.4, R00.0, R45.0
A patient with AIDS presents for follow up care. The total T-cell count is ordered to evaluate any progression of the disease. Report the CPT ® code(s) for the facility.
86359
A patient will be undergoing a transplant and needs (Human Leukocyte Antigen) HLA tissue typing with DR/DQ multiple antigen and lymphocyte mixed culture. How will these services be coded in the facility setting?
86817, 86821
A patient suffering from a staphylococcal B infection is tested for effective treatment with the drug Meth icillin. A sensi- tivity test is performed using agar dilution methodology. What CPI® code(s) is/are reported?
87181
A patient undergoes an appendectomy to remove a diseased appendix . The specimen is sent for gross surgical pathology and microscopic examination. What CPI® code is reported?
88304
A patient who developed a tumor on her right tonsil underwent surgical resection of the tonsils. After the tonsil was removed, the tonsil was sent to the pathologist for gross and microscopic evaluation. The tonsil was sent as a single specimen. How is the service reported?
88309
A patient with a benign neoplasm found in the duodenum was seen in the ASC for snare removal of the neoplasm by UGI endoscopy. What code is reported for this diagnosis?
D13.2
A patient returns to her gynecologist's office to review the results of her ultrasound. She has been experiencing heavy bleeding and painful menstruation. The results of the ultrasound reveal the patient has a uterine fibroid measuring 4.0 cm. Select the diagnosis code(s).
D25.9
A patient is having phacoemulsification ofan age-related nuclear cataract of the left eye. What ICD-10-CM code is reported?
H25.12
A patient presents with pigmentary glaucoma bilaterally, moderate stage on the right, mild stage on the left. Reference ICD-10-CM guideline I.C.7.a.3. What ICD-10-CM code(s) is/are reported?
H40.1312, H40.1321
A patient sees his family practitioner for a muted feeling in his ears. The provider determines there is impacted cerumen in both ears. What ICD-10-CM code(s) is/are reported?
H61.23
A patient with a history of bilateral otitis media is not responsive to medical therapy. Given the history and physical examination, the provider felt he was a candidate for bilateral myringotomy and tubes. The patient went to the ASC for the procedure. The provider's findings were bilateral chronic serous otitis media. What diagnosis code is reported?
H65.23
A patient presents with right ear pain and fever. The provider diagnoses acute otitis media. What ICD-10-CM code(s) is/are reported?
H66.91
A patient sees her provider for spontaneous episodes of vertigo lasting 30 minutes each, fluctuating hearing loss, and tinnitus. The provider performs a hearing test and confirms hearing loss in the right ear. The provider documents the patient has Meniere's disease in the right ear. What ICD-10-CM code(s) is/are reported?
H81.01
A patient is receiving pain management treatment for chronic cervical pain caused by a motor vehicle accident. Report the ICD-10-CM code(s).
G89.21, M54.2, V49.9XXA
A patient is having surgery to repair a recurrent left inguinal hernia without obstruction. What ICD-10-CM code is reported?
K40.91
A patient presents for a liver transplant. The provider documents the patient has Laennec's cirrhosis associated with long term alcohol dependent use. What are the diagnosis codes for this encounter?
K70.30, FI0.20
A patient presents to her physician and tells him she drinks each night when she gets home from work. She asks her physician to recommend an alcohol treatment center because her life has become unmanageable and she wishes to quit drinking. The patient is diagnosed with uncomplicated alcohol dependence. Select the diagnosis code.
F10.20
A patient with a four- year history of eating disorders is seen in the physician's office due to significant weight loss over the past three months. She went from 82 pounds down to 53 pounds due to restricting her food intake. She is diagnosed with anorexia nervosa. Select the diagnosis code(s).
F50.01
A patient is seen in the outpatient clinic for follow-up on hypertension. He also has CKD stage 3. The Pts blood pressure is stable at 138/88. The doctor instructs the Pt to continue with the same doses of Vorvasc. He also writes a script for blood work to be drawn at lab:CBC, BMP.
I12.9, N18.3
A patient presents to the ED with weakness on the left side and aphasia. Tests are ordered and the patient is admitted with a cerebrovascular accident (CVA). What ICD-10-CM code(s) is/are reported?
I63.9
A patient presents with abdominal pain. The physician performs an abdominal ultrasound and discovers the patient has gallstones and inflammation of the gallbladder. Select the diagnosis code(s).
K80.10
A patient sees his primary care provider for chest pain and regurgitation. The provider's diagnosis for the patient is gastroesophageal reflux. What diagnosis code(s) should be reported?
K21.9
A patient sees the nephrologist for a B-12 injection to treat erythropoietin resistant anemia due to stage 3 chronic kidney disease. What ICD-10-CM codes are reported?
N18.3, D63.1
A patient is in outpatient surgery for a laparoscopic oophorectomy for a right ovarian cyst. After admission, the anesthesiologist discovered the patient had an upper respiratory infection and the surgery was cancelled. Applying the coding concept from ICD-10-CM guideline IV.A.I, what is the appropriate ICD-10-CM code selection?
N83.201, J06.9, Z53.09
A patient underwent a high cost procedure in urban Vermont. The charge for the procedure was $12,000. The procedure performed was a reconstruction of an elbow joint. The APC payment rate for this procedure is $3,450.00. Does this procedure qualify for an outlier payment?
NO If yes, what is the outlier payment? If no, why does it not qualify?;$12,000 x .454 = $5,448 (.426 = $5112);$3,450 x 1.75 = $6037.5;$4,325 + $3,775 = $8100 Total Exceeds
A patient was seen in the physician's office and was directly referred to Observation with atrial fibrillation. Decision was made to perform cardioversion (92960 status indicator S), but minutes before defibrillation, the patient went into normal sinus rhythm. After 3 hours in Observation the decision was then made to admit the patient for 2 days for monitoring to test the effectiveness of a new oral medication for atrial fibrillation. Report the CPT ® code(s) and ICD-10-CM code for the outpatient facility.
No outpatient facility charges are filed
A patient was seen in the hospital outpatient department with complaints of chronic coughing and wheezing. The documentation in the medical record indicated, "suspect asthma." Report the ICD-10-CM code(s).
R05, R06.2
A patient sees the physician for chest pain, fever, and cough. The physician orders an X-ray to rule out pneumonia. Applying the coding concept from ICD-10-CM guideline IV.H., which ICD-10-CM code(s) are reported?
R07.9, RS0.9, RO5
A patient visits his primary care physician for complaints of nausea and vomiting. Which option is appropriate to report a diagnosis of nausea and vomiting? Apply the coding concept from ICD-10-CM guideline I.B.9.
Rll.2
A patient is seen in the emergency department to treat a second-degree burn to his right arm (9 percent) and third-degree burns on his chest and left arm (25 percent). Select the diagnosis codes.
T21.31XA, T22.30XA, T22.20XA, T31.32
A patient presented to the emergency department with second degree burns to both forearms, which makes up 9 percent TBSA (Total Body Surface Area). She is three months pregnant, 12 weeks. The burns are not affecting the pregnancy. Select the diagnosis codes.
T22.212A, T22.211A, T31.0, Z33.1
A patient visits the ED for ringing in the ears, nausea, vomiting and drowsiness. During the history taking, the provider learns the patient has been taking 2 aspirins every hour for the last three days. After examination and performing blood tests the provider diagnoses the patient with aspirin poisoning. What ICD-10-CM codes are reported?
T39.011A, H93.13, R11.2, R40.0
A patient was prescribed an antidepressant. She forgot she had taken her pills for the day and took another pill by accident. She is now complaining of dizziness and excessive sweating . Select the diagnosis codes in the correct sequence.
T43.201A, R42, R61
A patient was sent home with a PICC line for Vancomycin treatment at home. He returns to his physician with an infection due to the PICC Line . The infection is determined to be MRSA. Select the diagnosis code(s) in the correct sequence.
T80.218A, A49.02
A patient visits her family provider for her annual wellness exam. The provider notices a suspicious skin lesion on her arm and refers her to a dermatologist. Applying the coding concept from ICD-10-CM guideline IV.P, which ICD-10-CM code(s) is/are reported?
Z00.01, L98.9
A patient with a Pancoast's tumor in the left lung arrives at the oncologist office for chemotherapy . Applying the coding concept from ICD-10-CM guideline I.C.2.e.2., what ICD-10-CM code(s) should be reported? Note: Use the ICD-10-CM Alphabetic Index instead of the Table of Neoplasms to locate the code for a Pancoast's tumor.
ZSl.11, C34.12