CPC Mock Exam 1

Ulcer at the second MPJ was circumscribed and removed in toto. An Apligraft skin graft was prepared, cut, and sutured into place. 15155 15240 15441 15156

15155

Chronic wound ont the right thigh. FTSG was obtained from the opposite thigh and placed on the 4 x 4 cm wound of the right thigh. 15220 15040, 15200 15120 15200

15220

A left curvilinear breast incision was made and tissue divided down to the firm palpable mass. A silk retraction suture was placed through the area in question and dissection performed to remove the spherical-shaped 5 cm tissue sample. 19125-LT 11420 19101-LT 19120-LT

19101-LT

U/S-guided needle localization of right breast lesion. Excisional biopsy of right breast lesion; lesion sent to pathology revealed fibroadenoma of the right breast. 19120-RT 19125-RT 19281 19125

19125-RT

Left heart catheterization with left ventriculogram and right coronary vessels to perform PTCA right coronary and left circumflex. Intracoronary stent right coronary x2, left circumflex x1, left descending vessel x1 93458, 92920-LC, 92921-RC, 92928-RC, 92929-LC, 92929-LC 92928-RC, 92929-LC, 92929-LD, 92921-RC, 92921-LC 92928-RC, 92929-LC, 92929-LD 93458, 92928-RC, 92929-LC, 92929-LC

92928-RC, 92929-LC, 92929-LD As the left heart catheterization is the "approach" by which the interventional procedures are performed, it would not be codeable. Therefore, 92928 is assigned for right coronary (only one per vessel), 92929-LC for left circumflex, and 92929-LD for left descending.

Nerve conduction studies, two studies 95905 95907 95907 X2 95908-52

95907

Bronchoscope inserted through right nostril. Nasopharyngeal mucosa normal; vocal cords and trachea normal. There were moderate, thick mucoid secretions from the trachea that was suctioned. Right main bronchus appeared normal. Washings from the right lower lobe were obtained and sent to microbiology. 31624 31623 31625 31622

31622

Patient presented for diagnostic bronchoscopy for possible lung nodule on radiological study. The scope was advanced into the right middle and lower lobe, where a biopsy was obtained of a suspicious nodule. 31628 31632 31625 31623

31625 Bronchoscopy was performed with biopsy, which codes to 31625. Code 31628 is for transbronchial biopsies, which were not performed in this instance.

A patient with Paget's disease of the bone receives an intravenous infusion of Aredia that begins at 12:29 PM and ends at 4:11 PM. Code this drug administration service. 96365, 96366, 96366, 96366 96365, 96366 x3 96365 x2 96365

96365, 96366 x3

Bronchoscopy performed with transbronchial biopsies—two biopsies to the right upper lobe and two biopsies to the left lower lobe. 31628 x2, 31632 x2 31632, 31628 31628 31625

31632, 31628 Transbronchial biopsies are assigned codes based on each lobe; therefore, 31628 should be assigned for the first lobe and 31632 for the additional lobe.

Blood transfusion 36420 36416 36430 36415

36430

A 36-year-old presents for tonsillectomy. Tonsils were grasped with Allis forceps, and tonsil was bluntly dissected free. Identical procedure was performed on the other tonsil as well. The nasopharynx was viewed, and considerable amount of adenoidal tissue was also removed. 42820 42825 42860 42821

42821

Tonsillectomy/adenoidectomy, age 20 42821 42825 42820 42826

42821

Digital rectal exam was performed, and no masses were palpable. Scope was introduced to the cecum. The scope was withdrawn, and there were several areas of liquid stools at various stages. In the sigmoid region, there were two polyps adjacent to each other, both less than 5 mm which were hot biopsied and sent to pathology. 45380 45384 45380, 48384-51 45384 x2

45380 Colonoscopy was performed with multiple biopsies, therefore 45380 would be appropriate. The hot biopsy polypectomy code (45384) is only appropriate if the polyp, lesion, tumor is excised.

When multiple biopsies are performed at four different sites during the course of a colonoscopy, what code(s) should be reported? 45380, 45380-51, 45380-51, 45380-51 45380 X 4 45380 once only 45380, 45380-59, 45380-59, 45380-59

45380 once only

Craniofacial approach to the anterior cranial fossa, extradural with resection of lesion of anterior cranial fossa, extradural 61601, 61581-51 61601, 61581-51, 61618-51 61600, 61581-51 61600, 61580-51

61600, 61580-51

Cervical laminoplasty to four vertebral segments 63050 x4 63050 22842, 63045, 63050 22600, 63051-51

63050

A 45-year-old man presents with severe neck pain. The physician examines the patient and makes the diagnosis of cervical nerve impingement and injects an anesthetic agent into the cervical plexus using three injections. 64405 64413 x3 64400 x3 64413

64413 Injection into the cervical plexus is assigned code 64413 as the three injections are considered one procedure.

Removal of impacted cerumen by surgical instrumentation 69205 69210 69200 69209

69210

Bilateral microscopic ear examination and removal of bilateral cerumen impactions. Utilizing the ear speculum and surgical forceps, the external canal was cleared of impacted cerumen by surgical forceps. 69210-50 69209-50 69200-50 69209

69210-50

Radial incision was made in the posterior quadrant of the left and right tympanic membrane. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears under general anesthesia. 69436 69433, 69433-50 69436-50 69421, 69421-50

69436-50

CT brain is performed with and without contrast. 70480 70450 70470 70482

70470

MRI chest 71555 71551 71552 71550

71550

X-ray, hip with pelvis, 2 V, left 73501 73521 73500 73502-LT

73502-LT

Abdomen flat/upright, 2 V. Punctate pelvic phleboliths on the left just below the level of the ischial spine. Deformity in left lateral iliac crest, exostoses/bone process versus postbiopsy site. 74010 74019 74150 74018

74019

Renal ultrasound. Small area of echogenicity with shadowing in the midleft kidney that could represent a small calculus. Exam of right kidney is negative. Urinary bladder is not visualized. 76775 76700 76776 76706

76775

Left and right mammogram for benign fibrocystic breast disease 77051 77055-RT-LT 77065 77066

77066

A 69-year-old Medicare patient presents for annual mammogram, indicating she is leaving for an extended trip and would like her screening mammogram performed before the one-calendar-year period. Assign the appropriate CPT code(s) for this service. 77065 77063 77066-GA 77067-GA

77067-GA

Radiation treatment, two treatment areas, 20 MeV 77427 77407 77412 77425

77407 Code 77407 assigned for radiation treatment to two treatment areas, 20 MeV from radiation oncology section, radiation treatment category

Basic metabolic panel with ionized calcium 80050 80048 80047 80053

80047

BMP with total calcium 80053 80048 80050 80047

80048

Acute hepatitis panel 80074 80061 80069 80076

80074

PTT (thromboplastin time, partial), whole blood 85810 85732 85999 85730

85730

Surgical pathology, oophorectomy, non-neoplastic 88307 88305 88304 88300

88305

Surgical pathology submitted to the pathologist is as follows: three surgical specimens taken from a liver biopsy. 88305 88307 x3 88307 88305 x3

88307 Code 88307 only is assigned for the liver biopsy, as each specimen was not individually identified.

Psychotherapy, 45 minutes, office 90833 90834 90812 90836

90834

Psychotherapy, 45 minutes, outpatient office 90834, 90836 90838 90834 90836

90834 Code 90834 should be assigned for 45 minutes of psychotherapy.

Gastric motility study 91010 91013 91020 91030

91020

New office visit for patient with lupus with kidney disease, edema with cardiac problems. History was problem focused for this visit. Exam encompasses skin, CV, renal, neurovascular systems. Significant PMH and PHF of lupus and cardiac disease. No tests are ordered or interpreted, management/treatment options are moderate as well as risk. 99213 99201 99204 99203

99201 As this is a new office visit, all three elements (history, exam, and medical decision making) are required. As the history was problem focused only, the level of service would be limited to 99201.

A 17-year-old presents for his initial visit with complaints of left knee pain after playing football. An expanded problem-focused history and exam were performed with straightforward MDM. 99201 99202 99213 99212

99202

New patient presents with neck and back pain worsening over the past year. Pain is worse when she bends, relieved sometimes by ibuprofen. Positive aches and weakness in her muscles, tingling and numbness in arms and hands. She also reports headaches. All other systems reviewed and negative. PMH Hysterectomy, Social, recently divorced. Exam performed of eyes, ENT, respiratory, CV, GI, MS, Neur, and VS, pulse and temperature also performed. She was given prescription and set up for an MRI and physical therapy. What E/M should be assigned for this service? 99214 99204 99244 99203

99203

Patient presents for follow-up for her hypertension. She is seen by another physician in the same practice. BP, pulse, and temp are taken. Chest is clear. Cardiac normal sinus rhythm. There are no new problems and her hypertension appears to be stable. MDM is straightforward. What E/M service would be assigned? 99202 99212 99201 99213

99212

Patient admitted to observation care at 11:00 PM for chest pain. Detailed history, comprehensive exam, and low MDM are performed. Patient is discharged at 11:00 AM the following day. 99219, 99217 99218 99238 99218, 99217

99218, 99217

Established patient presents for 3-year-old annual exam. Comprehensive history and exam and moderate MDM were performed based on CPT guidelines. Appropriate anticipatory guidance was provided during the encounter. Assign the appropriate E/M code(s) and modifier(s). 99382 99392 99212 99214

99392

Which code(s) would be utilized for a critically ill 20-day-old patient initial care? 99293-99294 99294-99296 99221-99223 99468-99469

99468-99469

The three parts of the small intestine are the duodenum, the jejunum, and the ileum. The duodenum, the jejunum, and the colon. The duodenum, the jejunum, and the ischium. the duodenum, the jejunum, and the stomach.

the duodenum, the jejunum, and the ileum.

Anesthesia services for septoplasty on a healthy 24-year-old male 00164-P1 00162 00160 00160-P1

00160-P1

Anesthesia services for cardiac radiofrequency ablation, 63-year-old with severe atrial fibrillation 00537-P1 00537 00530 00537-P3

00537-P3

A normally healthy 50-year-old for anesthesia for repair of an incarcerated inguinal hernia 00820-P1 00830-P1 00830-P3 00830

00830-P1

Anesthesia for radical orchiectomy, inguinal on 45-year-old normally healthy male 00928 00928-P1 00926-P2 00926-P1

00926-P1

Anesthesia services for emergency C-section on a 29-year-old normally healthy female with eclampsia 01961-P1, 99140 01961-P1 01960-P1, 99140 01960-P1

01961-P1, 99140 Anesthesia code 01961 is for Cesarean delivery, and physical status modifier is P1 (normally healthy documented), with qualifying circumstance code 99140 as stated as emergency.

Anesthesia time is assigned in the days/units column in increments of minutes. 10 minutes. 15 minutes. 10 or 15 minutes depending on carrier.

10 or 15 minutes depending on carrier.

Extensive basal cell carcinoma (BCC) of the left retroauricular area. Wide excision of BCC. Skin graft was obtained from the left thigh and placed at the excision site. 15120 11640, 15000, 15120 11440 11640, 15120

11640, 15120

The rib cage is formed by the sternum and how many pairs of ribs? 10 8 15 12

12

A 7-year-old patient has a v-shaped laceration approximately 2.5 cm in length and a small one about 0.5 cm on the right side of the hand. Lacerations are cleaned and closed with 4-0 Ethilon sutures. 12031 12002 12001 12011

12002

Treatment of molluscum contagiosum by cryotherapy. Patient was given light sedation and the two lesions were exposed. Curettage was attempted, but the lesions were not easily removed; therefore, cryotherapy was used to treat each of the lesions through two freeze/thaw cycles. 17000, 17003 17003 17000 17003 x 2

17000, 17003

Patient presents for status post pin removal following ORIF bimalleolar ankle fracture 2 years ago. One of the pins has apparently dislodged and can be manipulated right under the skin. The pin is removed and area closed with sutures. 20680 E/M only 20670 20690

20670

Mass in the left flank at its widest measuring 4 x 2 cm. Incision was extended into the subcutaneous and fascial layers and the lesion was removed in toto. 21931 11404 21920 11403

21931

Arthroscopy, left knee with open lateral retinacular release. Arthroscope cannula was introduced, and the anatomy was examined and appears normal. There was a tight lateral retinaculum noted through range of motion of the knee. A longitudinal skin incision was made, incision carried down to the subcutaneous tissue. Nick was made in the lateral patellar retinaculum and lateral patellar release was accomplished. Arthroscopic portal as well as the lateral release incision was closed. 27420-LT 27428-LT 27425-LT 26746-LT

27425-LT

Internal derangement of the left knee with operative arthroscopy of the left knee with chondroplasty of the patellofemoral joint and the medial compartment with partial medial meniscectomy of the left knee 29881-LT 29881-LT, 29877-59-LT 29877-LT 29881-LT, 29877-LT

29881-LT

Utilizing a 5" sinuscope and microdebrider, the right concha bullosa was resected in its lateral portion. Subsequently, the anterior wall of both ethmoids was removed with the microdebrider, and the hypertrophic mucosa and anterior ethmoid cells were cleared with the microdebrider. The maxillary sinus ostia were cleared of hypertrophic mucosa on the right side followed by the same procedures on the left. 31267, 31254-51 31267-50, 31254-50-51 31254, 31254-50 31267, 31267-50

31267-50, 31254-50-51

The old tracheostomy site was palpated for signs of a tracheal defect; none was noted. A vertical incision was made through the old scar until the trachea was reached. There were significant calcifications of the tracheal rings, making identification of the individual rings difficult. A number 11 blade was used to create a vertical incision, and scar tissue over the previous tracheostoma was excised until the endotracheal tube could be visualized. A number 8 nonfenestrated, cuffed tracheostomy tube was easily inserted into the tracheostomy. 31603-22 31600 31603 31603, 31830

31600 Replaced tracheostomy tube. Not stated as emergency and, therefore, assumed planned, so code 31600 is assigned.

Bronchoscopy with washings 31622 31624 31625 31623

31622

CT-guided lung biopsy. An appropriate area was cleansed and an 18-gauge spring-loaded needle was inserted into a 6 × 5 cm mass in the right base. Three cores of tissue were removed into the biopsy needle. 39000 32400 32405 32097

32405

Placement of temporary cardiac pacemaker, single chamber 33210 33208 33216 33227

33210

A 67-year-old patient with known CAD and a history of MI was admitted for CABG. A portion of the right radial artery was procured for bypass grafting, and then proceeded to perform two arterial grafts. Then a portion of femoropopliteal vein for graft was harvested. 33535, 35600, 35572 33534, 35572 33510, 33534 35534, 33517

33534, 35572

EGD. Scope was passed and visually guided into the esophagus, the stomach, and advanced all the way to the third part of the duodenum. A couple of biopsies were taken from the small bowel mucosa. An esophageal ulcer was examined and biopsy taken as well. 43239 43235 43239 x2 43251

43239

ERCP with removal of obstructed biliary stent, balloon of CBD stones and sludge, placement of biliary stent. Duodenoscopy was advanced through the esophagus, stomach, and pylorus into the duodenum. An obstructed biliary stent was snared and removed. Selective cannulation of the CBD was performed. Balloon of the CBD was performed, removing soft stones and sludge followed by a new 10 French biliary stent placed across the strictures. 43264 43276 43276, 43269-51, 43274-51 43276, 43264-51

43276, 43264-51

Inguinal hernia repair, age 4 49505 49501 49500 49491

49500

Diagnostic cystourethroscopy is performed, which reveals 2 cm ureter stone. 52310 50590 52317 52000

52000

Cystourethroscopy with placement of urethral stent 52282 52001 52204 52332k

52282

Evaluation under anesthesia, hysteroscopy, dilation and curettage, and endometrial ablation. Using a Storz hysteroscope, a hysteroscopy was performed, which revealed uterus consistent with menorrhagia. Then, using an Ethicon endometrial ablation apparatus, endometrial ablation of the cavity for 8 minutes at 87 degrees Celsius. 58120 58563 58563, 58558-51 58558

58563

Bilateral L5-S1 transforaminal epidural steroid injections 64483, 64484 64483-50 62322 62322-50

64483-50 Assign code 64483-50 for transforaminal epidural steroid injections found under injection, anesthetic agent, diagnostic, therapeutic somatic nerves.

Extracapsular right cataract extraction on a 72-year-old that requires an iris expansion device. Upon completion of phacoemulsification of the opacified lens, an intraocular lens is inserted. 66850-RT 66982-RT 66984-RT 66982-RT, 66985-RT

66982-RT

A patient with severe mental retardation and cerumen impactions in both ears was unable to be cleared in the office. Using surgical instrumentation, the canal was cleared of impacted cerumen bilaterally. 69200 69210 69205-50 69210-50

69210-50

Placement of ventilation tube, left ear, with local anesthesia 69433-LT 69436-LT, 69424-RT 69433 69436

69433-LT

X-rays taken and interpreted, bilateral standing knees, AP 73560, 73560-50 73560-RT, 73560-LT 70560 73565

73565

BRCA2 gene analysis, full sequence analysis 81216 81215 81217 81214

81216

Reticulocyte count, automated 85045 85041 85044 85032

85045

Antinuclear antibody titer 86022 86039 86021 86038

86039

Comprehensive ophthalmological exam, new patient 92014 92012 92002 92004

92004

Electrocardiogram, interpretation and report only 93015 93000 93000-26 93010

93010

Allergy immunotherapy with no provision of extract as well as a problem-focused history, exam, and low MDM 95115, 99212 95115, 99212-25 95115 95120

95115, 99212-25

Dermatological ultraviolet light treatment 96570 96902 96900 96904

96900

Blood pressure check, done by the physician's nurse. 99212 None 99213 99211

99211

Office visit for 24-year-old patient with acute bronchitis. Expanded problem-focused history and exam are performed. 99211 99213 99202 99201

99213

Office visit for follow-up for stable diabetes mellitus. Patient has multiple medical problems; however, all appear stable at this time. No complaints of diplopia, excessive thirst. She has been symptom-free except for some lower back pain in the past few weeks. Exam completed for back, heart, and lungs. Glucose level normal. Assessment: diabetes type II stable. 99203 99214 99202 99213

99213

An established patient presents with diagnosis of allergic sinusitis. The physician performs an expanded problem-focused history, exam, and low MDM. Following the completion of the visit, 12 percutaneous scratch tests were performed to determine the origin of the allergens. 95004 x12 99213-25, 95004 x12 99213-25, 95004 95010

99213-25, 95004 x12 As history, exam, and MDM were performed and decision was made to perform allergy tests, as a result, both an E/M would be assigned 99213-25 as well as 12 scratch tests were also performed; therefore, 95004 x12 would also be appropriate.

Dr. Smith spent 1 hour and 30 minutes delivering critical care to a 48-year-old patient. Over the course of this time, Dr. Smith provided interpretation of cardiac output measurements and withdrawal of arterial blood. Dr. Smith did not attend other patients during this time. 99289, 99290 99291, 99292 x 2, 93561, 36000 99291, 99292-51 99291, 99292 x 1

99291, 99292 x 1 According to the time grid in the critical care section, critical care from 75 to 104 minutes qualifies for 99291 and 99292 x 1.

A psychoneurotic disorder characterized by prolonged refusal to eat resulting in extreme weight loss is known as hypochondria. schizophrenia. bulimia. Anorexia nervosa.

Anorexia nervosa.

Anesthesia coding and billing always require the following elements: CPT code and modifier code CPT Code CPT code, physical status modifier, and time units CPT code, physical status modifier, and qualifying circumstance

CPT code, physical status modifier, and time units

Which of the following is NOT a part of the computer planning service for intensity-modulated radiation therapy (IMRT)? Creating highly conformal radiation dose distribution Verification of treatment setup and interpretation of verification methodology Verification of positional accuracy Inverse treatment planning

Creating highly conformal radiation dose distribution Creating highly conformal radiation dose distribution is NOT part of IMRT.

When a sigmoidoscopy is performed, what areas are included in the examination? Entire rectum, sigmoid colon, portion of descending colon Rectum and sigmoid colon Entire colon from rectum to cecum Rectum, sigmoid colon, terminal ileum

Entire rectum, sigmoid colon, portion of descending colon

Expressive aphasia, history of CVA I69.920 F80.1, I25.2 F80.1, Z86.73 F80.1, I63.9

F80.1, Z86.73

Medicare patient with history of adematous polyps presents for periodic screening colonoscopy. G0121 G0105 G0101 G0120

G0105 Patient with history of colon polyps is considered high risk; therefore, code G0105 would be appropriate.

Migraine headache with aura G43.109 G43.10 G43.1 G43.909

G43.109

CAD would be coded as I25.110. I77.9. I25.119. I25.10.

I25.10.

URI determined to be the cause of pharyngitis J02.0 J06.9 J06.9, J02.9 J02.9

J06.9 Not necessary to assign code for pharyngitis as inflammation of throat would be sign/symptom of the URI

Injection, ceftazidime, 750 mg J0713 J0713 X 2 units J0714 J0713, J0713

J0713 X 2 units

Food aspiration pneumonia J69.8 J18.9 J69.0 J12.9

J69.0

Repair of nonoxygen, durable medical equipment, 30 minutes K0740 K0740 X 2 units K0739 K0739 X 2 units

K0739 X 2 units

Abnormal chest x-ray Z00.01 R90.0 Z00.00 R91.8

R91.8

Fracture left distal radius following fall from bus S52.502S S52.502A S52.522A S52.509A

S52.502A

Fracture of the right tibial shaft as a result of a fall S82.221A A84.47 S82.201A S82.201

S82.201A

Medicaid, Incontinence pull on protective underwear, youth, disposable T4535 T4534 T4532 T4533

T4534 Code T4534 only code for youth, disposable underwear

What is one factor of the federal guidelines for compliance programs? Always be trustworthy. The organization has communicated standards and procedures to employees and agents. Do not divulge any information to federal entities. Make sure the practice engages the use of an attorney.

The organization has communicated standards and procedures to employees and agents.

Level II surgical pathology codes are utilized for specimens that are not removed for suspected malignant, but other reasons. False True

True Level II surgical pathology is intended for surgical specimens that are not suspected of malignancy per guidelines in the CPT Surgical Pathology section.

Child presents to physician due to exposure to chickenpox. B01.9 Z20.820 Z20.828 Z23

Z20.820

Under HIPAA, all patients are entitled to all of those listed. review of their records. request copies of their records. all records be kept confidential except as specified by the patient.

all of those listed.

Ballooning of a weakened portion of an arterial wall refers to a(n) aneurysm. thromboangiitis obliterans. varicosity. embolus.

aneurysm.

Modifier -26 indicates only utilized in E/M section. codes in CPT for supervision/interpretation. radiology codes for supervision/interpretation. may be used in all sections of CPT.

codes in CPT for supervision/interpretation.

An artificial opening through the abdominal wall into the colon is referred to as a(n) gastrostomy. colostomy. ileostomy. colotomy.

colostomy

CHF refers to congestive heart failure. chronic hypertension. congestive hypertension with failure. chronic heart failure.

congestive heart failure.

What body movement involves a straightening of a body part by increasing the angle of a joint? dorsiflexion extension flexion abduction

extension

The rapid, quivering, noncoordinated contractions of the atria or ventricles is called intermittent claudication. fibrillation. cardiac tamponade. hypertensive heart disease.

fibrillation.

A superficial burn, characterized by pain, redness, and swelling is classified as a first-degree burn. fourth-degree burn. second-degree burn. third-degree burn.

first-degree burn.

When the repair of a fracture also necessitates the application of a cast, what services are reportable? cast and fracture fracture and cast code with modifier -58 fracture repair only evaluation and management with modifier -25 and fracture code

fracture repair only

The ilium, ischium, and pubis make up what bone? collarbone shoulder bone hip bone humerus

hip bone

What modifier is appended when multiple procedures are performed during the same operative session, through the same approach, and in the same anatomical site, and when all are appropriate to code/bill? modifier -RT/LT modifier -59 modifier -GA modifier -51

modifier -51

Arthro pertains to which anatomical system? digestive disease/gastrointestinal musculoskeletal integumentary nervous

musculoskeletal

A condition in which bones become thin and result in a decrease in bone density is referred to as osteosarcoma. arthritis. osteoporosis. osteopenia.

osteoporosis. "Osteo" means "bone," and "porosis" means "abnormal condition of porous"; osteoporosis refers to a condition where the bones become thin and there is a decrease in bone density. While the other answer choices are disorders related to the bone and the joint, they do not refer to decreased bone density; therefore, osteoporosis is the most appropriate.

Tachycardia refers to sick sinus syndrome. irregular heartbeat. rapid heartbeat. slow heartbeat.

rapid heartbeat.

In addition to the usual information submitted on each claim, what additional information must be reported when submitting ancillary services? NPI number, name, and address of requesting/referring physician referring/requesting physician and NPI number referring/requesting physician provider number of requesting/referring physician

referring/requesting physician and NPI number

The diaphysis of a long bone is also referred to as the end. distal end. shaft. proximal end.

shaft.

Any pathological change in skin tissue is called a(n) impetigo. skin lesion. tumor. keloid.

skin lesion.

According to CPT guidelines, in addition to the appropriate anesthesia CPT code(s) and modifier code(s), what other anesthesia procedural information is required to correctly report anesthesia services? Start time Time of day procedure performed Preoperative evaluation time start time and stop time

start time and stop time

The outer layer of the skin is referred to as the dermis. subcutaneous. the epidermis. the fascia.

the epidermis.

Modifier -FA denotes thumb, left hand. first toe, left foot. thumb, right hand. first toe, right foot.

thumb, left hand.

When locating an open wound in ICD10 in the alphabetic section, the coder would look under laceration. abrasion. wound, open. contusion.

wound, open.

Excision of malignant lesion, 4.0 cm cheek with 8 sq cm advancement flap 14040 14020 14350 14060

14040

Laceration repairs as follows: 1.5 cm arm, simple; 2.5 cm arm, simple; 1.5 cm arm, intermediate 12001, 12001-51, 12031-51 12001 x 2, 12031 12002, 12031-51 12031, 12002-51

12031, 12002-51

Repair, 6.0 cm leg, intermediate 12032 12002 12031 12001

12032

Excision of lipoma, shoulder, extending into the deep subcutaneous tissue 11400 23075 23076 11600

23075

Incision and drainage, deep abscess, forearm 25110 25028 25031 25024

25028

Procedure performed: Repair of right little finger distal interphalangeal fusion nonunion with screw. Incision was made, full-thickness flaps were developed, and nonunion site was indented. It was cleaned with ronguer and Preer elevator; bony surfaces were repaired, and an Acutrak II guide wire was placed across the fusion site. It was then placed with a 28 mm screw and overdrilled with a 28 mm mini screw. 26861 26860 26770-F9 26860-F9

26860-F9

Hammertoe repair, right foot, second toe 28270-RT 28285-T6 28285-RT 28292-T6

28285-T6

Application of knee immobilizer, left 29345 29505-LT 29345-LT 29505

29505-LT

Arthroscope was inserted and there were areas of diffuse chondromalacia, Grade III that was treated with chondroplasty. The lateral meniscus was torn on its inner third and partial lateral meniscectomy was performed. There was an unrepairable tear on the posterior horn of the medical meniscus and this was also excised. 29881 29880 29881, 29877-51 29880, 29877-51

29880 Meniscectomy of both medial and lateral compartments was performed. Chondroplasty is included per CPT.

Gastroscope was introduced through the mouth and passed into the stomach, through the pylorus and into the second portion of the duodenum. Just inferior to the Z-line, a small polyp was identified and cold biopsied. Rectal exam was performed, and colonoscope was advanced to the cecum. Multiple sessile polyps were removed utilizing snare and cauterized. There were two other tiny polyps that were fulgurated due to their size. 45388, 45385-51, 43239 45385, 43239 45385, 45388-51, 43239 45385, 45384-51, 43235

45388, 45385-51, 43239 Both colonoscopy and EGD (esophagogastroduodenoscopy) were performed. The colonoscopy involved fulgurating polyps (45388) and polypectomy by snare (45385-51). The cauterization of the snared polypectomy is not separately reportable to control bleeding created by the excision. An EGD was also performed with biopsy, which would be assigned 43239.

Percutaneous liver biopsy. The upper right abdomen was prepped and 18 gauge coaxial needle was inserted into the right lobe of the liver. Needle tip was placed within one of the lesions and core biopsies X 3 were obtained. 47010 47000 47000 X3 47100

47000 When percutaneous liver biopsies are performed by needle, code 47000 is assigned. This code is assigned only once regardless of the number of biopsies/specimens obtained.

Liver biopsy due to elevated liver enzymes. The area of biopsy site was chosen and a small nick was made on the skin and advanced to the liver capsule. Patient was told to hold her breath, biopsy gun was inserted into the liver, and the obtained biopsy was sent to pathology. 47010 47000 47100 47399

47399

Left renal stone was seen, which was right next to the stent placed previously. Stone was targeted in both AP and lateral views. Starting at an energy of 2 Kv and going to 9 Kv, the stone was fragmented utilizing ESWL. Additional 500 shocks were required for total pulverization of the stone. 52317 52353 50590-LT 52353, 52310-51

50590-LT Extracorpeal shock wave lithotripsy or ESWL was performed. Code as 50590-LT.

Cystoscopy was introduced into the bladder. Tumor measuring 2 cm was located on the bladder. Using cutting current, this was resected and particles removed through the evacuator. Tumor measuring 1 cm was located on the bladder base, which was also resected along with a third tumor, 2 cm, located on the upper portion of the bladder. 52235 52235 x3 52235, 52235-59, 52235-55 52235, 52234-51

52235

Electrosurgical transurethral resection of prostate 52601 55821 55810 52630

52601

Excision of a local lesion of the epididymis. 54860-47 54861-50 54830 54830, 54860-47

54830

Abdomen, vulva, and vagina were prepped and the cervix was visualized extending outside the vagina. Anterior incision was made 2 cm from cervix. The denuded strip was approximately 2-3 cm in width. The denuded strip was grasped with the clamp, and posterior incision made. Procedure was completed by suturing the anterior vaginal mucosa to the posterior vaginal mucosa and then successive suturing to elevate the uterus and anterior bladder wall. 57100 57130 57120 57110

57120 The suturing of the vagina is performed with strips to correct prolapsed vagina. Assign code 57120.

Dilation and curettage 57505-51, 58120 57505 57505, 58120 58120

58120

Treatment of incomplete abortion. 59812 59841 59820 59830

59812

Additional authoritative coding guidelines for procedures may be found in what publication? physician-specific source AMA CPT Assistant Coders Desk Reference Internet/Google sites

AMA CPT Assistant

Which of the following situations could be considered upcoding? All of those listed. A provider bills for services as though a physician rendered them, even though there was no physician involvement. A provider bills Medicare for treating a patient with a more serious form of pneumonia than the patient has. A podiatrist performs simple nail clipping services but bills for foot surgery.

All of those listed.