RHIA- CH 9-CPT coding

Patient has recurrent spontaneous pneumothorax, which has resulted in a chemical pleurodesis by thoracoscopy.

32650

surgical thorascopy with control of a traumatic hemorrhage

32654

Patient undergoes ocular resurfacing construction utilizing stem cell allograft from a cadaver.

65781

Code anesthesia for upper abdominal ventral hernia repair.

00752

thyroidectomy, including the substernal thyroid, by cervical approach

60271

re-exploration of the parathyroids

60502

Aphakia penetrating corneal transplant.

65750

Radial keratotomy

65771

Male presented to operating room for sterilization by bilateral vasectomy.

55250

Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.

-25

Which of the following indicates a co-surgeon? a) -80 b) -81 c) -66 d) -62

-62

The modifier for a repeat procedure by the same physician is ______? a) -79 b) -78 c) -77 d) -76

-76

Code anesthesia for corneal transplant.

00144

Code anesthesia for decortication of left lung.

00542

Code anesthesia for vaginal hysterectomy.

00944

anesthesia for procedures on bony pelvis

01120

Code anesthesia for total hip replacement.

01214

Code anesthesia for total shoulder replacement.

01638

Code anesthesia for placement of vascular shunt in forearm.

01844

Code anesthesia for cesarean section

01961

Patient presents to the radiology department where a fine-needle aspiration of the breast is performed utilizing computed tomography.

10022, 77012

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.

11044

Patient presents to the operating room for excision of three lesions. The 1.5-cm and 2-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.

11604, 11420

The code for a simple repair of superficial scalp would not exceeding 2.5 cm in length is ___________? a) 120011 b) 12011 c) 12031 d) 13100

12001

Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5 cm and 2.7 cm.

12034

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-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.

12034, 12002-59

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-cm benign lesion of the cheek was excised and was repaired with a rotation skin graft.

14040, 11604

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.

14301 14301 - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

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

15002, 15273

A 10-square-centimeter epidermal autograft to the face from the back.

15115

Nonhuman graft for temporary wound closure. Patient has a 5-cm defect on the scalp.

15275

Facelift utilizing the superficial musculoaponeurotic system (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; SMAS flap

15829

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.

15877, 15879-50

Patient presents to the operating room where the physician performed, using imaging guidance, a percutaneous breast biopsy utilizing a rotating biopsy device.

19081

The code for a percutaneous needle core breast biopsy (without imaging) is _________? a) 19100 b) 76095 c) 19101 d) 19102

19100

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.

19120-LT

The preoperative placement of a needle localization wire in the breast is coded _________? a) 19100 b) 19291 c) 19290 d) 19295

19290

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.

20838

The code for harvesting a small bone graft when the graft is not already listed as a part of the procedure is _________? a) 27170 b) 20930 c) 20936 d) 20900

20900

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.

21390

Open I&D of a deep abscess of the cervical spine.

22010

Chronic nontraumatic rotator cuff tear. Arthroscopic subacromial decompression with coracoacromial ligament release, and open rotator cuff repair.

23412, 29826-59

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.

24505-LT

excision of lesion of the tendon sheath of the forearm

25110

excision of a bone cyst of the carpal bones with auto graft

25135

incision and drainage of an infect bursa on the ankle

27604

Patient comes into his physician's office complaining of wrist pain. Physician gives the patient an injection and sends the patient to the hospital for an arthrography. Code the complete procedure.

25246, 73115

osteotomy of the radius and ulna

25365

open treatment of an ulnar styloid fracture

25652

krukenburg procedure

25915

The code for a simple drainage of a finger abcess is ________? a) 26011 b) 26010 c) 26951 d) 26034

26010

Patient presents to the hospital with a right index trigger finger. Release of the trigger finger was performed.

26055-F6

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.

26951-F6, 26951-F7, 26951-F8

open tenotomy of the hip adductor.

27001

primary coccygectomy

27080

Girdlestone procedure

27122

osteotomy of the femoral neck

27161

open treatment of a coccygeal fracture.

27202

Trauma patient was rushed to the operating room with multiple injuries. Open reduction with internal fixation of intertrochanteric femoral fracture, and open reduction of the tibial and fibula shaft with internal fixation was performed.

27244, 27758

hamstring muscle neurectomy

27325

The code for a complex arthotomy of the knee (lateral) with menisectomy is ________? a) 27332 b) 27332-22 c) 27333 d) 27333-22

27332-22

radical resection of femoral tumor

27365

injection of contrast for a knee arthropathy

27370

dr. performs a knee arthrotomy with meniscus repair

27403

femur legthening osteoplasty

27466

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.

27532-LT

physician excises a 3.2 cm subcutaneous tumor from the soft tissue of the leg.

27632

radical resection of a tumor of the calcaneus

27647

The code for repair of a flexor tendon of the leg is _______? a) 27650 b) 27658 c) 27658 x2 d) 27659

27658

If an arthroplasty is performed for reasons of a fractured ankle, is is called __________? a) 20605 b) 27700 c) 27870 d) 29891

27700

proximal fibula fracture without manipulation.

27780

closed treatment of proximal tibiofibular joint dislocation requiring anesthesia

27831

The code for the complicated removal of a subcutaneous foreign body of the foot is ________? a) 28190 b) 28192 c) 28193 d) 11010

28193

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.

28292

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.

28899-RT

Patient with a deviated nasal septum that was repaired by septoplasty.

30520

Patient presents to the surgical unit and undergoes unilateral nasal endoscopy, partial ethmoidectomy, and maxillary antrostomy.

31254, 31256-51

Patient has been diagnosed with metastatic laryngeal carcinoma. Patient underwent subtotal supraglottic laryngectomy with radical neck dissection.

31368

The appropriate code for an indirect laryngoscopy with removal of foreign body is __________? a) 31505 b) 31530 c) 31511 d) 31512

31511

Laryngoscopic stripping of vocal cords for leukoplakia of the vocal cords.

31540

Lye burn of the larynx repaired by laryngoplasty.

31588

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. A thoracentesis with insertion of tube was performed.

31603, 32555

Patient with laryngeal cancer has a tracheoesophageal fistula created and has a voicebox inserted.

31611

doctor performs a simple tracheostoma revision without flap rotation

31613

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

31614

tracheobronchoscopy through an establishes tracheostomy incision

31615

Patient has a bronchoscopy with endobronchial biopsies of three sites.

31625

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. 31625 Bronchoscopy with bronchial or endobronchial 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)

31628, 32480

Bronchoscopy with multiple transbronchial right upper and right lower lobe lung biopsy with fluoroscopic guidance.

31628-RT, 31632-RT

bronchoscopy with removal of foreign body

31635

nasotracheal catherter aspiration

31720

revision if tracheostomy scar

31830

unilateral thoracotomy with diagnostic biopsies of lung infiltrates

32096

thoracotomy for postoperative complications

32120

Upper lobectomy of the right lung with repair of the bronchus.

32480, 32501

removal of an indwelling tunneled pleural catheter with cuff

32552

percutaneous pleural drainage with insertion of an indwelling catheter with imaging guidance

32557

Which code describes a surgical thoracoscopy with excision-plication of bullae as well as pleural procedures? a) 32650 b) 32601 c) 32655 d) 32656

32655

Patient presents to the operating room where a CABG x 3 is performed using the mammary artery and two sections of the saphenous vein.

33533, 33518

The code for a coronary artery bypass graft using three arterial grafts is _______? a) 33535 b) 33534 c) 33533 d) 33510

33535

Patient undergoes construction of apical aortic conduit with an insertion of a single-ventricle ventricular assist device.

33975

Patient presents to the operating room and undergoes an endovascular repair of an infrarenal abdominal aortic aneurysm utilizing a unibody bifurcated prosthesis.

34804

Patient complains of recurrent syncope following carotid thromboendarterectomy. Patient returns 2 weeks after initial surgery and undergoes repeat carotid thromboendarterectomy.

35301

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.

35371

Patient returns to the operating room following open-heart bypass for exploration of blood vessel to control postoperative bleeding in the chest.

35820

The physician punctures the left common femoral to examine the right common iliac.

36245

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

36430

Eighty-year-old patient has carcinoma and presents to the operating room for placement of a tunneled implantable centrally inserted venous access port.

36561

Patient is admitted with alcohol cirrhosis and has a TIPS procedure performed.

37182 transvenous intrahepatic portosystemic shunt(s) (TIPS)

Patient undergoes percutaneous transluminal iliac artery balloon angioplasty.

37220

Trauma patient is rushed to the operating room with multiple injuries. The patient had his spleen removed due to a massive rupture, with repair of the lacerated diaphragm.

38100, 39501

Patient has a bone marrow aspiration of the iliac crest and of the tibia.

38220, 38220-59

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 a peripheral stem cell transplant.

38240

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.

38525, 38792

Patient diagnosed with cystic hygroma of the axilla, which was excised.

38550

Laparoscopic retroperitoneal lymph node biopsy.

38570

Laparoscopy with multiple biopsies of retroperitoneal lymph nodes.

38570

Cannulation of the thoracic duct

38794

Excision of mediastinal cyst.

39200

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.

42215, 40700

Hydrocelectomy of spermatic cord.

55500

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 re-creation of defect and reclosure 42145 Palatopharyngoplasty 42220 Palatoplasty for cleft palate; secondary lengthening procedure 42226 Lengthening of palate and pharyngeal flap

42220

Injection snoreplasty for treatment of palatal snoring.

42299

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

42826

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.

43239, 43243

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.

43274

Patient arrives to the hospital and has a Nissen fundoplasty done laparoscopically.

43280

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.

43336

Laparoscopic gastric banding.

43770

The appropriate code for a gastrojejunostomy without vagotomy is _________? a) 43820 b) 43810 c) 43860 d) 48547

43820

Morbidly obese patient comes in for vertical banding of the stomach.

43842

excision of two lesions of the large intestine with a single enterotomy

44110

physician performs an intestinal allotransplanation from a living donor.

44136

The code for a partial colectomy with anastomosis is __________? a) 44140 b) 44141 c) 44140 -52 d) 44150

44140

total abdominal colectomy with proctectomy and ileostomy.

44155

small intestinal endoscopy via enteroscopy beyond the second portion of duodenum including the ilium with control of bleeding

44378

stomal colonscopy with removal of foreign bodies

44390

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.

44970

Patient underwent anoscopy followed by colonoscopy. The physician examined the colon to 60 cm.

45378

Ultrasonic guidance for the needle biopsy of the liver. Code the complete procedure.

47000, 76942

hepatectomy with a total left lobectomy

47125

hepatectomy from a cadaver donor, including the graft and cold preservation

47133

backbench reconstruction of a living donor liver graft prior to allotransplantation with venous anastomosis

47146

marsupialization of a cyst of the liver

47300

percutaneous cryoablation of two liver tumors

47383

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. An intraoperative cholangiogram was performed. Pathology report states acute and chronic cholecystitis with cholelithiasis.

47605

open drainage of a retroperitoneal abscess

49060

peritoneal lavage with imaging guidance

49084

physician removes a peritoneal-venous shunt

49429

physician repairs a lumbar hernia

49540

repair of a spigelian hernia

49590

Patient undergoes total thyroidectomy with parathyroid autotransplantation.

60240, 60512

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

49652

Basic CPT codes use ___________? a) 3 to 5 digits b) 5 digits c) 2 digits d) 3 digits

5 digits

Nephrectomy with resection of half of the ureter

50220

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)

50240

Removal of nephrostomy tube with fluoroscopic guidance.

50389

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.

50541

Patient has ovarian vein syndrome and has ureterolysis performed.

50722

Closure of ureterocutaneous fistula.

50920

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)

50945

tranvesical ureterolithotomy

51060

complete cystectomy with ureterosigmoidostomy

51580

Patient has extensive bladder cancer. She underwent a complete cystectomy with bilateral pelvic lymphadenectomy and creation of ureteroileal conduit.

51595

complicated change of a cystostomy tube

51710

simple cystometrogram

51725

closure of a vesicouterine fistula

51920

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.

51990

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.

52234

Excision of 2.5-cm bladder tumor with cystoscopy.

52235

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

52352

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.

52648

Male with urinary incontinence. Sling procedure was performed 6 months ago and now the patient has returned for a revision of the sling procedure.

53442

Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy.

53852

Laser destruction of penile condylomas.

54057

First-stage repair for hypospadias with skin flaps.

54304

Priapism operation with spongiosum shunt.

54430

Patient has been diagnosed with prostate cancer. Patient arrived in the operating room where a therapeutic orchiectomy is performed.

54520

Patient undergoes laparoscopic orchiopexy for intra-abdominal testes.

54692

Scrotal wall abscess drainage.

55100

Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician's office 2 weeks ago and the final pathology was positive for carcinoma. Patient is admitted for prostatectomy. The 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.

55815

Patient has a Bartholin's gland cyst that was marsupialized.

56440

Laser destruction of extensive herpetic lesions of the vulva.

56515

Patient has been diagnosed with carcinoma of the vagina, and she has a radical vaginectomy with complete removal of the vaginal wall.

57111

Patient was admitted with a cystocele and rectocele. An anterior colporrhaphy was performed.

57240

Patient has been diagnosed with uterine fibroids and undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy.

58150

Which code describes a laparoscopic vaginal hysterectomy with the removal of the ovaries? a) 58150 b) 58260 c) 58262 d) 58552

58262

Hysteroscopy with D&C and polypectomy.

58558

Patient undergoes hysteroscopy with excision uterine fibroids.

58561 uterine fibroids - leiomyomata

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.

58662

Laparoscopic tubal ligation utilizing Endoloop.

58671

Patient is at a fertility clinic and undergoes intrauterine embryo transplant

58974

Patient is admitted to the hospital following an ultrasound at 25 weeks, which revealed fetal pleural effusion. A fetal thoracentesis was performed.

59074

Hysterotomy for hydatidifom mole and tubal ligation.

59100, 58611

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.

59151

A D&C is performed for postpartum hemorrhage.

59160

A pregnant patient has an incompetent cervix, which was repaired using a vaginal cerclage.

59320

A code indicating a vaginal delivery only, not including obstetric care, is _____________? a) 59409 b) 59410 c) 59610 d) 59561

59409

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.

59409

Cesarean delivery with antepartum and postpartum care.

59510

Attempted vaginal delivery in a previous cesarean section patient, which resulted in a repeat cesarean section.

59620

D&C performed for patient with a diagnosis of incomplete abortion at 8 weeks.

59812

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.

59855

The CPT manual is divided into how mayn sections? a) 6 b) 5 c) 4 d) 8

6

Patient comes in for a percutaneous needle biopsy of the thyroid gland

60100

Unilateral partial thyroidectomy.

60210

unilateral partial thyroid lobectomy.

60210

complete thyroidectomy

60240

Left carotid artery excision for tumor of carotid body.

60605

excision of a carotid body tumor with excision of the carotid artery

60605

Laparoscopic adrenalectomy, complete.

60650

Patient has metastatic brain lesions. Patient undergoes stereotactic radiosurgery gamma knife of two lesions.

61796, 61797

Patient with Parkinson's disease is admitted for insertion of a brain neurostimulator pulse generator with one electrode array.

61885

Patient has rhinorrhea, which requires repair of the CSF leak with craniotomy.

62100

Patient comes in for steroid injection for lumbar herniated disk. Marcaine and Aristocort were injected into the L2-L3 space.

62311

Laminectomy and excision of intradural lumbar lesion.

63272

Patient requires repair of a 6-cm meningocele.

63702

Patient has right sacroiliac joint dysfunction and requires a right S2-S3 paravertebral facet joint anesthetic nerve block with image guidance.

64493

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.

64836, 64837

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.

64840, 64874

Patient undergoes enucleation of left eye, and muscles were reattached to an implant.

65105-LT

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.

66821

Patient suffers from strabismus and requires surgery. Recession of the lateral rectus (horizontal) muscle with adjustable sutures was performed.

67311, 67335

Correction of trichiasis by incision of lid margin

67830

Lagophthalmos correction with implantation using gold weight.

67912

Patient is admitted for a blepharoplasty of the left lower eyelid and a repair for a tarsal strip of the left upper lid.

67917-E1, 15820-E2

Lacrimal fistula closure.

68770

Drainage of simple external ear abscess.

69000

Patient comes into the office for removal of impacted earwax

69210

Modified radical mastoidectomy.

69505

Patient came in for excision of a middle ear lesion.

69540

Myringoplasty

69620

Patient with a traumatic rupture of the eardrum. Repaired with tympanoplasty with incision of the mastoid. Repair of ossicular chain not required.

69635

Patient with chronic otitis media requiring eustachian tube catheterization.

69799

Insertion of cochlear device inner ear.

69930

Patient with Bell's palsy requiring a total facial nerve decompression.

69955

Decompression internal auditory canal

69960

CT scan of the head with contrast.

70460

radiologic examination of the spine for a scoliosis study, including supine and erect studies

72090

CT of the cervical spine without contrast material.

72125

Patient comes into the outpatient department at the local hospital for an MRI of the cervical spine with contrast. Patient status post automobile accident.

72142

MRI of the lumbar spinal canal and contents without contrast material

72148

MRI of the pelvis with contrast materials

72196

radiological supervision and interpretation of a lumbar discography

72295

Patient undergoes x-ray of the foot with three views.

73630

Obstetric patient comes in for a pelvimetry with placental placement.

74710

Pregnant female comes in for a complete fetal and maternal evaluation via ultrasound.

76811

Unilateral mammogram with computer-aided detection with further physician review and interpretation.

77055, 77051

Patient has carcinoma of the breast and undergoes proton beam delivery of radiation to the breast with a single port.

77520

parathyroid planar imaging

78070

bone marrow imaging of the whole body

78104

diagnostic tomographic bone imaging.

78320

cardiac shunt detection

78428

pulmonary ventilation and perfusion imaging

78582

Administration of initial oral radionuclide therapy for hyperthyroidism.

79005

Basic metabolic panel (calcium, total) and total bilirubin.

80048, 82247

The CPT that appropriately describes a set of obstetric laboratory test for the first obstetric visit is _______? a) 59409 b) 80050 c) 80055 d) 86762

80055

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. 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

82465, 83718

Clotting factor VII

85230

Partial thromboplastin time utilizing whole blood

85730

Chlamydia culture

87110

Pathologist performs a postmortem examination, including the brain, of an adult. Tissue is sent to the lab for microscopic examination.

88025

Cytopathology of cervical Pap smear with automated thin-layer preparation utilizing computer screening and manual rescreening under physician supervision

88175

Gross Exam

88300

Appendix (incidental) (gross exam)

88302

Fallopian Tube (sterilization)-(gross exam)

88302

Finger/toe amputation (traumatic)-(gross exam)

88302

Foreskin (newborn)-(gross exam)

88302

Hernia sac-(gross exam)

88302

Nerve-(gross exam)

88302

Thymus (incidental)-(gross exam)

88302

Vas deferens (sterilization)-(gross exam)

88302

Appendix (other then incidental)-(gross exam)

88304

Arterial/Ventricular (aneurysm)-(gross exam)

88304

Bone fragments (other than Path fracture)-(gross exam)

88304

Carpal Tunnel Tissue-(gross exam)

88304

Cartilage shavings-(gross exam)

88304

Cornea-(gross exam)

88304

Femoral head (other than fracture)-(gross exam)

88304

Foreskin (other than newborn)-(gross exam)

88304

Gallbladder(gross exam)

88304

Ganglion cyst(gross exam)

88304

Hematoma (gross exam)

88304

Hemorrhoids (gross exam)

88304

Intervertebral disc (gross exam)

88304

Nasal/sinusoidal Polyp (inflammatory) (gross exam)

88304

Pathologist bills for gross and microscopic examination of medial meniscus.

88304

Femoral head (fracture)-(gross exam)

88305

The highest level of pathology coding which would include examination of neoplastic tissue or very involved specimens is __________? a) 90703 b) 90698 c) 90700 d) 90715

88309

What code is used for a culture of embryos less than 4 days old?

89250

Huhner test and semen analysis.

89300

When using CPT codes to indicate an unlisted procedure, the last digit will usually be a _______? a) 9 b) 2 c) 3 d) 4

9

Which code indicates an immunization for tetanus toxoid? a) 90703 b) 90698 c) 90700 d) 90715

90703

Caloric vestibular test using air.

92700 unlisted procedure code because of the use of air

A physician performs a PTCA with drug-eluting stent placement in the left anterior descending artery and angioplasty only in the right coronary artery.

92928-LD, 92920-RC

Cardioversion of cardiac arrhythmia by external forces.

92960

Transesophageal echocardiography (TEE) with probe placement, image, and interpretation and report.

93312

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.

93458

Which code listed below would be used to report an esophageal electrogram during an EPS?

93615

Patient presents to the Respiratory Therapy Department and undergoes a pulmonary stress test. CO2 production with O2 uptake with recordings was also performed.

94621

IV push of one antineoplastic drug.

96409

One-half hour of IV chemotherapy by infusion followed by IV push of a different drug.

96413, 96411

Osteopathic manipulative treatment to three body regions.

98926

Patient with hematochromatosis had a therapeutic phlebotomy performed on an outpatient basis.

99195

A 55-year-old man is seen by the dermatologist for the first time and complains of two cystic lesions on his back. Considering that the patient is otherwise healthy and has a primary care physician caring for him, the dermatologist focuses the history of the present illness on the skin lesions (problem focused history) and focuses the problem focused physical examination on the patient's trunk. The physician concludes with straightforward decision making that the lesions are sebaceous cysts. The physician advises the patient that the lesions should be monitored for any changes, but that no surgical intervention is warranted at this time. CPT Code: ________.

99201

An 8-month-old infant, who is a new patient, is brought in by her mother for diaper rash. The physician focuses on the problem of the diaper rash for the problem focused history and examination. The MDM complexity is straightforward. CPT Code: ________.

99201

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.

99201

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 physical examination with straightforward medical decision making. Also checked is a laceration repair for a 1.5-cm finger wound.

99201, 12001

A 42-year-old woman, who is an established patient, visits her family practitioner with the chief complaint of a self-discovered breast lump. She describes a feeling of fullness and tenderness over the mass that has become more pronounced in the past 2 weeks. Because the patient is otherwise healthy and has had a physical within the past 6 months, the physician focuses his attention on the breast lump during the taking of a problem focused history and the performance of a problem focused physical examination. The physician orders an immediate mammography to be performed and a follow-up appointment in 5 days. The physician has given the patient no other options and indicates that the MDM complexity is straightforward. CPT Code: ________

99212

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.

99213

CHART NOTE CC: Dizziness SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49. OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9. ASSESSMENT: Hypothyroidism (MDM was low). PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months. CPT Code:

99213

A 68-year-old woman visits her internist again complaining of angina that seems to have worsened over the past 3 days. The patient had had an acute anterior wall myocardial infarction (MI) 2 months earlier. One month after the acute MI, she began to have angina pectoris. The patient also states that she thinks the medications are causing her to have gastrointestinal problems while not relieving her symptoms. She had refused a cardiac catheterization after her MI to evaluate the extent of her coronary artery disease. The physician performs a detailed history and a detailed physical examination of her cardiovascular, respiratory, and gastrointestinal systems. The physician indicates that the decision making process is moderately complex, given the number of conditions it is necessary to consider. CPT Code: ________.

99214

A 33-year-old man is brought to his private physician's office by his wife. The man, who is an established patient, has been experiencing severe leg pain of 2 weeks' duration. In the past 2 days, the patient has experienced fainting spells, nausea, and vomiting. The patient has had multiple other vague complaints over the past month that he dismissed as unimportant, but his wife is not so sure, and she describes his general health as deteriorating. The physician performs a comprehensive multisystem physical examination after performing a complete review of systems and a complete past medical, family, and social history, with an extended history of the present illness (comprehensive history). The physician has to consider an extensive number of diagnoses, orders a variety of tests to be performed immediately, and indicates the MDM complexity to be high. CPT Code: ________.

99215

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 physical examination were performed and the medical decision was low complexity. The patient stayed overnight and was discharged the next afternoon.

99218, 99217

An established patient is admitted on observation status for influenza symptoms and extreme nausea and vomiting. The patient is severely dehydrated and has been experiencing dizziness and mental confusion for the past 2 days. Prior to this episode the patient was well but became acutely ill overnight with these symptoms. Given the abrupt onset of these symptoms, the physician has to consider multiple possible causes and orders a variety of laboratory tests to be performed. The patient is at risk for a moderate number of complications. The MDM complexity is moderate. A comprehensive history is collected, and a comprehensive head-to-toe physical examination is performed. CPT Code: ________.

99219

A physician visits another patient on observation status who has severe influenza. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical examination to reflect the patient's current status. The patient's problem is of low severity but requires ongoing active management, with possible surgical consultation. The MDM complexity is low. CPT Code: ________.

99221

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

99222

The code for Subsequent Hospital Care which indicates physician visits for a patient in stable condition is ___________? a) 99231 b) 99232 c) 99233 d) 99238

99231

CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Mandy Horton ATTENDING PHYSICIAN: Ronald Green, MD This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out. The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.) CPT Code:

99232

IALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Gloria Baxter ATTENDING PHYSICIAN: Ronald Green, MD This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized. The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient's intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response. The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better. This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.) CPT Code

99233

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol. PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC. Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward). Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones

99242

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 examination were performed with a low-complexity medical decision.

99243

An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity

99253

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 comprehensive history and physical examination. To rule out pancreatitis, the physician orders lab work, along with an ultrasound of the gallbladder and an abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.

99254

LOCATION: Emergency Room SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage. OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced. ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above. PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems. CPT Code:

99281

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.

99281

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.

99281-25, 73080

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM? 99284 99291 99283 99220

99284

Which Emergency Department Services code indicates a need for immediate attention without the presence of a life-theatening condition? a) 99285 b) 99284 c) 99283 d) 99282

99284

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.

99291

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)

99291, 99292

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.

99291, 99292

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.

99324

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward. CPT Code:

99341

A 22-year-old woman visits the gynecologist for the first time since relocating from another state last year. The patient wants a gynecologic examination and wants to discuss contraceptive options with the physician (think Preventive Medicine Services!). The physician collects pertinent past and social history related to the patient's reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history of her present physical state. A physical examination includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient's history of not tolerating certain types of oral contraceptives in the past, the physician's decision making involves a limited number of management options, all with low risk of morbidity to the patient. CPT Code: ________.

99385

The physician provides initial intensive care service for the evaluation and management of a critically ill newborn (5 days old) inpatient for one day. CPT Code: ________.

99468

When a physician performs a preventive care service, the extent of the exam is determined by the: Age Gender Gender and age Length of time elapsed since last exam

Age

The CPT coding system was developed by the ______? a) American Medical Association b) federal government c) state government d) Social Security Administration

Amerian Medical Association

CPT codes, descriptions and two digit modifiers are copyrighted by the _______? a) American Medical Association b) Blue Cross and Blue Shield Organization c) CPT Assistant d) World Hospital Organizaiton

American Medical Association

A code used to indicate that a physician assisted the primary surgeon in a major procedure is __________? a) -81 b) -80 c) -54 d) -51

B

Is examination of the back an organ system or body area examination?

Body Area

Where in the CPT manual are codes for anethesia provided under difficult circumtances? a) Anesthesia guidelines b) Medicine c) Surgery d) Both anesthesia guidelines and medicine are correct answers

Both anesthesia guidelines and medicine are correct answers

Surgeries which are prolonged or extremely difficult are coded with the modifier _________? a) -62 b) -59 c) -22 d) -52

C

CHART NOTE CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration. OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted. ASSESSMENT: Hemorrhoid. PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity. CPT Code:

CPT CODE 99212

The ________ is a statement describing the reason for the encounter and is a history element.

Chief Complaint

According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam. Problem-focused Expanded problem focused Detailed Comprehensive

Comprehensive

The definition of low birth weight can be found in the notes for subheading ________.

Continuing intensive care

Counseling, coordination of care, nature of presenting problem, and time are considered: Levels of E/M service Key components Contributory factors Medical decision-making process

Contributory factors

Which of the following is an example of unethical or illegal coding? a) Dividing services provided into separate codes when a single code is available b) Inclusion of all relevant complications as documented in the patients medical record c) Using code numbers for the minimum payment allowed d) strict adherence to coding for only procedures performed at your facility

Dividing services provided into separate codes when a single code is available

What term is used to describe a patient who has been formally admitted to a hospital?

Inpatient

Which history is more complex: the problem focused history or the expanded problem focused history?

Expaneded Problem Focused

Which of the following is NOT included in the CPT surgery package ___________? a) The operation b) the surgery c) Normal follow-up care d) General anethesia

General anesthesia

In the CPT manual, where is a complete summary of additions, deletions and revisions located? a) In Appendix B b) In Appendix A c) In the Index d) In the Table of Contents

In Appendix B

The first outpatient visit is called the ________ visit, and the second visit is called the ________ visit.

Initial, subsequent

Which of the following is NOT one of the sections in the CPT manual? a) Evalution and management b) Integumentary system c) Surgery d) Medicine

Integumentary system

Which of the following conditions would not require critical care? a) Cardiac arrest b) Labor leading to childbirth c) Shock d) Respiratiory failure

Labor leading to childbirth

What are the four levels of medical decision making complexity?

Low Complexity High Complexity Moderate Complexity Straightforward

What are the four types of patient status?

New, Established, Outpatient and Inpatient

The first three factors a coder must consider when coding are patient? .

Patient status, type of service, place of service

The examination that is limited to the affected body area is the ________.

Problem Focused

These elements would be part of the ________ history: employment, education, use of drugs. Past Social Family Any of above

Social

What medical decision making involves a situation in which the diagnosis and management options are minimal, data amount and complexity that must be reviewed are minimal/none, and there is a minimal risk to the patient of complications or death?

Straightforward

Which section of the CPT manual is the largest? a) Medicine b) Evaluation and Management c) Surgery d) Radiolgy

Surgery

The HPI must be documented in the medical record by: The physician Any office staff member The patient Any of the above

The physician

A surgical endoscopy always includes ______? a) an x-ray b) a diagnostic endoscopy c) a -51 modifier d) a sigmoidoscopy

a diagnostic endoscopy

Level I pathology code 88300 identifies specimens that normally do not need to be viewed under a microscope such as __________? a) tooth b) malignant uterus tissue c) fluid from a breas biopsy d) neoplastic tissue

a tooth

There are two types of CPT codes: stand-alone and __________? a) sub codes b) parent codes c) stand aside codes d) add on or indeted codes

add on or indented codes

If multiple lacerations are repaired under the same classification and in the same group of anatomic parts a billing and coding specialist should _______? a) add the sum of lengths and report one code b) report a code for each laceration c) include a printed report d) report only the longest laceration

add the sum of lengths and report one code

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?

administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever

When coding the radiation oncology, consider all of the following EXCEPT __________? a) treatment type b) level of treatment planning c) age of the patient d) number of ports and blocks

age of the patient

In the CPT index, main terms are listed by _____? a) procedure or service b) organ or anatomic site c) condition, synonym, or abbreviation d) all answers are correct

all answers are correct

The code for a total hysterectomy includes removal of the ________? a) uterus b) ovaries c) fallopian tubes d) all answers are correct

all answers are correct

The level of E/M service is based on: -Documentation -Key components -Contributing factors -All of the above

all of the above

Anesthesia codes are divided by ___________? a) medication b) anatomical site c) drug name d) number of anethesiologists

anatomical site

Physicians Current Procedural Terminology (CPT) is revised ________? a) annually b) when necessary c) every 6 months d) every 2 years

annually

Codes for the digestive system are arranged by site, beginning with the mouuth and ending with the __________? a) feet b) anus c) rectum d) sigmoid

anus

Considerations when coding urinalysis and chemistry laboratory procedures include all of the following EXCEPT __________? a) names of specific tests b) number of tests done c) specification of qualitative or quantitative results d) brand names for lab equipment

brand names for lab equipment

Codes in the Diagnostic Radiology subsection are arrange __________. a) by amount of radiation given b) by anatomic site c) alphabetically d) technologically

by anatomic site

Codes for the nervous system subsection of the CPT manual are divided __________? a) by the specific names of nerves b) by body region c) by anatomic site and type of procedure d) alphabetically by nerve type

by anatomic site and type of procedure

In the CPT index, hernia codes are listed __________? a) by anatomic site of hernia b) by type of repair c) by patients gender d) under 'Protrusion"

by anatomic site of hernia

Which of the following is NOT needed when coding a laceration repair ________? a) depth of wound b) size of wound c) location of wound d) cause of wound

cause of wound

When coding trauma cases, the most severe injury is _________? a) bundled with all other injuries b) th eonly one coded c) coded first d) coded last

coded first

For a breast biopsy, the placement of a wire marker is ___________. a) coded separately b) included in the excision code c) coded by size of the wire guage d) coded by the depth the marker is placed

coded separately

The transformation of verbal descriptions of diseases, injuries, and procedures into numbers is called ________? a) indexing b) posting c) tabulation d) coding

coding

The purpose of CPT is to ________? a) revise technologic advances b) simplify the CMS-1500 form c) convert medical descriptions into 5 digit codes d) organize insurance billers work

convert medical descriptions into 5 digit codes

The key components of documentation that support levels of E?M codes includes the following EXCEPT __________? a) history b) examination c) counseling and coordination of care d) medical decision-making

counseling and coordination of care

Physician counseling is considered a key component for selecting the level of code assignment for Evaluation and Management services only when ____________? a) the physician is a psychiatrist b) counseling exceeds 50% of the time spent c) the physician does not take a history or perform a physical examination d) the physician is a physchologist

counseling exceeds 50% of the time spent

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused Expanded problem focused Detailed Comprehensive

detailed

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination? Problem-focused Expanded problem focused Detailed Comprehensive

detailed

Unbundling, exploding, or a la carte coding are __________? a) common b) fraudulent c) necessary d) complex

fraudulent

In some billing cases it is necessary to add a 2 digit modifier in order to __________? a) indicate usual charges b) prevent miscoding c) give a more accurate description d) meet carrier criteria

give a more accurate description

When one fee is used for a surgical procedure and uncomplicated follow-up care, this is called a __________? a) surgical unit b) global surgical package c) general procedure d) cluster

global surgical package

When coding ostomies, it is critical to _______? a) indicate the anatomosis b) use a medical dictionary c) identify the site from which it originated d) determine the type of material used

identify the site from which it originated

Critical care is coded _____________. a) in quarter hours units b) each time the patient is seen in a 24 hours period c) the minute the patient is determined to have a life threatening emergency d) in minutes starting with 30-74 minutes

in minutes starting with 30-74 minutes

At the beginning of the CPT index are ________? a) diagrams b) instructions c) definitions d) anatomical listings

instructions

When transferring codes to claim forms he careful to __________? a) include descriptions b) write out all abbreviations c) keep from transposing numbers d) write neatly

keep from transposing numbers

In CPT coding, the words following the semicolon may indicate all of the following EXCEPT ___________? a) alternative anatomic site b) alternative procedure c) lesser important procedures d) extent of procedures

lesser important procedures

A key component in coding medical decision-making is _____________? a) patient childhood diseases b) level of complexity c) the physician's level of education d) the amount of time the physician spends with the patient

level of complexity

Components of a medical history inlude all of the following except __________? a) medical decision making b) chief complaint c) family history d) review of systems

medical decision making

Modifier code - 99 indicates ________? a) laboratory work b) surgical tray c) universal application d) multiple modifiers

multiple modifiers

Even if only one code is listed for the desired procedure in the index of the CPT manual, the user ____________? a) can select that code b) must refer to the main text c) can expect across references d) notes that code on the claim form

must refer to the main text

In the CPT manual, a round bullet symbol indicates a ________? a) bundled code b) new code c) revised code d) deleted code

new code

When an exploratory laparotomy is used as surgical approach for another procedure, it is ____________ ? a) always coded separately b) not coded separately c) considered the most definitive procedure d) considered the primary procedure

not coded separately

Physicians telephone calls are usually __________? a) coded according to area codes b) not paid by third party payers c) paid by third party payers d) coded using HCPCS Level II codes

not paid by third party payers

The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.

outpatient

The Evaluation and Management section is organized by type of service, place of service, and __________? a) nature of presenting problem b) time c) patient status d) coordination of care

patient status

For anesthesia coding purposes, physical status modifiers are used to indicate ________? a) age of patients at time of surgery b) patient's status upon admittance c) patient's status at the time of anesthesia d) patient's status at the time of completion of surgery

patient's status at the time of anesthesia

The CPT coding system is used by all of the following EXCEPT ___________? a) doctors offices and clinics b) outpatient departments c) third party payers d) patients

patients

What are the four levels of history type?

problem-focused, expanded problem-focused, detailed, comprehensive

Code groupings for arteries and veins vary according to ___________? a) procedure b) surgical intstruments c) functions d) directional flow

procedure

Add-on modifier - 26 indicates the _______? a) service is significant and separately identifiable b) unusual nature of the service or procedure c) technical component d) professional component

professional component

The following are subsections of the surgery section of the CPT manual EXCEPT __________? a) musculoskeletal b) cardiovascular c) radiology d) female genital

radiology

Free skin grafts are coded by _________? a) degree of burn b) type of wound c) recipient site and size of defect d) length of grafted area

recipient site and size of defect

Care Plan Oversight Sevices for hospice and homebound patients _____________? a) require vast documentation and are typically not paid by third party payers b) are usually paid by the third party payers c) are not listed services in CPT d) are coded once for every 24 hours period the patient is seen

require vast documentation and are typically not paid by third party payers

A triangle symbol in the CPT manual indicates a _______? a) minor surgical procedure b) decision for surgery c) new code d) revised description

revised description

To code diagnostic endoscopy procedures _________? a) code each area that is passed with the scope b) never code more than one procedure in an operative setting c) select the code that refects the farthest extent of the procedure d) ignore the approach

select the code that reflects the farthest extent of the procedure

If a physician spends 50 minutes with a patient after he or she has been admitted for a suicide attemt in connection with depression, the psychotherapy coding would be _________? a) bundled b) separate from initial care c) considered outpatient d) disregarded

separate from initial care

Two coding systems are used by phsicians offices. One is for diagnoses and the other is for ___________? a) symtoms b) computer directories c) services and procedures d) appointments

services and procedures

Fractures are coded by _____________? a) application of casts and strapping procedures b) cast material and type c) site and treatment d) cause of injury

site and treatment

When contrast material is injected by a radiologist, the injection procedure code is taken from the __________? a) surgery section b) radiology section c) anesthesiology section d) E/M section

surgery section

Modifier code - 66 indicates ________? a) procedure performed on infants b) surgical team c) assistant physician d) two surgeons

surgical team

For coding purposes, information about the size of a lesion should come from __________? a) the physician report b) the medical assistant's measurements c) radiology report d) pathology report

the physicial report

CPT surgical packages are used only by _________? a) third party payers b) physicians c) anethesiologists d) radiologist

third party payers

The Physical Medicine codes are indications of type of modalities and ____________? a) temperature b) location c) time d) method

time

The major factor for coding psychiatry is _______? a) time b) physician credentials c) inpatient outpatient status d) counseling

time

When coding spinal procedures, consider all of the following EXCEPT __________? a) the segmens involved b) unilateral or bliateral orientation c) approach d) condition

unilateral or bilateral orientation

If a radiologist is reading films taken at another facility ________? a) use a modifier to indicate the technical component b) use a modifier to indicate the professional component c) a global code is used d) an outpatient code is used

use a modifier to indicate tha technical component

In a case requiring critical care coding __________. a) the coder is expected to unbundle b) no other services are included c) ventilator management is not included d) ventilator management is included

ventilator management is included

What does VLBW stand for?

very low birth weight

Claims including codes for an unusual,new,seldom performed or unlisted procedure should include a _________? a) duplicate copy b) written medical report c) written description by the code number d) numerical summary

written medical report