RHIA: CPT Coding
Patient undergoes x-ray of the foot with three views. A. 73620 B. 73610 C. 73630 D. 27648; 73615
C
Patient undergoes laparoscopic orchiopexy for intra-abdominal testes. A. 54650 B. 54699 C. 54692 D. 55899
C
Patient returns to the physician's office complaining of obscured vision. Patient has had cataract surgery 6 months prior. Patient requires laser discission of secondary cataract. A. 66821 B. 66940 C. 67835 D. 66830
A
Patient undergoes total thyroidectomy with parathyroid autotransplantation. A. 60240; 60512 B. 60520; 60500 C. 60260; 60512 D. 60650; 60500
A
A D&C is performed for postpartum hemorrhage. A. 59160 B. 58120 C. 58558 D. 58578
A
Amniocentesis. 57530 Trachelectomy, amputation of cervix (separate procedure) 57550 Excision of cervical stump, vaginal approach 59000 Amniocentesis, diagnostic 59200 Insertion of cervical dilator (separate procedure) A. 59000 B. 59200 C. 57550 D. 57530
A
An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient's last three glucose tests. The patient is still running above normal glucose levels, so the physician decides to adjust the patient's insulin. An expanded history was taken and a physical examination was performed. A. 99213 B. 99232 C. 99202 D. 99214
A
Basic metabolic panel (calcium, total) and total Bilirubin. A. 80048; 82247 B. 80053 C. 80100 D. 82239; 80400; 80051
A
CT scan of the head with contrast. A. 70460 B. 70542 C. 70551 D. 70470
A
Cannulation of the thoracic duct. A. 38794 B. 36810 C. 36260 D. 38999
A
Chlamydia culture. A. 87110 B. 87106 C. 87118 D. 87109; 87168
A
Code anesthesia for corneal transplant. A. 00144 B. 00140 C. 00147 D. 00190
A
Code anesthesia for placement of vascular shunt in forearm. A. 01844 B. 01850 C. 00532 D. 01840
A
Cytopathology of cervical Pap smear with automated thin-layer preparation utilizing computer screening and manual rescreening under physician supervision. A. 88175 B. 88148 C. 88160; 88141 D. 88161
A
D&C performed for patient with diagnosis of incomplete abortion at 8 weeks. A. 59812 B. 59820 C. 58120 D. 59160
A
Drainage of simple external ear abscess. A. 69000 B. 69100 C. 10060 D. 69020
A
Excision of Cowper's gland. 53220 Excision or fulguration of carcinoma of urethra 53250 Excision of bulbourethral gland (Cowper's gland) 53260 Excision or fulguration; urethral polyp(s), distal urethra 53450 Urethromeatoplasty, with mucosal advancement A. 53250 B. 53450 C. 53260 D. 53220
A
Excision of simple internal and external hemorrhoids. 46221 Hemorrhoidectomy, internal, by rubber band ligation(s) 46255 Hemorrhoidectomy, internal and external, single column/group 46260 Hemorrhoidectomy, internal and external, two or more columns/groups 46945 Hemorrhoidectomy, internal, by ligation other than rubber band, single hemorrhoid, column/group A. 46255 B. 46945 C. 46221 D. 46260
A
Hydrocelectomy of spermatic cord. A. 55500 B. 55000 C. 55041 D. 55520
A
Patient with Parkinson's disease is admitted for insertion of a brain neurostimulator pulse generator with one electrode array. A. 61885 B. 61850; 61863 C. 61888 D. 61867; 61870
A
Injection of anesthesia for nerve block of the brachial plexus. 64413 Injection, anesthetic agent; cervical plexus 64415 Injection, anesthetic agent; brachial plexus, single 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring A. 64415 B. 64413 C. 64530 D. 64510
A
Injection snoreplasty for treatment of palatal snoring. A. 42299 B. 42145 C. 42999 D. 40899
A
Lagophthalmos correction with implantation using gold weight. A. 67912 B. 67911 C. 67901 D. 67121
A
Laminectomy and excision of intradural lumbar lesion. A. 63272 B. 63267 C. 63282 D. 63252
A
Laparoscopic adrenalectomy, complete. A. 60650 B. 60650-50 C. 60659 D. 60540
A
Laparoscopic gastric restrictive procedure and placement of adjustable gastric band. A. 43770 B. 43800 C. 43845 D. 43846
A
Laparoscopic retroperitoneal lymph node biopsy. A. 38570 B. 38780 C. 49323 D. 38589
A
Laparoscopy with multiple biopsies of retroperitoneal lymph nodes. A. 38570 B. 38571 C. 38570-22 D. 38572
A
Laser destruction of penile condylomas. A. 54057 B. 17106 C. 17270 D. 54055
A
Lye burn of the larynx repaired by laryngoplasty. A. 31588 B. 16020 C. 31360 D. 31540
A
Myringoplasty. A. 69620 B. 69635 C. 69610 D. 69420
A
Nephrectomy with resection of half of the ureter. A. 50220 B. 50234 C. 50230; 50650 D. 50546
A
Obstetric patient comes in for a pelvimetery with placental placement. A. 74710 B. 76946 C. 76805 D. 76825
A
Osteopathic manipulative treatment to three body regions. A. 98926 B. 98941 C. 97110 D. 97012
A
Patient comes into the office for removal of impacted earwax. A. 69210 B. 69200 C. 69222 D. 69000
A
Patient comes to the hospital with a history of right flank pain. Urine tests are negative. Radiology examination reveals that the patient has renal cysts. Patient is now admitted for laparoscopic ablation of the cysts. A. 50541 B. 50390 C. 50280 D. 50920
A
Patient had been diagnosed with a bunion. Patient was taken to the operating room where a simple resection of the base of the proximal phalanx along with the medial eminence was performed. Kirschner wire was placed to hold the joint in place. A. 28292 B. 28290 C. 28293 D. 2829
A
Patient has a bone marrow aspiration of the iliac crest and of the tibia. A. 38220, 38220-59 B. 38221 C. 38230 D. 38220
A
Patient has a history of PVD for many years and experiences chest pains. The patient underwent Doppler evaluation which showed a common femoral DVT. Patient is now admitted for thromboendarterectomy. A. 35371 B. 35372 C. 37224 D. 35256
A
Patient has recurrent spontaneous pneumothorax which has resulted in a chemical pleurodesis by thoracoscopy. A. 32650 B. 32310; 32601 C. 32605 D. 32960
A
Patient in late stages of labor arrives at the hospital. Her OB physician is not able to make the delivery and the house physician delivers the baby vaginally. Primary care physician resumes care after delivery. Code the delivery. A. 59409 B. 59612 C. 59620 D. 59400
A
Patient is admitted for contact laser vaporization of the prostate. The physician performed a TURP and transurethral resection of the bladder neck at the same time. A. 52648 B. 52648; 52450; 52500 C. 52450; 53500 D. 52648; 52450
A
Patient is admitted to the hospital following an ultrasound at 25 weeks which revealed fetal pleural effusion. A fetal thoracentesis was performed. A. 59074 B. 32421 C. 32422 D. 76815
A
Patient presents to the emergency room following a fall. X-rays were ordered for the lower leg and results showed a fracture of the proximal left tibia. The emergency room physician performed a closed manipulation of the fracture with skeletal traction. A. 27532-LT B. 27536-LT C. 27530-LT D. 27524-LT
A
Patient presents to the operating room for fulguration of bladder tumors. The cystoscope was inserted and entered the urethra which was normal. Bladder tumors measuring approximately 1.5 cm were removed. 50957 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 51530 Cystotomy; for excision of bladder tumor 52214 Cystourethroscopy, with fulguration of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands 52234 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of small bladder tumor(s) (0.5 up to 2.0 cm) A. 52234 B. 50957 C. 52214 D. 51530
A
Patient presents to the operating room where the physician performed, using imaging guidance, a percutaneous breast biopsy utilizing a rotating biopsy device. 19000 Puncture aspiration of cyst of breast 19103 Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion +19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure) A. 19103 B. 19125; 19295 C. 19120 D. 19000
A
Patient presents to the surgical unit and undergoes unilateral endoscopy, partial ethmoidectomy, and maxillary antrostomy. A. 31254; 31256-51 B. 31201; 31225-51 C. 31290; 31267-51 D. 31233; 31231-51
A
Patient returns to the operating room following open-heart bypass for exploration of blood vessel to control postoperative bleeding in the chest. A. 35820 C. 35761 B. 20101 D. 35905
A
Patient with hematochromatosis had a therapeutic phlebotomy performed on an outpatient basis. A. 99195 B. 36522 C. 36514 D. 99199
A
Patient with laryngeal cancer has a tracheoesophageal fistula created and has a voicebox inserted. A. 31611 B. 31580 C. 31395 D. 31502
A
Scrotal wall abscess drainage. A. 55100 B. 55150 C. 54700 D. 55110
A
The physician punctures the left common femoral to examine the right common iliac. A. 36245 B. 36246 C. 36247 D. 36140
A
Ultrasonic guidance for the needle biopsy of the liver. Code the complete procedure. A. 47000; 76942 B. 47000; 76937 C. 47000; 76999 D. 47000; 77002
A
Patient presents to the emergency room following a fall from a tree. X-rays were ordered for the left upper arm which showed a fracture of the humerus shaft. The emergency room physician performed a closed reduction of the fracture and placed the patient in a long arm spica cast. Code the diagnoses and procedures, excluding the x-ray. 812.21 Fracture humerus, shaft, closed 812.31 Fracture, humerus, shaft, open E000.9 unspecified external cause status E030 Unspecified activity E884.9 Other fall from one level to another 24500 Closed treatment of humeral shaft fracture; without manipulation 24505 Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction 24515 Open treatment of humeral shaft fracture with plate/screws, with or without cerclage 29065 Application, cast; shoulder to hand (long arm) LT Left side A. 812.21, E884.9, E030, E000.9, 24505-LT B. 812.21, 24515-LT C. 812.21, E884.9, E030, E000.9, 24505-LT, 29065 D. 812.31, 24500-LT
A Casting is included in the surgical procedure.
Open I&D of a deep abscess of the cervical spine. A. 22010 B. 22015 C. 10060 D. 10140
A Codes 10060 and 10140 are used for I&Ds of superficial abscesses.
Blood transfusion of three units of packed red blood cells. 36430 Transfusion, blood or blood components 36455 Exchange transfusion; blood, other than newborn 36460 Transfusion, intrauterine, fetal A. 36430 B. 36430; 36430; 36430 C. 36460 D. 36455
A Report this code only once no matter how many units were given.
Patient presents to the operating room for excision of three lesions. The 1.5 cm and 2.0 cm lesions of the back were excised with one excision. The 0.5 cm lesion of the hand was excised. The pathology report identified both back lesions as squamous cell carcinoma. The hand lesion was identified as seborrheic keratosis. A. 11604; 11420 B. 11402; 11420; 11403 C. 11403; 11642; 11462 D. 11602; 11402
A See Principles of CPT Coding 6th edition. Page 129 If two lesions are removed with one excision, only one excision code would be reported
An office consultation is performed for a postmenopausal woman who is complaining of spotting in the past 6 months with right lower quadrant tenderness. A detailed history and physical were performed with a low-complexity medical decision. A. 99242 B. 99243 C. 99253 D. 99254
B
An out-of-town patient presents to a walk-in clinic to have a prescription refilled for a nonsteroidal anti-inflammatory drug. The physician performs a problem-focused history and physical examination with a straightforward decision. A. 99211 B. 99201 C. 99212 D. 99202
B
Closure of ureterocutaneous fistula. A. 50930 B. 50920 C. 57310 D. 50520
B
Code anesthesia for cesarean section. A. 00840 B. 01961 C. 00940 D. 01960
B
Code anesthesia for decortication of left lung. A. 01638-LT B. 00542-LT C. 00546-LT D. 00500-LT
B
Code anesthesia for vaginal hysterectomy. A. 00846 B. 00944 C. 00840 D. 01963
B
Comprehensive electrophysiologic evaluation (EPS) with induction of arrhythmia. 93618 Induction of arrhythmia by electrical pacing 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia 93620 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording +93623 Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure.) 93640 Electrophysiologic evaluation of single- or dual-chamber pacing cardioverter defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement A. 93618; 93620 B. 93620 C. 93640; 93623 D. 93619; 93620
B
Correction of trichiasis by incision of lid margin. A. 67840 B. 67830 C. 67835 D. 67850
B
Excision of mediastinal cyst. A. 11400 B. 39200 C. 17000 D. 39400
B
Excision of thyroid adenoma. 60100 Biopsy thyroid, percutaneous core needle 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy 60280 Excision of thyroglossal duct cyst or sinus A. 60210 B. 60200 C. 60280 D. 60100
B
Female with 6 months of stress incontinence. Outpatient therapies are not working and the patient decides to have the problem fixed. Laparoscopic urethral suspension was completed. A. 51992 B. 51990 C. 51840 D. 51845
B
Hepatitis C antibody. 86803 Hepatitis C antibody 86804 Hepatitis C antibody; confirmatory test (e.g., immunoblot) 87520 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification A. 86804 B. 86803 C. 87522 D. 87520
B
Hysteroscopy with D&C and polypectomy. A. 58563 B. 58558 C. 58120; 58100; 58555 D. 58558; 58120
B
IV push of one antineoplastic drug. A. 96401 B. 96409 C. 96411 D. 96413
B
Laparoscopic removal and replacement of both a gastric band and the subcutaneous port components. A. 43774, 43659 B. 43659 C. 43773 D. 43848
B
Laryngoscopic stripping of vocal cords for leukoplakia of the vocal cords. A. 31535 B. 31540 C. 31541 D. 31570
B
Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy. A. 52648 B. 53852 C. 52601 D. 53850
B
Male with urinary incontinence. Sling procedure was performed 6 months ago and now the patient has returned for a revision of the sling procedure. A. 53449 B. 53442 C. 53440 D. 53431
B
Modified radical mastoidectomy. A. 69511 B. 69505 C. 69635 D. 69641
B
Mother brings her 1-year-old in for the influenza split virus vaccine. Physician discusses merits of the vaccine with the mother. A. 90658; 90472 B. 90657; 90460 C. 90703 D. 90657
B
One-half hour of IV chemotherapy by infusion followed by IV push of a different drug. A. 96413 B. 96413; 96411 C. 96413; 96409 D. 96409; 96411
B
Partial thromboplastin time utilizing whole blood. A. 85732 B. 85730 C. 85245 D. 85246
B
Pathologist performs a postmortem examination including brain of an adult. Tissue is being sent to the lab for microscopic examination. A. 88309 B. 88025 C. 88099 D. 88028
B
Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life-threatening injuries due to a multiple car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient. A. 99285; 99288; 99291 B. 99291; 99292 C. 99291; 99292; 99285 D. 99282
B
Patient came in for excision of a middle ear lesion. A. 11440 B. 69540 C. 69552 D. 69535
B
Patient came to the hospital from a local nursing home for a PEG tube placement via EGD. Patient had neurogenic dysphagia and dominant hemiplegia due to prior CVA. 436 Acute, but ill-defined, cerebrovascular disease 438.21 Late effect of CVA with hemiplegia affecting dominant side 438.81 Late effect of CVA with apraxia 438.82 Late effect of CVA with dysphagia 787.29 Dysphagia, neurogenic 43219 Esophagoscopy, rigid or flexible with insertion of plastic tube or stent 43246 Upper gastrointestinal endoscopy of esophagus, stomach, and either the duodenum and/or jejunum with directed placement of percutaneous gastrostomy tube 44372 Small intestine endoscopy, enteroscopy beyond second portion of duodenum with placement of percutaneous jejunostomy tube A. 438.81, 43219 B. 438.82, 438.21, 787.29, 43246 C. 436, 787.29, 44372 D. 436, 43246
B
Patient comes into the outpatient department at the local hospital for an MRI of the cervical spine with contrast. Patient is status post automobile accident. A. 72156 B. 72142 C. 72149 D. 72126
B
Patient complains of frequent temporal headaches and the physician suspects temporal arteritis. Patient underwent temporal artery biopsy. 784.0 Headache 446.5 Giant cell arteritis 37600 Ligation; external carotid artery 37609 Ligation or biopsy, temporal artery 37615 Ligation, major artery (e.g., post-traumatic, rupture); neck A. 784.0; 37615 B. 784.0; 37609 C. 446.5; 37600 D. 446.5; 37609
B
Patient complains of recurrent syncope following carotid thromboendarterectomy. Patient returns 2 weeks after initial surgery and undergoes repeat carotid thromboendarterectomy. A. 33510 B. 35301 C. 35201 D. 35301; 35390
B
Patient has a bronchoscopy with endobronchial biopsies of three sites. A. 31625; 31625; 31625 B. 31625 C. 31622; 31625 D. 31622; 31625; 31625; 31625
B
Patient has a history of hiatal hernia for many years, which has progressively gotten worse. The decision to repair the hernia was made and the patient was sent to the operating room where the repair took place via the thorax and abdomen. A. 39545 B. 43336 C. 43332 D. 39503
B
Patient has been diagnosed with uterine fibroids and undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy. A. 58200 B. 58150 C. 58262 D. 58150; 58720
B
Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician office 2 weeks ago and final pathology was positive for carcinoma. Patient is admitted for prostatectomy. Frozen section of the prostate and one lymph node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectomy became a radical perineal with bilateral pelvic lymphadenectomy. A. 55845 B. 55815 C. 55815; 38562 D. 38770
B
Patient has right sacroiliac joint dysfunction and requires a right S2-S3 paravertebral facet joint anesthetic nerve block with image guidance. A. 62311 B. 64493 C. 64490 D. 64520
B
Left carotid artery excision for tumor of carotid body. A. 60650 B. 60600 C. 60605 D. 60699
C
Patient is 24 weeks' pregnant and arrives in the emergency room following an automobile accident. No fetal movement or heartbeat noted. Patient is taken to the OB ward where prostaglandin is given to induce abortion. A. 59200 B. 59855 C. 59821 D. 59410
B
Patient is admitted for a blepharoplasty of the left lower eyelid and a repair for a tarsal strip of the left upper lid. A. 67917-E1; 15822-E2 B. 67917-E1; 15820-E2 C. 67917-E1 D. 67917-E1; 15823-E2
B
Patient presented to the operating room where an incision was made in the epigastric region for a repair of ureterovisceral fistula. 50520 Closure of nephrocutaneous or pyelocutaneous fistula 50525 Closure of nephrovisceral fistula, including visceral repair; abdominal approach 50526 Closure of nephrovisceral fistula including visceral repair; thoracic approach 50930 Closure of ureterovisceral fistula (including visceral repair) A. 50526 B. 50930 C. 50520 D. 50525
B
Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5.0 cm and 2.7 cm. A. 11406; 11403 B. 12034 C. 12032; 12031 D. 12032
B
Patient presents to the hospital for a two-view chest x-ray for a cough. The radiology report comes back negative. What would be the correct codes to report to the insurance company? 786.2 Cough 786.30 Hemoptysis V72.5 Radiology examination, not elsewhere classified 71010 Radiologic examination, chest; single view, frontal 71020 Radiologic examination, chest, two views, frontal and lateral 71035 Radiologic examination, chest, special views A. V72.5; 71020 B. 786.2; 71020 C. V72.5; 71035 D. 786.2; 786.30, 71010
B
Patient presents to the hospital with a diagnosis of femoral artery atherosclerotic disease. The patient is taken to the operating room and undergoes an aortofemoral popliteal bypass. A. 35551 B. 35651 C. 35556 D. 35656
B
Patient presents to the hospital with a right index trigger finger. Release of the trigger finger was performed. A. 26060-F7 B. 26055-F6 C. 26170-F6 D. 26110
B
Patient presents to the operating room for a secondary Achilles tendon repair. 27599 Unlisted procedure, femur or knee 27650 Repair, primary, open or percutaneous, ruptured Achilles tendon 27654 Repair, secondary, Achilles tendon, with or without graft 27698 Repair, secondary, disrupted ligament, ankle, collateral (e.g., Watson-Jones procedure) A. 27599 B. 27654 C. 27650 D. 27698
B
Patient presents to the operating room where a 3.2 cm malignant lesion of the shoulder was excised and repaired with simple sutures. A 2.0 cm benign lesion of the cheek was excised and was repaired with a rotation skin graft. A. 11604, 11442; 14040; 12001 B. 14040, 11604 C. 15002, 15120 D. 17264, 17000; 12001
B
Patient undergoes construction of apical aortic conduit with an insertion of a single-ventricle ventricular assist device. A. 33400 B. 33975 C. 33977 D. 33975; 33404
B
Patient undergoes enucleation of left eye and muscles were reattached to an implant. A. 65135-LT B. 65105-LT C. 65730-LT D. 65103-LT
B
Patient was admitted with hemoptysis and underwent a bronchoscopy with transbronchial lung biopsy. Following the bronchoscopy the patient was taken to the operating room where a left lower lobe lobectomy was performed without complications. Pathology reported large cell carcinoma of the left lower lobe. 162.5 Malignant neoplasm of the lower lobe of the lung 162.8 Malignant neoplasm of other parts of bronchus or lung 162.9 Malignant neoplasm of the bronchus and lung, unspecified 31625 Bronchoscopy with biopsy, with or without fluoroscopic guidance 31628 Bronchoscopy with transbronchial lung biopsy, with or without fluoroscopic guidance 32405 Biopsy, lung or mediastinum, percutaneous needle 32440 Removal of lung, total pneumonectomy 32480 Removal of lung, other than total pneumonectomy, single lobe (lobectomy) 32484 Removal of lung, other than total pneumonectomy, single segment (segmentectomy) A. 162.9, 31625 B. 162.5, 31628, 32480 C. 162.9, 32405, 32484 D. 162.8, 32440
B
Removal of nephrostomy tube with fluoroscopic guidance. A. 50387 B. 50389 C. 99212 D. 99213
B
SPECT bone imaging. 77080 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g. hips, pelvis, spine) 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 78300 Bone and/or joint imaging; limited area 78320 Bone and/or joint imaging; tomographic (SPECT) A. 76977 B. 78320 C. 77080 D. 76977
B
Ten sq cm epidermal autograft to the face from the back. A. 15110 B. 15115 C. 15110, 15115 D. 15120
B
Two-year-old patient returns to the hospital for cleft palate repair where a secondary lengthening procedure takes place. 40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure 42145 Palatopharyngoplasty 42220 Palatoplasty for cleft palate; secondary lengthening procedure 42226 Lengthening of palate, and pharyngeal flap A. 40720 B. 42220 C. 42226 D. 42145
B
Unilateral partial thyroidectomy. A. 60252 B. 60210 C. 60220 D. 60520
B
Which code listed below would be used to report an esophageal electrogram during an EPS? A. 93600 B. 93615 C. 93612 D. 93616
B
Chronic nontraumatic rotator cuff tear. Arthroscopic subacromial decompression with mini-open rotator cuff repair. 726.10 Disorders of bursae and tendons in shoulder region, unspecified 727.61 Complete rupture of rotator cuff, nontraumatic 840.4 Sprains and strains of rotator cuff (capsule) 23410 Repair of ruptured musculotendinous cuff (e.g., rotator cuff); open, acute 23412 Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; chronic 29821 Arthroscopy, shoulder, surgical; synovectomy, complete 29823 Arthroscopy, shoulder, surgical; debridement, extensive 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair -59 Distinct procedural service A. 840.4, 726.10, 29823 B. 727.61, 23412, 29826-59 C. 840.4, 29826, 29821 D. 727.61, 23410
B Code both the arthroscopic procedure and the open procedure. Both need to be reported because there were two separate procedures. Modifier -59 must be added to code 29826 because it is a component of the comprehensive procedure 23412. That is allowed if an appropriate modifier is used per NCCI edits.
A physician performs a PTCA with drug-eluting stent placement in the left anterior descending artery and angioplasty only in the right coronary artery. A. 92996; 92980 B. 92980-LD; 92984-RC C. 92980; 92981 D. 92982; 92996; 92981
B Physicians use codes 92980 or 92981 for placement of drug eluting stents. Hospitals report placement of drug eluting stents with HCPCS Level II codes (G0290 or G0291)
Litholapaxy, 3.0 cm calculus. 50590 Lithotripsy, extracorporeal shock wave 52317 Litholapaxy, simple or small (less than 2.5 cm) 52318 Litholapaxy, complicated or large (over 2.5 cm) 52353 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy A. 52353 B. 50590 C. 52318 D. 52317
C
Male presented to operating room for sterilization by bilateral vasectomy. A. 55200 B. 55400 C. 55250 D. 55450
C
Morbidly obese patient comes in for vertical banding of the stomach. A. 43848 B. 43659 C. 43842 D. 43999
C
A pregnant patient has an incompetent cervix which was repaired using a vaginal cerclage. A. 57700 B. 57531 C. 59320 D. 59325
C
Aphakia penetrating corneal transplant. A. 65755 B. 65730 C. 65750 D. 65765
C
Attempted vaginal delivery in a previous cesarean section patient, which resulted in a repeat cesarean section. A. 59409 B. 59612 C. 59620 D. 59514
C
Cardioversion of cardiac arrhythmia by external forces. A. 92961 B. 92950 C. 92960 D. 92970
C
Closure of traumatic kidney injury. 13100 Repair, complex trunk, 1.1 cm to 2.5 cm 50400 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy or ureteral splinting; simple 50500 Nephrorrhaphy, suture of kidney wound or injury 50520 Closure of nephrocutaneous or pyelocutaneous fistula A. 50520 B. 13100 C. 50500 D. 50400
C
Code anesthesia for procedures on bony pelvis. A. 00400 B. 01170 C. 01120 D. 01190
C
Code anesthesia for upper abdominal ventral hernia repair. A. 00832 B. 00750 C. 00752 D. 00830
C
Creatinine clearance. 82550 Creatine kinase (CK), (CPK); total 82565 Creatinine; blood 82575 Creatinine; clearance 82585 Cryofibrinogen A. 82550 B. 82565 C. 82575 D. 82585
C
Eighty-year-old patient has carcinoma and presents to the operating room for placement of a tunneled implantable centrally inserted venous access port. A. 36558 B. 36571 C. 36561 D. 36481
C
Excision of 2.5 cm bladder tumor with cystoscopy. A. 51550 B. 51530 C. 52235 D. 51060
C
Facelift utilizing the SMAS flap technique. 15788 Chemical peel, facial; epidermal 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap A. 15825 B. 15788 C. 15829 D. 1582
C
Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion. A. 19100; 19125 B. 19100; 19120-LT C. 19120-LT D. 19100; 19120; 19120
C
High-energy ESW of the lateral humeral epicondyle using general anesthesia. A. 0019T B. 0101T C. 0102T D. 28890
C
IV infusion of chemotherapy for 3 hours. A. 96422, 96423, 96423 B. 96409, 96411 C. 96413, 96415, 96415 D. 96413, 96413, 96413
C
Insertion of cochlear device inner ear. A. 69711 B. 69949 C. 69930 D. 69960; 69990
C
Laparoscopic gastric banding. A. 43842 B. 43843 C. 43770 D. 43771
C
Laparoscopic tubal ligation utilizing Endoloop. A. 58670 B. 58615 C. 58671 D. 58611
C
Laryngoscopic submucosal removal of non-neoplastic lesion of the vocal cord with graft reconstruction. An operating microscope was used. A. 31546, 69990 B. 31546, 20926 C. 31546 D. 31546, 20926-51
C
Laser destruction extensive herpetic lesions of the vulva. A. 17106 B. 17004 C. 56515 D. 56501
C
Nonhuman graft for temporary wound closure. Patient has a 5 cm defect on the scalp. A. 15335 B. 15400 C. 15420 D. 15430
C
Patient comes in for steroid injection for lumbar herniated disk. Marcaine and Aristocort were injected into the L2-L3 space. A. 64520 B. 64483 C. 62311 D. 64714
C
Patient comes in through the emergency room with a laceration of the posterior tibial nerve. Patient is taken to the operating room where the nerve requires transposition and suture. A. 64856 B. 64831; 64832; 64876 C. 64840; 64874 D. 64834; 64859; 64872
C
Patient comes in through the emergency room with a wound that was caused by an electric saw. Patient is taken to the operating room where two ulna nerves are sutured. A. 64837 B. 64892; 69990 C. 64836; 64837 D. 64856; 64859
C
Patient diagnosed with cystic hygroma of the axilla, which was excised. A. 38555 B. 11400 C. 38550 D. 38300
C
Patient has a history of chronic alcohol abuse with portal hypertension. Patient has been vomiting blood for the past 3 days and presented to his physician's office. Patient was sent to the hospital for evaluation and an EGD was performed. Biopsy findings showed gastritis, esophagitis and bleeding esophageal varices, which were injected with sclerosing solution. A. 43235; 43244; 43204 B. 43239; 43244 C. 43239; 43243 D. 43239; 43243; 43204
C
Patient has carcinoma of the breast and undergoes proton beam delivery of radiation to the breast with a single port. A. 77523 B. 77432 C. 77520 D. 77402
C
Patient has extensive bladder cancer. She underwent a complete cystectomy with bilateral pelvic lymphadenectomy and creation of ureteroileal conduit. A. 51575; 50820 B. 50825; 51570; 38770 C. 51595 D. 51550; 38770
C
Patient has metastatic brain lesions. Patient undergoes stereotactic radiosurgery gamma knife of two lesions. A. 61533 B. 61500 C. 61796; 61797 D. 61796
C
Patient has rhinorrhea which requires repair of the CSF leak with craniotomy. A. 63707 B. 63709 C. 62100 D. 62010
C
Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a omprehensive history and physical examination. The physician ordered lab work to rule out pancreatitis, along with an ultrasound of the gallbladder and abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made. A. 99244 B. 99222 C. 99254 D. 99204
C
Patient is admitted with alcohol cirrhosis and has a TIPS procedure performed. A. 35476; 36011; 36481 B. 37183 C. 37182 D. 37140
C
Patient presents to the emergency room following an assault. Examination of the patient reveals blunt trauma to the face. Radiology reports that the patient suffers from a fracture to the frontal skull and a blow-out fracture of the orbital floor. Patient is admitted and taken to the operating room where a periorbital approach to the orbital fracture is employed and an implant is inserted. A. 21407; 21275 B. 21387; 61330 C. 21390 D. 61340; 21401
C
Patient presents to the emergency room with chest pains. The patient is admitted as a 23-hour observation. The cardiologist orders cardiac workup and the patient undergoes left heart catheterization via the left femoral artery with visualization of the coronary arteries and left ventriculography. The physician interprets the report. Code the heart catheterization. A. 93452; 93455 B. 93452; 93458 C. 93458 D. 93459
C
Patient presents to the emergency room with lacerations sustained in an automobile accident. Repairs of the 3.3 cm skin laceration of the left leg that involved the fascia, 2.5 cm and 3.0 cm lacerations of the left arm involving the fascia, and 2.7 cm of the left foot, which required simple sutures, were performed. Sterile dressings were applied. A. 12032; 12032-51; 12031-51; 12002-51 B. 12002, 12002-51 C. 12034, 12002-51 D. 13150; 12032-51, 12032-51, 12001-51
C
Patient presents to the emergency room with right lower abdominal pains. Emergency room physician suspects possible appendicitis. Patient was taken to the operating room where a laparoscopic appendectomy was performed. Pathology report was negative for appendicitis. A. 44950 B. 44950; 49320 C. 44970 D. 44901
C
Patient presents to the hospital for debridement of a diabetic ulcer of the left ankle. The patient has a history of recurrent ulcers. Medication taken by the patient includes Diabeta and the patient was covered in the hospital with insulin sliding scales. The decubitus ulcer was debrided down to the bone. 250.70 Diabetes with peripheral circulatory disorders, type II, or unspecified 250.71 Diabetes with peripheral circulatory disorders, type I 250.80 Diabetes with other specified manifestations, type II, or unspecified 250.81 Diabetes with other specified manifestations, type I 707.06 Decubitus ulcer, ankle 707.09 Decubitus ulcer other site 707.20 Pressure ulcer unspecified stage 707.24 Pressure ulcer stage IV, Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone 11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less A. 250.81, 707.06, 707.20, 11044 B. 250.71, 707.24, 11043 C. 250.80, 707.06, 707.24, 11044 D. 250.81, 250.70, 707.09, 707.20, 11044
C
Patient presents to the operating room and undergoes an endovascular repair of an infrarenal abdominal aortic aneurysm utilizing a unibody bifurcated prosthesis. A. 34800; 34813 B. 34802 C. 34804 D. 35081
C
Patient presents to the operating room for excision of a 4.5 cm malignant melanoma of the left forearm. A 6 cm x 6 cm rotation flap was created for closure. A. 14021 B. 11606; 14020 C. 14301 D. 11606; 15100
C
Patient presents with a traumatic partial amputation of the second, third, and fourth fingers on the right hand. Patient was taken to the operating room where completion of the amputation of three fingers was performed with direct closure. A. 26910-F6; 26910-F7; 26910-F8 B. 26843-RT C. 26951-F6; 26951-F7; 26951-F8 D. 26550-RT
C
Patient undergoes hysteroscopy with excision uterine fibroids. A. 58545 B. 58140 C. 58561 D. 58140; 49320
C
Patient underwent anoscopy followed by colonoscopy. The physician examined to colon to 60cm. A. 46600; 45378 B. 46600; 45378-59 C. 45378 D. 45999
C
Patient was admitted for right upper quadrant pain. Workup included various x-rays that showed cholelithiasis. Patient was taken to the operating room where a laparoscopic cholecystectomy was performed. During the procedure, the physician was unable to visualize through the ports and an open cholecystectomy was elected to be performed. Intraoperative cholangiogram was performed. Pathology report states acute and chronic cholecystitis with cholelithiasis. 574.00 Calculus of gallbladder with acute cholecystitis without obstruction 574.10 Calculus of gallbladder with other cholecystitis without obstruction 789.01 Abdominal pain of the right upper quadrant V64.41 Laparoscopic procedure converted to open procedure 47605 Cholecystectomy with cholangiography 47563 Laparoscopy, surgical; cholecystectomy with cholangiography A. 789.01, 574.10, 47563 B. 789.01, 574.00, 574.10, 47563, 47605 C. 574.00, 574.10, V64.41, 47605 D. 574.00, 47563, 47605
C
Patient was admitted to the hospital for removal of excessive tissue due to massive weight loss. Liposuction of the abdomen and bilateral thighs was performed. A. 15830 B. 15830; 15833; 15833 C. 15877; 15879-50 D. 15839
C
Patient was admitted with a cystocele and rectocele. An anterior colporrhaphy was performed. A. 57250 B. 57260 C. 57240 D. 57110
C
Patient was involved in an accident and has been sent to the hospital. During transport the patient develops breathing problems and, upon arrival at the hospital, an emergency transtracheal tracheostomy was performed. Following various x-rays, the patient was diagnosed with traumatic pneumothorax and a thoracentesis with insertion of tube was performed. A. 31603; 31612 B. 31610; 32421 C. 31603; 32422 D. 31603; 32421
C
Patient with Bell's palsy requiring a total facial nerve decompression. A. 64742 B. 64771 C. 69955 D. 64864
C
Patient with a deviated nasal septum that was repaired by septoplasty. A. 30400 B. 30620 C. 30520 D. 30630
C
Pregnant female comes in for a complete fetal and maternal evaluation via ultrasound. A. 76856 B. 76805 C. 76811 D. 76810
C
Priapism operation with spongiosum shunt. A. 54450 B. 54352 C. 54430 D. 55899
C
Repair of retinal detachment with vitrectomy. 67040 Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation 67105 Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid 67108 Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique 67112 Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques A. 67112 B. 67105 C. 67108 D. 67040
C
Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered x-rays of the ankle, which came back negative for a fracture. A problem-focused history and physical examination were performed and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only. A. 99201 B. 99282 C. 99281 D. 99211
C
The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made. A. 99304 B. 99325 C. 99324 D. 99334
C
Tracheostoma revision with flap rotation. 31613 Tracheostoma revision; simple, without flap rotation 31614 Tracheostoma revision; complex, with flap rotation 31750 Tracheoplasty; cervical 31830 Revision of tracheostomy scar A. 31830 B. 31750 C. 31614 D. 31613
C
A 69-year-old established female patient presents to the office with chronic obstructive lung disease, congestive heart failure, and hypertension. The physician conducts a comprehensive history and physical examination and makes a medical decision of moderate complexity. Physician admits the patient from the office to the hospital for acute exacerbation of CHF. 428.0 Congestive heart failure, unspecified 402.91 Hypertensive heart disease, with congestive heart failure 401.9 Essential hypertension, unspecified 401.1 Essential hypertension, benign 496 Chronic obstructive pulmonary disease 99212 Established office visit for problem-focused history and exam, straightforward medical decision making 99214 Established office visit for a detailed history and exam, moderate medical decision making 99222 Initial hospital care for comprehensive history and exam, moderate medical decision making 99223 Initial hospital care for comprehensive history and exam, high medical decision making A. 402.91; 496; 99214 B. 428.0; 496; 401.1; 99223 C. 428.0; 496; 401.9; 99222 D. 402.91; 496; 401.1; 99212
C According to CPT guidelines, when a patient is admitted to the hospital on the same day as an office visit, the office visit is not billable. Code rules do not allow the use of 402.91 because the scenario given does not state that the patient has hypertensive heart disease.
A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. A. 45385; 45385-51; 45385-51 B. 45385; 99144 C. 45385 D. 45385, 45385-51, 45385-51, 99144
C CPT designates certain procedures as including moderate sedation; therefore moderate sedation is included in the code for the removal of polyps.
Caloric vestibular test using air. A. 92543; 92700 B. 92543; 92543 C. 92700 D. 92543
C Code 92543 is for use when an irrigation substance is used.
Patient is admitted to the hospital with facial droop and left-sided paralysis. CT scan of the brain shows subdural hematoma. Burr holes were performed to evacuate the hematoma. 432.1 Subdural hemorrhage 852.20 Subdural hemorrhage following injury without mention of open intra-cranial wound, unspecified state of unconsciousness 61150 Burr hole(s) or trephine; with drainage of brain abscess or cyst 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural 61156 Burr hole(s); with aspiration of hematoma or cyst, intracerebral 61314 Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural A. 852.20; 61156 B. 432.1; 61314 C. 432.1; 61154 D. 852.20; 61150
C Codes starting with 852 are considered to be traumatic injuries. No injury was stated in the case, so 432.1, nontraumatic subdural hematoma, would be the appropriate code.
A physician orders a lipid panel on a 54-year-old male with hypercholesterolemia, hypertension, and a family history of heart disease. The lab employee in his office performs and reports the total cholesterol and HDL cholesterol only. 272.0 Pure hypercholesterolemia 401.9 Essential hypertension, unspecified 402.90 Hypertensive heart disease, unspecified, without heart failure V17.49 Family history of other cardiovascular disease 80061 Lipid panel; this panel must include the following: Cholesterol, serum, total (82465); Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718); Triglycerides (84478) 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 84478 Triglycerides 52 Reduced services A. 272.0, 80061-52 B. 272.0, 401.9, V17.49, 80061-52 C. 272.0, 401.9, V17.49, 82465, 83718 D. 272.0, 402.90, 82465, 83718
C In order to use the code for the panel, every test must have been performed.
. Patient has ovarian vein syndrome and has ureterolysis performed. A. 58679 B. 58660 C. 52351 D. 50722
D
A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and 10 minutes providing critical care for this patient. A. 99281, 99291, 99292, 94002 B. 99291, 99292, 94002 C. 99291, 94002 D. 99291
D
Administration of initial oral radionuclide therapy for hyperthyroidism A. 78015 B. 77402 C. 78099 D. 79005
D
An established patient was seen in her primary physician's office. The patient fell at home and came to the physician's office for an examination. Due to a possible concussion, the patient was sent to the hospital to be admitted as an observation patient. A detailed history and examination were performed and the medical decision was low complexity. The patient stayed overnight and was discharged the next afternoon. A. 99214; 99234 B. 99214; 99218; 99217 C. 99218 D. 99218; 99217
D
Bronchoscopy with multiple transbronchial right upper and right lower lobe lung biopsy with fluoroscopic guidance. A. 31628-RT; 76000-RT B. 31717-RT; 31632-RT C. 32405-RT D. 31628-RT; 31632-RT
D
Cesarean delivery with antepartum and postpartum care. A. 59610 B. 59514 C. 59400 D. 59510
D
Clotting factor VII. A. 85220 B. 85240 C. 85362 D. 85230
D
Code anesthesia for total hip replacement. A. 01210 B. 01402 C. 01230 D. 01214
D
Code anesthesia for total shoulder replacement. A. 01760 B. 01630 C. 01402 D. 01638
D
Decompression internal auditory canal. A. 69979 B. 69915 C. 69970 D. 69960
D
First-stage repair for hypospadias with skin flaps. A. 54300 B. 54308; 14040 C. 54322 D. 54304
D
Huhner test and semen analysis. A. 89325 B. 89258 C. 89310 D. 89300
D
Lacrimal fistula closure. A. 68760 B. 68761 C. 68700 D. 68770
D
Laparoscopic repair of umbilical hernia. 49580 Repair umbilical hernia, under age 5 years, reducible 49585 Repair umbilical hernia, age 5 years or over, reducible 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion when performed); reducible 49654 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion when performed); reducible A. 49580 B. 49654 C. 49585 D. 49652
D
Laparoscopic takedown of the splenic flexure and a partial colectomy with anastomosis. A. 44140, 44213 B. 44204 C. 44213 D. 44204, 44213
D
Pathologist bills for gross and microscopic examination of medial meniscus. A. 88300 B. 88302; 88311 C. 88325 D. 88304
D
Patient arrives to the hospital and has a Nissen fundoplasty done laparoscopically. A. 43410 B. 43415 C. 43502 D. 43280
D
Patient comes in for a percutaneous needle biopsy of the thyroid gland. A. 60000 B. 60270 C. 60699 D. 60100
D
Patient comes into his physician's office complaining of wrist pain. Physician sends the patient to the hospital for an arthrography. Code the complete procedure. A. 73115 B. 73100 C. 73110 D. 25246; 73115
D
Patient has a Bartholin's gland cyst that was marsupialized. A. 54640 B. 10060 C. 58999 D. 56440
D
Patient has been diagnosed with carcinoma of the vagina and she has a radical vaginectomy with complete removal of the vaginal wall. A. 57107 B. 57110 C. 58150 D. 57111
D
Patient has been diagnosed with metastatic laryngeal carcinoma. Patient underwent subtotal supraglottic laryngectomy with radical neck dissection. A. 31540 B. 31367 C. 31365 D. 31368
D
Patient has been diagnosed with prostate cancer. Patient arrived in the operating room where a therapeutic orchiectomy is performed. A. 54560 B. 54530 C. 55899 D. 54520
D
Patient has been on the bone marrow transplant recipient list for 3 months. A perfect match was made and the patient came in and received peripheral stem cell transplant. A. 38242 B. 38230 C. 38241 D. 38240
D
Patient has breast carcinoma and is now undergoing sentinel node biopsy. Patient was injected for sentinel node identification and two deep axillary lymph nodes showed up intensely. These two lymph nodes were completely excised. Path report was positive for metastatic carcinoma. A. 38525; 38790 B. 38589 C. 38308; 38790 D. 38525; 38792
D
Patient is 6 weeks' pregnant and complains of left-sided abdominal pains. Patient is suspected of having an ectopic pregnancy. Patient has a laparoscopic salpingectomy with removal of the ectopic tubal pregnancy. A. 59120 B. 59200 C. 59121 D. 59151
D
Patient is at a fertility clinic and undergoes intrauterine embryo transplant. A. 58679 B. 58322 C. 58323 D. 58974
D
Patient is brought to the emergency room following a shark attack. The paramedics have the patient's amputated foot. The patient is taken directly to the operating room to reattach the patient's foot. A. 28800 B. 28200; 28208 C. 28110 D. 20838
D
Patient presents to the Respiratory Therapy Department and undergoes a pulmonary stress test. CO 2 production with O 2 uptake with recordings was also performed. A. 94450 B. 94620 C. 94002 D. 94621
D
Patient presents to the emergency room complaining of right forearm/elbow pain after racquetball last night. Patient states that he did not fall, but overworked his arm. Past medical history is negative and the physical examination reveals the patient is unable to supinate. A four-view x-ray of the right elbow is performed and is negative. The physician signs the patient out with right elbow sprain. Prescription of Motrin is given to the patient. 841.2 Sprain of radiohumeral joint 841.8 Sprain of other specified sites of the elbow and forearm 841.9 Sprain of unspecified site of the elbow and forearm E000.8 External cause status E008.2 Activities involving racquet and hand sports E927.2 Excessive physical exertion from prolonged activity E928.9 Unspecified accident 73040 X-ray of shoulder, arthrography radiological supervision and interpretation 73070 X-ray of elbow, two views 73080 X-ray of elbow, complete, minimum of three views 99281 E/M visit to emergency room—problem-focused history, problem-focused exam, straightforward medical decision. 99282 E/M visit to emergency room—expanded problem-focused history, expanded problem-focused exam, and medical decision of low complexity -25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. A. 841.8, 73080 B. 841.9, E928.9, 99281, 73070, E000.8, E008.2 C. 841.2, 73080, 99282, 73040 D. 841.9, E927.2, 99281-25, E000.8, E008.2, 73080
D
Patient presents to the hospital for a three-view x-ray of the right shoulder. The diagnosis is shoulder pain and the radiology report states the patient has a dislocated shoulder. What would be the correct codes to report to the insurance company? 719.41 Shoulder pain 831.00 Closed dislocation shoulder, unspecified 831.01 Closed dislocation shoulder, anterior 73020 Radiologic examination, shoulder; one view 73030 Radiologic examination, shoulder; complete, minimum of two views 73060 Radiologic examination; humerus, minimum of two views RT Right side A. 831.00; 73060-RT B. 719.41; 73020-RT C. 831.01; 73030-RT D. 831.00; 73030-RT
D
Patient presents to the hospital for skin grafts due to previous third-degree burns. The burn eschar of the back was removed. Once the eschar was removed, the defect size measured 10 cm x 10 cm. A skin graft from a donor bank was placed onto the defect and sewn into place as a temporary wound closure. A. 15170, 15002 B. 15300 C. 15002, 15200 D. 15002, 15300
D
Patient presents to the hospital with right ureteral calculus. Patient is taken to the operating room where a cystoscopy with ureteroscopy is performed to remove the calculus. A. 52353 B. 52310 C. 51065 D. 52352
D
Patient presents to the hospital with ulcer of the right foot. Patient is taken to the operating room where a revision of the right metatarsal head is performed. A. 28104-RT B. 28111-RT C. 28288-RT D. 28899-RT
D
Patient presents to the operating room where a CABG x 3 is performed using the mammary artery and two sections of the saphenous vein. A. 33534; 33511 B. 33534; 33518; 33511 C. 33535 D. 33533; 33518
D
Patient presents to the radiology department where a fine-needle aspiration of the breast is performed utilizing computer tomography. A. 19120; 77012 B. 19102 C. 19125 D. 10022, 77012
D
Patient requires repair of a 6 cm meningocele. A. 63700 B. 63709 C. 63180 D. 63702
D
Patient suffers from strabismus and requires surgery. Recession of the lateral rectus (horizontal) muscle with adjustable sutures was performed. A. 67340; 67500 B. 67314; 67320 C. 67332; 67334 D. 67311; 67335
D
Patient undergoes ocular resurfacing construction utilizing stem cell allograft from a cadaver. A. 67320 B. 66999 C. 68371 D. 65781
D
Patient undergoes partial nephrectomy for carcinoma of the kidney. 50220 Nephrectomy, including partial ureterectomy, any open approach including rib resection 50234 Nephrectomy with total ureterectomy and bladder cuff; through same incision 50240 Nephrectomy, partial 50340 Recipient nephrectomy (separate procedure) A. 50234 B. 50220 C. 50340 D. 50240
D
Patient was admitted to the hospital with sharp pelvic pains. A pelvic ultrasound was ordered and the results showed a possible ovarian cyst. The patient was taken to the operating room where a laparoscopic destruction of two corpus luteum cysts was performed. A. 49321 B. 58925 C. 58561 D. 58662
D
Patient with a traumatic rupture of the eardrum. Repaired with tympanoplasty with incision of the mastoid. Repair of ossicular chain not required. A. 69641 B. 69646 C. 69642 D. 69635
D
Patient with chronic otitis media requiring eustachian tube catheterization. A. 69400 B. 69424 C. 69421 D. 69405
D
Placement of double-J stent. 52320 Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus 52330 Cystourethroscopy; with manipulation, without removal of ureteral calculus 52332 Cystourethroscopy with insertion of indwelling ureteral stent (e.g. Gibbons or double-J type) 52341 Cystourethroscopy, with treatment of ureteral stricture (e.g. balloon dilation, laser electrocautery, and incision) A. 52341 B. 52320 C. 52330; 52332 D. 52332
D
Radial keratotomy. A. 92070 B. 65855 C. 65767 D. 65771
D
Spinal tap. 62268 Percutaneous aspiration, spinal cord cyst or syrinx 62270 Spinal puncture, lumbar diagnostic 62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 64999 Unlisted procedure, nervous system A. 62272 B. 64999 C. 62268 D. 62270
D
The patient is on vacation and presents to a physician's office with a lacerated finger. The physician repairs the laceration and gives a prescription for pain control and has the patient follow up with his primary physician when he returns home. The physician fills out the superbill as a problem-focused history and examination with straightforward medical decision making. Also checked is a laceration repair for a 1.5 cm finger wound. 99201 New patient office visit with a problem-focused history, problem-focused examination and straightforward medical decision making 99212 Established patient office visit with a problem-focused history, problem-focused examination and straightforward medical decision making 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm A. 99212; 13131 B. 12001 C. 99212; 12001 D. 99201; 12001
D
Tonsillectomy on a 14-year-old. 42820 Tonsillectomy and adenoidectomy; under age 12 42821 Tonsillectomy and adenoidectomy; age 12 or over 42825 Tonsillectomy, primary or secondary; under age 12 42826 Tonsillectomy, primary or secondary; age 12 or over A. 42820 B. 42821 C. 42825 D. 42826
D
Transesophageal echocardiography (TEE) with probe placement, image, and interpretation and report. A. 93307 B. 93303; 93325 C. 93312; 93313; 93314 D. 93312
D
Trauma patient is rushed to the operating room with multiple injuries. The patient had his spleen removed due to massive rupture with repair of lacerated diaphragm. A. 38115; 39501 B. 38120; 39599 C. 38102; 39540 D. 38100; 39501
D
Trauma patient was rushed to the operating room with multiple injuries. Open reduction with internal fixation of intertrochanteric femoral fracture; open reduction of the tibial and fibula shaft with internal fixation was performed. A. 27245; 27759 B. 20690 C. 27248; 27756 D. 27244; 27758
D
Unilateral mammogram with computer-aided detection with further physician review and interpretation. A. 77055, 77032 B. 77055-22 C. 77056-52, 77051 D. 77055, 77051
D
Upper lobectomy of the right lung with repair of the bronchus. A. 32480 B. 32486 C. 32320 D. 32480, 32501
D
Ureterolithotomy completed laparoscopically. 50600 Ureterotomy with exploration or drainage (separate procedure) 50945 Laparoscopy, surgical ureterolithotomy 52325 Cystourethroscopy; with fragmentation of ureteral calculus 52352 Cystourethroscopy, with urethroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) A. 52352 B. 52325 C. 50600 D. 50945
D
Vitamin B 1 2. 82180 Ascorbic acid (vitamin C), blood 82607 Cyanocobalamin (vitamin B12) 84590 Vitamin A 84591 Vitamin, not otherwise specified A. 84590 B. 82180 C. 84591 D. 82607
D
What code is used for a culture of embryos less than 4 days? A. 89251 B. 89272 C. 89268 D. 89250
D
Young child presents with cleft lip and cleft palate. This is the first attempt of repair, which includes major revision of the cleft palate and unilateral cleft lip repair. A. 42200; 40701 B. 42225; 40700 C. 42220; 40720 D. 42215; 40700
D
Established 42-year-old patient comes into your office to obtain vaccines required for his trip to Sri Lanka. The nurse injects intramuscularly the following vaccines: hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As the coding specialist, what would you report on the CMS 1500 form? A. office visit, hepatitis A and B vaccine, cholera vaccine and yellow fever vaccine B. office visit, intramuscular injection; HCPCS Level II codes C. office visit; administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever D. Administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever.
D According to the CPT coding guidelines for vaccines, only a separate identifiable Evaluation and Management code may be billed in addition to the vaccine. In this scenario, the patient was seen only for his vaccines. This guideline immediately eliminates all the other answers.
Patient presents with a history of upper abdominal pain. Cholangiogram was negative and patient was sent to the hospital for ERCP. During the procedure the sphincter was incised and a stent was placed for drainage. A. 43260; 43262; 43264 B. 43262; 43269 C. 43267 D. 43262; 43268
D Radiology codes would be used for the supervision and interpretation.
Hysterotomy for hydatidifom mole and tubal ligation. A. 58285; 58600 B. 58150; 58605 C. 51900; 58605 D. 59100; 58611
D When tubal ligation is performed at the same time as hysterotomy, use 58611 in addition to 59100