2020 CPC Coding Practice

A 25-year-old female patient with ESRD received a dual renal transplant without nephrectomy. What is the correct code for this transplant? A. 50360 -50 B. 50360 C. 50365 D. 50365 -50

A - 50360 -50

A radiographic image of the colon's interior is referred to as which of the following? A. Colonography B. Colonoscopy C. Duodenoscopy D. Cholangiography

A - Colonography Answer: A - A radiographic image of the colon's interior is referred to as a colonography. A colonoscopy occurs when an endoscope is passed into the colon for visualization, while a duodenoscopy occurs when the endoscope is passed from the colon into the duodenum. A cholangiography is a radiographic image of the bile duct

Cell

A basic unit of all living things

Operative report

A document that contain the details of a procedure performed on a patient

4 parts of Medicare

A,B,C,D

A very large lipoma is removed from the chest measuring 8 sq cm and the defect is 12.2 cm requiring a layered closure with extensive undermining. MAC is performed by a medically directed Certified Registered Nurse Anesthetist (CRNA). Code the anesthesia service. A. 00400-QX-QS B. 00400-QS C. 00300-QS D. 00300-QX-QS

A. 00400-QX-QS

PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse marginal, saphenous vein graft to the diagonal. The patient is placed on heart and lung bypass during the procedure. Anesthesia time: 6:00 PM to 12:00 AM Surgical time: 6:15 PM to 11:30 PM What is the correct anesthesia code and anesthesia time? A. 00567, 6 hours B. 00566, 6 hours C. 00567, 5 hours and 30 minutes D. 00566, 5 hours and 30 minutes

A. 00567, 6 hours

A 45-year-old male is in outpatient surgery to excise a basal cell carcinoma of the right nose and have reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect. Which CPT® code(s) is (are) reported? A. 14060 B. 11642, 14060 C. 11642, 15115 D. 15574

A. 14060

PRE OP DIAGNOSIS: Left Breast Abnormal MMG or Palpable Mass; Other Disorders of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What is (are) the CPT® code(s)? A. 19081 B. 19283 C. 19081, 19283 D. 19100, 19283

A. 19081

The patient is a 49-year-old woman who presents to the ER with an acute onset of pain in her right wrist after falling while being chased by a dog. She fell onto an outstretched hand and struck it sharply against her front doorstep. X-rays of her right hand and wrist confirm she sustained a Colles distal radius fracture. The orthopedist on call places her in a short-arm cast and the visit is documented to Level 3. A. 25600-RT, 99283-57 B. 25600-RT, 29075-59-RT, 99283-57 C. 25605-RT, 29075-51-RT, 99283-25 D. 25605-RT, 99283

A. 25600-RT, 99283-57

Question 5 PREOPERATIVE DIAGNOSIS: Right scaphoid fracture. TYPE OF PROCEDURE: Open reduction and internal fixation of right scaphoid fracture. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room; anesthesia having been administered. The right upper extremity was prepped and draped in a sterile manner. The limb was elevated, exsanguinated, and a pneumatic arm tourniquet was elevated. An incision was made over the dorsal radial aspect of the right wrist. Skin flaps were elevated. Cutaneous nerve branches were identified and very gently retracted. The interval between the second and third dorsal compartment tendons was identified and entered. The respective tendons were retracted. A dorsal capsulotomy incision was made, and the fracture was visualized. There did not appear to be any type of significant defect at the fracture site. A 0.045 Kirschner wire was then used as a guidewire, extending from the proximal pole of the scaphoid distal ward. The guidewire was positioned appropriately and then measured. A 25-mm Acutrak® drill bit was drilled to 25 mm. A 22.5-mm screw was selected and inserted and rigid internal fixation was accomplished in this fashion. This was visualized under the OEC imaging device in multiple projections. The wound was irrigated and closed in layers. Sterile dressings were then applied. The patient tolerated the procedure well and left the operating room in stable condition. What CPT® code is reported for this procedure? A. 25628-RT B. 25624-RT C. 25645-RT D. 25651-RT

A. 25628-RT

The patient is a 66-year-old female who presents with Dupuytren's disease in the right palm and ring finger. This results in a contracture of the ring digit MP joint. She is having a subtotal palmar fasciectomy for Dupuytren's disease right ring digit and palm. An extensile Brunner incision was then made beginning in the proximal palm and extending to the ring finger PIP crease. This exposed a large pretendinous cord arising from the palmar fascia extending distally over the flexor tendons of the ring finger. The fascial attachments to the flexor tendon sheath were released. At the level of the metacarpophalangeal crease, one band arose from the central pretendinous cord-one coursing toward the middle finger. The digital nerve was identified, and this diseased fascia was also excised. What procedure code(s) is (are) used? A. 26123-RT, 26125-F7 B. 26121-RT C. 26035-RT D. 26040-RT

A. 26123-RT, 26125-F7

Question 8 A CT scan identified moderate-sized right pleural effusion in a 50 year-old male. This was estimated to be 800 cc in size and had an appearance of fluid on the CT Scan. A needle is used to puncture through the chest tissues and enter the pleural cavity to insert a guidewire under ultrasound guidance. A pigtail catheter is then inserted at the length of the guidewire and secured by stitches. The catheter will remain in the chest and is connected to drainage system to drain the accumulated fluid. The CPT® code is: A. 32557 B. 32555 C. 32556 D. 32550

A. 32557

A 79-year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where an insertion of a DDD pacemaker will be performed. After the anesthesiologist provided moderate sedation, the cardiologist performed a left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed and the second needle was withdrawn. An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire and the wire and dilator were withdrawn. An atrial lead was passed through the introducer and the introducer was broken away in the routine fashion. Each of the leads were sutured down to the chest wall with two 2-0 silk sutures each, connected the leads to the generator, curled the leads, and the generator was placed in the pocket. We assured hemostasis. We assured good position with the fluoroscopy. What CPT® code(s) is (are) reported by the cardiologist? A. 33208 B. 33212 C. 33226 D. 33235, 71090-26

A. 33208

The patient is a 77-year-old white female who has been having right temporal pain and headaches with some visual changes and has a sed rate of 51. She is scheduled for a temporal artery biopsy to rule out temporal arteritis. A Doppler probe was used to isolate the temporal artery and using a marking pen the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade scalpel the skin was opened in the preauricular area and dissected down to the subcutaneous tissue where the temporal artery was identified in its bed. It was a medium size artery and we dissected it out for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the artery was removed from its bed and sent to Pathology as specimen. What CPT® code is reported? A. 37609 B. 37605 C. 36625 D. 37799

A. 37609

The patient is a 78-year-old white female with morbid obesity that presented with small bowel obstruction. She had surgery approximately one week ago and underwent exploration, which required a small bowel resection of the terminal ileum and anastomosis leaving her with a large inferior ventral hernia. Two days ago she started having drainage from her wound which has become more serious. She is now being taken back to the operating room. Reopening the original incision with a scalpel, the intestine was examined and the anastomosis was reopened , excised at both ends, and further excision of intestine. The fresh ends were created to perform another end- to-end anastomosis. The correct procedure code is: A. 44120-78 B. 44126-79 C. 44120-76 D. 44202-58

A. 44120-78

The patient is a 50-year-old gentleman who presented to the emergency room with signs and symptoms of acute appendicitis with possible rupture. He has been brought to the operating room. An infraumbilical incision was made which a 5-mm VersaStep™ trocar was inserted. A 5-mm 0- degree laparoscope was introduced. A second 5-mm trocar was placed suprapubically and a 12-mm trocar in the left lower quadrant. A window was made in the mesoappendix using blunt dissection with no rupture noted. The base of the appendix was then divided and placed into an Endo-catch bag and the 12-mm defect was brought out. Select the appropriate code for this procedure: A. 44970 B. 44950 C. 44960 D. 44979

A. 44970

A 53-year-old woman with ascites consented to a procedure to withdraw fluid from the abdominal cavity. Ultrasonic guidance was used for guiding the needle placement for the aspiration. What CPT® codes should be used? A. 49083 B. 49180, 76942-26 C. 49082, 77002-26 D. 49180, 76998-26

A. 49083

A 5-year-old male with a history of prematurity was found to have a chordee due to congenital hypospadias. He presents for surgical management for a plastic repair in straightening the abnormal curvature. Under general anesthesia, bands were placed around the base of the penis and incisions were made degloving the penis circumferentially. The foreskin was divided in Byers flaps and the penile skin was reapproximated at the 12 o'clock position. Two Byers flaps were reapproximated, recreating a mucosal collar which was then criss- crossed and trimmed in the midline in order to accommodate median raphe reconstruction. This was reconstructed with use of a horizontal mattress suture. The shaft skin was then approximated to the mucosal collar with sutures correcting the defect. Which CPT® code should be used? A. 54304 B. 54340 C. 54400 D. 54440

A. 54304

A 67-year-old female having urinary incontinence with intrinsic sphincter deficiency is having a cystoscopy performed with a placement of a sling. An incision was made over the mid urethra dissected laterally to urethropelvic ligament. Cystoscopy revealed no penetration of the bladder. The edges of the sling were weaved around the junction of the urethra and brought up to the suprapubic incision. A hemostat was then placed between the sling and the urethra, ensuring no tension. What CPT® code(s) is (are) reported? A. 57288 B. 57287 C. 57288, 52000-51 D. 51992, 52000-51

A. 57288

After several attempts to reproduce, a female patient and her doctor decide to try artificial insemination. The procedure is done intra-cervically. How would this procedure be billed? A. 58321 B. 58322 C. 58323 D. 58356

A. 58321

An infant who has chronic otitis media in the right and left ears was placed under general anesthesia and a radial incision was made in the posterior quadrant of the left and right tympanic membranes. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears. What CPT® and ICD-10-CM codes are reported? A. 69436-50, H65.33 B. 69436-50, H66.43 C. 69433-50, H65.113 D. 69421-50, H65.33

A. 69436-50, H65.33

A 76-year-old female had a ground level fall when she tripped over her dog earlier this evening in her apartment. The Emergency Department took X-rays of the left wrist in oblique and lateral views which revealed a displaced distal radius fracture, type I open left wrist. What radiological service and ICD-10-CM codes are reported? A. 73100-26, S52.502B, W18.31XA, Y92.039 B. 73110-26, S52.602A, W18.31XA, Y92.039 C. 73115-26, S52.502A, W18.31XA, Y92.039 D. 73100-26, S52.602B, W18.31XA, Y92.039

A. 73100-26, S52.502B, W18.31XA, Y92.039

An 18-year-old female with a history of depression comes into the ER in a coma. The ER physician orders a drug screen on antidepressants, phenothiazines, and benzodiazepines. The lab performs a screening for single drug class using an immunoassay in a random access chemistry analyzer. Presence of antidepressants is found and a drug confirmation is performed to identify the particular antidepressant. What correct CPT® codes are reported? A. 80307, 80338 B. 80305, 80338 C. 80306 x 3, 80332 D. 80307 x 3, 80333

A. 80307, 80338

A pathologist performs a comprehensive consultation and report after reviewing a patient's records and specimens from another facility. The correct CPT® code to report this service is: A. 88325 B. 99244 C. 88323 D. 88329

A. 88325

An established patient had a comprehensive exam in which she has been diagnosed with dry eye syndrome in both eyes. The ophthalmologist measures the cornea for placement of the soft contact lens for treatment of this syndrome. What codes are reported by the ophthalmologist? A. 92014-25, 92071-50 B. 99214-25, 92072-50 C. 92014-25, 92325-50 D. 92014-25, 92310-50

A. 92014-25, 92071-50

A cancer patient is coming in to have a chemotherapy infusion. The physician notes the patient is dehydrated and will first administer a hydration infusion. The infusion time was 1 hour and 30 minutes. Select the code(s) that is (are) reported for this encounter? A. 96360 B. 96360, 96361 C. 96365, 96366 D. 96422

A. 96360

A patient that has multiple sclerosis has been seeing a therapist for four visits. Today's visit the therapist will be performing a comprehensive reevaluation to determine the extent of progress. There was a revised plan assessing the changes in the patient's functional status. Initial profile was updated to reflect changes that affect future goals along with a revised plan of care. A total care of 30 minutes were spent in this re-evaluation. What CPT® and ICD-10-CM codes should be reported? A. 97168, Z51.89, G35 B. 97164, Z56.89, G35 C. 97167, G35 D. 97163, Z56.9, G35

A. 97168, Z51.89, G35

A 50-year-old patient is coming to see her primary care physician for hypertension. The patient also discusses with her physician that the OBGYN office had just told her that her Pap smear came back with an abnormal reading and is worried because her aunt had passed away with cervical cancer. The physician documents she spent 40 minutes face-to-face time with the patient, and 25 minutes of that time is giving counseling on the awareness, other screening procedures and treatment if it turns out to be cervical cancer. What E/M code(s) is (are) reported for this visit? A. 99215 B. 99213, 99358 C. 99214, 99354 D. 99213

A. 99215

A 2 year-old is brought to the ER by EMS for near drowning. EMS had gotten a pulse. The ER physician performs endotracheal intubation, blood gas, and a central venous catheter placement. The ER physician documents a total time of 30 minutes on this critical infant in which the physician already subtracted the time for the other billable services. Select the E/M service and procedures to report for the ER physician? A. 99291-25, 36555, 31500 B. 99291-25, 36556, 31500, 82803 C. 99285-25, 36556, 31500, 82803 D. 99475-25, 36556

A. 99291-25, 36555, 31500

A 20-day-old infant was seen in the ER by the neonatologist admitting the baby to NICU for cyanosis and rapid breathing. The neonatologist performed intubation, ventilation management and a complete echocardiogram in the NICU and provided a report for the echocardiography which did indicate congenital heart disease. Select the correct codes for the physician service. A. 99468-25, 93303-26 B. 99471-25, 31500, 94002, 93303-26 C. 99460-25, 31500, 94002, 93303-26 D. 99291-25, 93303-26

A. 99468-25, 93303-26

Which of the following is an example of electronic data? A. A digital X-ray B. An explanation of benefits C. An advance beneficiary notice D. A written prescription

A. A digital X-ray

What is the full CPT® code description for 00846? A. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy B. Radical hysterectomy C. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified radical hysterectomy D. Radical hysterectomy not otherwise specified

A. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy

A radiographic image of the colon's interior is referred to as which of the following? A. Colonography B. Colonoscopy C. Duodenoscopy D. Cholangiography

A. Colonography

Which of the following is part of a trauma wound exploration? A. Debridement B. Fine needle aspiration C. Simple repair of wound not requiring wound enlargement D. Muscle biopsy

A. Debridement

What is the difference between entropion and ectropion? A. Entropion is the inward turning of the eyelid and ectropion is the outward turning of the eyelid. B. Entropion is facial droop and ectropion is a facial spasm. C. Entropion is the outward turning of the hands and ectropion is the inward turning of the hands. D. Entropion inward turning of the feet and ectropion is the outward turning of the feet due to muscle disorder.

A. Entropion is the inward turning of the eyelid and ectropion is the outward turning of the eyelid.

Payer policies follow the indications for the drugs and what has been approved by the: A. FDA B. CMS C. OSHA D. None of the above.

A. FDA

When a patient is having a tenotomy performed on the abductor hallucis muscle, where is this muscle located? A. Foot B. Upper Arm C. Upper Leg D. Hand

A. Foot

Which of the following statements is False? A. Fraud consists of payment for items that are billed by mistake but should not be paid for by Medicare. B. The OIG Work Plan outlines priorities for investigating potential problem areas with submissions C. HIPAA requires that an individual be notified if there is an unauthorized disclosure of his PHI. D. An ABN is used to explain to the patient why Medicare may deny a particular service or procedure.

A. Fraud consists of payment for items that are billed by mistake but should not be paid for by Medicare.

What type of insurance plans do not include out-of-network benefits? A. HMO/EPO B. PPO C. POS D. Traditional

A. HMO/EPO

The root word trich/o means: A. Hair B. Sebum C. Eyelid D. Trachea

A. Hair

A patient that has hypertensive heart disease with congestive heart failure is coded: A. I11.0, I50.9 B. I13.0 C. I13.0, I11.0, I50.9 D. I50.9, I11.0

A. I11.0, I50.9

Which statement is an example in which a diabetes-related problem exists and the code for diabetes is NEVER sequenced first? A. If the patient has an underdose of insulin due to an insulin pump malfunction. B. If the patient is being treated for secondary diabetes. C. If the patient is being treated for Type 2 diabetes and uses insulin. D. If the patient is diabetic with an associated condition.

A. If the patient has an underdose of insulin due to an insulin pump malfunction.

Which statement is TRUE about reporting codes for diabetes mellitus? A. If the type of diabetes mellitus is not documented in the medical record the default type is E11.- Type 2 diabetes mellitus. B. When a patient uses insulin, Type 1 is always reported. C. The age of the patient is a sole determining factor to report Type 1. D. When assigning codes for diabetes and its associated condition(s), the code(s) from category E08-E13 are not reported as a primary code.

A. If the type of diabetes mellitus is not documented in the medical record the default type is E11.- Type 2 diabetes mellitus.

When a person has labyrinthitis what has the inflammation? A. Inner ear B. Brain C. Conjunctiva D. Spine

A. Inner ear

Which nerve stem from the spinal cord and essentially wrap around the ribs? A. Intercostal B. Sciatic C. Brachial Plexus D. Musculocutaneous

A. Intercostal All nerves essentially stem from the spinal cord since this is in the main part of the nervous system. There are many important nerves that run alongside the ribs are just as important as the ones running down our arms and legs. Looking at a basic diagram, you will see that the nerves essentially "wrapping" around the ribs are called the intercostal nerves. The brachial plexus is located at the collarbone; the musculocutaneous nerve(s) run down the arm, and the sciatic nerves are located in the upper leg and run to the lower back. AAPC ICD-10-CM Expert: For Physicians and Hospitals. Pg.27

The patient presents to the office for an injection. Joint prepped using sterile technique. Muscle group location: gluteus maximus. Sterilely injected with 40 mg of Kenalog-10, 2 cc Marcaine and 2 cc lidocaine 2%. Sterile bandage applied. Choose the HCPCS Level II code for this treatment. A. J3301 x 4 B. J3301 C. J3300 x 40 D. J3300

A. J3301 x 4

Can an NPP work as a scribe? A. Only if they indicate in the documentation that they are working as a scribe, and not as a clinician. B. Never. It's too expensive to use NPPs as scribes. C. Yes, because they are able to interject observations and impressions the provider might leave out, resulting in better documentation. D. Only if they have the appropriate scribe certification.

A. Only if they indicate in the documentation that they are working as a scribe, and not as a clinician.

A 10-year-old-male sustained a Colles' fracture in which the pediatrician performs an application of short arm fiberglass cast. Select the HCPCS Level II code that is reported. A. Q4012 B. A4580 C. A4570 D. Q4024

A. Q4012

Which of the following is a function of the pancreas ? A. Supplies digestive enzymes B. Manufactures melatonin C. Stimulates growth D. Secretes vasopressin

A. Supplies digestive enzymes

Orchitis affects which of the following? A. Testes B. Ureter C. Bladder D. Ovaries

A. Testes

Where on the tongue is the lingual frenulum located? A. Underneath, in the middle B. Underneath, to the right C. Toward the front of the mouth D. Toward the throat

A. Underneath, in the middle

When a patient has fractured the proximal end of his humerus, where is the fracture located? A. Upper end of the arm B. Lower end of the leg C. Upper end of the leg D. Lower end of the arm

A. Upper end of the arm

ABN

Advanced Beneficiary Notice (or Non-Coverage)

Stratum Corneum

Also called the horny layer; outer most layer

AHIMA

American Health Information Management Association

AHA

American Hospital Association

Diaphragmatic hernia repair codes are divided based upon what? A. The age of the patient and whether or not mesh was used B. The age of the patient and whether or not the hernia is acute or chronic C. The stage of the hernia and the site of the hernia D. The age of the patient and the site of the hernia

Answer: B - Diaphragmatic hernia repair codes are divided based upon the age of the patient and whether or not the hernia is acute or chronic. There are only three hernia codes, 39503 (Neonatal Diaphragmatic Hernia Repair) and codes 39540 and 39541 (Diaphragmatic Hernia Repair for Other than an Neonate). The codes 39540 and 39541 are divided into traumatic acute and traumatic chronic hernias.

PREOPERATIVE DIAGNOSIS: Cyst of Mediastinal WallPOSTOPERATIVE DIAGNOSIS: Tumor of Mediastinal WallA physician removed 1.5 cm mass from mediastinal wall, along with appropriate margins. The tumor was sent to pathology to determine the malignancy status.What is the correct code for this procedure? A. 39200 B. 39220 C. 39000 D. 39010

Answer: B - The correct code for this procedure is 39220 (Resection of Mediastinal Tumor). There are only two codes for the removal or resection of a mediastinal mass. Code 39200 is for the removal of a mediastinal cyst, whereas code 39220 is for the removal of a tumor. The postoperative diagnosis states that the mass is a tumor, therefore code 39220 is the most appropriate code for this service.

What is the difference between meningitis and encephalitis? A. Meningitis is the inflammation of the spinal cord, and encephalitis is the inflammation of the lining of the brain B. Meningitis is the inflammation of the lining of the brain and encephalitis is the inflammation of the brain C. Meningitis is the inflammation of the lining of the brain and encephalitis is the swelling of the spinal cord D. Meningitis is a respiratory infection and encephalitis is the inflammation of the nervous system

Answer: B - The difference between meningitis and encephalitis is that meningitis is the inflammation of the lining of the brain and encephalitis is the inflammation of the brain itself. Myelitis is the inflammation of the spinal cord, and encephalomyelitis is a combination of the inflammation of the brain and spinal cord. Generally speaking, when coding for any of the above conditions, the coder should report the organism responsible for the inflammation first and the inflammation second.

When selecting an evaluation and management code, what is the first thing that the coder needs to determine? A. The time the provider spent with the patient B. The appropriate category of E&M service C. Whether the patient was new or established D. How long the discharge took

Answer: B - When selecting an evaluation and management code, the first thing that the coder needs to determine is the appropriate category of E&M service. This means that the coder needs to determine where the service was provided (i.e., hospital inpatient, office/outpatient, hospital observation, etc.). Whether the patient was new or established would only be a question in certain categories. In addition, the time spent with the patient is only a determining factor in certain categories.

A physician performed craniotomy on a patient with a severe head trauma and intracerebral hematoma. Due to the patient's condition the procedure was extremely difficult, requiring a significant amount of extra time and effort. What is the correct code for this procedure? A. 61315 B. 61313 C. 61313 -22 D. 61315 -23

Answer: C - The correct code for the procedure is 61313 (Craniectomy or Craniotomy for Evacuation of Hematoma, Supratentorial; Intracerebral) combined with modifier -22 to indicate that the procedure was an increased procedural service. Code 61315 is inappropriate because it is used for an infratentorial, intracerebellar hematoma.

What is the difference between anterior nasal packing versus posterior nasal packing procedure codes? A. None, they are the same codes B. Posterior packing is done in the larynx, whereas anterior packing is done at the back of the throat C. There are no nasal packing procedure codes in the CPT manual D. Anterior packing is applied pressure and gauze and posterior packing is the insertion of a balloon into the back of the nasal cavity

Answer: D - The difference between anterior nasal packing versus posterior nasal packing procedure codes is that anterior packing applies pressure and gauze to the front of the nose, and posterior packing inserts a balloon into the back of the nasal cavity. Posterior packing includes packing the nose with gauze and applying pressure to the posterior aspect of the nasal cavity. This can include inserting a balloon to the back of the throat, which is inflated to block blood from draining into the back of the throat.

The amount on an ABN should be within how much of the cost to the patient? A. $250 of cost B. $100 or 25% of cost C. $10 or 10% D. $100 or 10% of cost

B. $100 or 25% of cost

A 10-month-old child is taken to the operating room for removal of a laryngeal mass. What is (are) the appropriate anesthesia code(s) to report? A. 00320 B. 00326 C. 00320, 99100 D. 00326, 99100

B. 00326

A 50-year-old female had a left subcutaneous mastectomy for cancer. She now returns for reconstruction which is done with a single TRAM flap. Right mastopexy is done for asymmetry. Select the anesthesia code for this procedure. A. 00404 B. 00402 C. 00406 D. 00400

B. 00402

A patient presents with an abscess on his back that requires drainage. The procedure note indicates: I&D of abscess - complicated. Area injected with 1% lidocaine, anesthesia achieved. Area incised with #11 blade, frank pus expressed approx. 5 mL. Abscess probed to break loculations and wound irrigated and then packed with nugauze. Sterile dressing applied. How should you code? A. 10040 B. 10061 C. 10060 D. 10180

B. 10061

A patient presents with an abscess on his back that requires drainage. The procedure note is: I&D of abscess, complicated. Area injected with 1 percent lidocaine, anesthesia achieved. Area incised with #11 blade, frank pus expressed approx. 5 mL. Abscess probed to break loculations, wound is irrigated, and then packed with Nu Gauze. Sterile dressing applied. Which code reports this procedure? A. 10040 B. 10061 C. 10060 D. 10180

B. 10061

A 53-year-old male is in the dermatologist's office for removal of 2 lesions located on his lower lip and nose. Lesions were identified and marked. The lower lip lesion of 4 mm in size was shaved to the level of the superficial dermis. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. What are the CPT® codes for these procedures? A. 40490, 11104-59 B. 11310, 11104-59 C. 17000, 17003 D. 11440, 11105-59

B. 11310, 11104-59

An arthrotomy is performed on the TMJ joint of a patient who has severe arthritis in her jaw. How would this be billed? A.20979 B. 21010 C. 21015 D. 21025

B. 21010

PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application of an external fixation system, left wrist fracture FINDINGS: The patient is a 46 year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixation system was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator. The frame was next placed and the site for the proximal pins was chosen. Small incision was made. Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was noted to be satisfactory. Final frame tightening was carried out. What CPT® code(s) is/are reported? A. 25600-LT, 20692-51 B. 25605- LT, 20690-51 C. 25606-LT D. 25607-LT

B. 25605- LT, 20690-51

A post-MI patient undergoes a myocardial resection due to a septal defect suffered after a heart attack. How would this be billed? A. 33542 B. 33545 C. 33615 D. 33622

B. 33545

The patient is a 59-year-old white male who underwent carotid endarterectomy for symptomatic left carotid stenosis a year ago. A carotid CT angiogram showed a recurrent 90% left internal carotid artery stenosis extending into the common carotid artery. He is taken to the operating room for re-do left carotid endarterectomy. The left neck was prepped and the previous incision was carefully reopened. Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was systematically heparinized and after a few minutes, clamps were applied to the common carotid artery and its branches. A longitudinal arteriotomy was carried out with findings of extensive layering of intimal hyperplasia with no evidence of recurrent atherosclerosis. A silastic balloon-tip shunt was inserted first proximally and then distally, with restoration of flow. Several layers of intima were removed and the endarterectomized surfaces irrigated with heparinized saline. An oval Dacron patch was then sewn into place with running 6-0 Prolene. Which CPT® code(s) is/are reported? A. 35301 B. 35301, 35390 C. 35302 D. 35311, 35390

B. 35301, 35390

67-year-old female fractured a port-a-cath surgically placed a year ago. Under sonographic guidance a needle was passed into the right common femoral vein. The loop snare was positioned in the right atrium where a portion of the fractured catheter was situated. The catheter crossed the atrioventricular valve with the remaining aspect of the catheter in the ventricle. A pigtail catheter was then utilized to loop the catheter and pull the catheter tip into the inferior vena cava. The catheter was then snared and pulled through the right groin removed in its entirety. What CPT® and ICD-10-CM codes are reported? A. 37200, T81.509D B. 37197, T82.514A C. 37193, T80.219A D. 37217, T88.8XXA

B. 37197, T82.514A

55 year-old patient was admitted with massive gastric dilation. The endoscope was inserted with a catheter placement. The endoscope is passed through the cricopharyngeal muscle area without difficulty. Esophagus is normal, some chronic reflux changes at the esophagogastric junction noted. Stomach significant distention with what appears to be multiple encapsulated tablets in the stomach at least 20 to 30 of these are noted. Some of these are partially dissolved. Endoscope could not be engaged due to high grade narrowing in the pyloric channel, the duodenum was not examined. It seems to be a high grade outlet obstruction with a superimposed volvulus. A repeat examination is not planned at this time. What code should be used for this procedure? A. 43246-52 B. 43241-52 C. 43235 D. 43191

B. 43241-52

PREOPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula POST OPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula PROCEDURE: Hartmann procedure, which is a sigmoid resection with Hartmann pouch and colostomy. DESCRIPTION OF THE PROCEDURE: Patient was prepped and draped in the supine position under general anesthesia. Prior to surgery patient was given 4.5 grams of Zosyn and Rocephin IV piggyback. A lower midline incision was made, abdomen was entered. Upon entry into the abdomen, there was an inflammatory mass in the pelvis and there was a large abscessed cavity, but no feces. The abscess cavity was drained and irrigated out. The left colon was immobilized, taken down the lateral perineal attachments. The sigmoid colon was mobilized. There was an inflammatory mass right at the area of the sigmoid colon consistent with a divertiliculitis or perforation with infection. Proximal to this in the distal left colon, the colon was divided using a GIA stapler with 3.5 mm staples. The sigmoid colon was then mobilized using blunt dissection. The proximal rectum just distal to the inflammatory mass was divided using a GIA stapler with 3.5 mm staples. The mesentary of the sigmoid colon was then taken down and tied using two 0 Vicryl ties. Irrigation was again performed and the sigmoid colon was removed with inflammatory mass. The wall of the abscessed cavity that was next to the sigmoid colon where the inflammatory mass was, showed no leakage of stool, no gross perforation, most likely there is a small perforation in one of the diverticula in this region. Irrigation was again performed throughout the abdomen until totally clear. All excess fluid was removed. The distal descending colon was then brought out through a separate incision in the lower left quadrant area and a large 10 mm 10 French JP drain was placed into the abscessed cavity. The sigmoid colon or the colostomy site was sutured on the inside using interrupted 3-0 Vicryl to the peritoneum and then two sheets of film were placed into the intra- abdominal cavity. The fascia was closed using a running #1 double loop PDS suture and intermittently a #2 nylon retention suture was placed. The colostomy was matured using interrupted 3-0 chromic sutures. I palpated the colostomy; it was completely patent with no obstructions. Dressings were applied. Colostomy bag was applied. Which CPT® code should be used? A. 44140 B. 44143 C. 44160 D. 44208

B. 44143

Patient is going into the OR for an appendectomy with a ruptured appendicitis. Right lower quadrant transverse incision was made upon entry to the abdomen. In the right lower quadrant there was a large amount of pus consistent with a right lower quadrant abscess. Intraoperative cultures anaerobic and aerobic were taken and sent to microbiology for evaluation. Irrigation of the pus was performed until clear. The base of the appendix right at the margin of the cecum was perforated. The mesoappendix was taken down and tied using 0-Vicryl ties and the appendix fell off completely since it was already ruptured with tissue paper thin membrane at the base. There was no appendiceal stump to close or to tie, just an opening into the cecum; therefore, the appendiceal opening area into the cecum was tied twice using figure of 8 Vicryl sutures. Omentum flap was tacked over this area and anchored in place using interrupted 3-0 Vicryl sutures to secure the repair. What CPT® and ICD-10-CM codes are reported? A. 44950, K35.890 B. 44960, 49905, K35.33 C. 44950, 49905-51, K35.20 D. 44970, K37

B. 44960, 49905, K35.33

A 52-year-old patient is admitted to the hospital for chronic cholecystitis for which a laparoscopic cholecystectomy will be performed. A transverse infraumbilical incision was made sharply dissecting to the subcutaneous tissue down to the fascia using access under direct vision with a Vesi-Port and a scope was placed into the abdomen. Three other ports were inserted under direct vision. The fundus of the gallbladder was grasped through the lateral port, where multiple adhesions to the gallbladder were taken down sharply and bluntly: The gallbladder appeared chronically inflamed. Dissection was carried out to the right of this identifying a small cystic duct and artery, was clipped twice proximally, once distally and transected. The gallbladder was then taken down from the bed using electrocautery, delivering it into an endo-bag and removing it from the abdominal cavity with the umbilical port. What CPT® and ICD-10-CM codes are reported? A. 47564, K81.2 B. 47562, K81.1 C. 47610, K81.2 D. 47600, K81.1

B. 47562, K81.1

A 70-year-old female who has a history of symptomatic ventral hernia was advised to undergo laparoscopic evaluation and repair. An incision was made in the epigastrium and dissection was carried down through the subcutaneous tissue. Two 5-mm trocars were placed, one in the left upper quadrant and one in the left lower quadrant and the laparoscope was inserted. Dissection was carried down to the area of the hernia where a small defect was clearly visualized. There was some omentum, which was adhered to the hernia and this was delivered back into the peritoneal cavity. The mesh was tacked on to cover the defect. What procedure code(s) is (are) reported? A. 49560, 49568 B. 49652 C. 49653 D. 49652, 49568

B. 49652

A 45-year-old male is going to donate his kidney to his son. Operating ports where placed in standard position and the scope was inserted. Dissection of the renal artery and vein was performed isolating the kidney. The kidney was suspended only by the renal artery and vein as well as the ureter. A stapler was used to divide the vein just above the aorta and three clips across the ureter, extracting the kidney. This was placed on ice and sent to the recipient room. The correct CPT® code is: A. 50543 B. 50547 C. 50300 D. 50320

B. 50547

A 63-year-old patient with bilateral ureteral obstruction presents to an outpatient facility for placement of a right and left ureteral stent along with an interpretation of a retrograde pyelogram. What codes should be reported? A. 52332, 74425 B. 52332-50, 74420-26 C. 52005, 74420 D. 52005-50, 74425-26

B. 52332-50, 74420-26

A 37-year-old female has menorrhagia and wants permanent sterilization. The patient was placed in Allen stirrups in the operating room. Under anesthesia the cervix was dilated and the hysteroscope was advanced to the endometrium into the uterine cavity. No polyps or fibroids were seen. The Novasure was used for endometrial ablation. A knife was then used to make an incision in the right lower quadrant and left lower quadrant with 5-mm trocars inserted under direct visualization with no injury to any abdominal contents. Laparoscopic findings revealed the uterus, ovaries and fallopian tubes to be normal. The appendix was normal as were the upper quadrants. Because of the patient's history of breast cancer and desire for no further children, it was decided to take out both the tubes and ovaries. This had been discussed with the patient prior to surgery. What are the codes for these procedures? A. 58660, 58353-51 B. 58661, 58563-51 C. 58661, 58558-51 D. 58662, 58563-51

B. 58661, 58563-51

A 22-year-old is 14 weeks pregnant and wants to terminate the pregnancy. She has consented for a D&E. She was brought to the operating room where MAC anesthesia was given. She was then placed in the dorsal lithotomy position and a weighted speculum was placed into her posterior vaginal vault. Cervix was identified and dilated. A 6.5-cm suction catheter hooked up to a suction evacuator was placed and products of conception were evacuated. A medium size curette was then used to curette her endometrium. There was noted to be a small amount of remaining products of conception in her left cornua. Once again the suction evacuator was placed and the remaining products of conception were evacuated. At this point she had a good endometrial curetting with no further products of conception noted. Which CPT® code should be used? A. 59840 B. 59841 C. 59812 D. 59851

B. 59841

The patient is a 73 year-old gentleman who was noted to have progressive gait instability over the past several months. Magnetic resonance imaging demonstrated a ventriculomegaly. It was recommended that the patient proceed forward with right frontal ventriculoperitoneal shunt placement with Codman® programmable valve. What is the correct code for this surgery? A. 62220 B. 62223 C. 62190 D. 62192

B. 62223

An entropion repair is performed on the left lower eyelid in which undermining was performed with scissors of the inferior lid and inferior temporal region. Deep sutures were used to separate the eyelid margin outwardly along with stripping the lateral tarsus to provide firm approximation of the lower lid to the globe. The correct CPT® code is: A. 67914-E4 B. 67924-E2 C. 67921-E2 D. 67917-E1

B. 67924-E2

The patient is 15-weeks pregnant with twins coming back to her obstetrician to have a transabdominal ultrasound performed to reassess anatomic abnormalities of both fetuses that were previously demonstrated in the last ultrasound. What ultrasound code(s) is (are) reported? A. 76815 B. 76816, 76816-59 C. 76801, 76802 D. 76805, 76810

B. 76816, 76816-59

A patient with severe asthma exacerbation has been admitted. The admitting physician orders a blood gas for oxygen saturation only. The admitting physician performs the arterial puncture drawing blood for a blood gas reading on oxygen saturation only. The physician draws it again in an hour to measure how much oxygen the blood is carrying. Select the codes for reporting this service. A. 82805, 82805-51 B. 82810, 82810-91 C. 82803, 82803-51 D. 82805, 82805-90

B. 82810, 82810-91

Cells were taken from amniotic fluid for analyzation of the chromosomes for possible Down's syndrome. The geneticist performs the analysis with two G-banded karyotypes analyzing 30 cells. Select the lab code(s) for reporting this service. A. 88248 B. 88267, 88280, 88285 C. 88273, 88280, 88291 D. 88262, 88285

B. 88267, 88280, 88285

Patient is coming in for a pathological examination for ischemia in the left leg. The first specimen is 1.5 cm of a single portion of arterial plaque taken from the left common femoral artery. The second specimen is 8.5 x 2.7 cm across x 1.5 cm in thickness of a cutaneous ulceration with fibropurulent material on the left leg. What surgical pathology codes should be reported for the pathologist? A. 88304-26, 88302-26 B. 88305-26, 88304-26 C. 88307-26, 88305-26 D. 88309-26, 88307-26

B. 88305-26, 88304-26

During a craniectomy the surgeon asked for a consult and sent a frozen section of a large piece of tumor and sent it to pathology. The pathologist received a rubbery pinkish tan tissue measuring in aggregate 3 x 0.8 x 0.8 cm. The entire specimen is submitted in one block and also a gross and microscopic examination was performed on the tissue. The frozen section and the pathology report are sent back to the surgeon indicating that the tumor was a medulloblastoma. What CPT® code(s) will the pathologist report? A. 80500 B. 88331-26, 88307-26 C. 80502 D. 88331-26, 88332-26, 88304-26

B. 88331-26, 88307-26

Sperm is being prepared through a washing method to get it ready for the insemination of five oocytes for fertilization by directly injecting the sperm into each oocyte. Choose the CPT® codes to report this service. A. 89257, 89280 B. 89260, 89280 C. 89261, 89280 D. 89260, 89268

B. 89260, 89280

A 10-year-old patient had a recent placement of a cochlear implant. She and her family see an audiologist to check the pressure and determine the strength of the magnet. The transmitter, microphone and cable are connected to the external speech processor and maximum loudness levels are determined under programming computer control. Which CPT® code should be used? A. 92601 B. 92603 C. 92604 D. 92562

B. 92603

An 80-year-old patient is returning to the gynecologist's office for pessary cleaning. Patient offers no complaints. The nurse removes and cleans the pessary, vagina is swabbed with betadine, and pessary replaced. For F/U in 4 months. What CPT® and ICD-10-CM codes are reported for this service? A. 99201, Z46.89 B. 99211, Z46.89 C. 99202, Z46.9 D. 99212, Z46.9

B. 99211, Z46.89

A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select the appropriate code(s) for this visit. A. 99284, 99219 B. 99219 C. 99284 D. 99235

B. 99219

A peer-to-peer prior authorization entails: A. A discussion between the ordering provider and nurse practitioner B. A discussion between the ordering provider and payer's medical director or pharmacist C. A discussion between two providers in the same office D. A discussion between a pharmacist and pharmacy technician

B. A discussion between the ordering provider and payer's medical director or pharmacist

If a patient has a non-healing burn, how would it be coded, according to ICD-10 guidelines? A. A third-degree burn B. An acute burn C. An infected burn D. Ask the Physician for more information/ documentation.

B. An acute burn

All Medicare Advantage plan members are assigned an RAF by which entity? A. AMA B. CMS C. AARP D. ACA

B. CMS

A patient admitted for left hip replacement has a medical history of COPD, with hospitalization six months ago due to acute exacerbation, diabetes with neuropathy, appendicitis s/p RT appendectomy 1997, and a history of prostate cancer s/p TURP, radiation and chemotherapy, no NED and no medications noted. Considering the importance of capturing comorbidities in the inpatient setting, which conditions should the providers document and address as active conditions for accurate code reporting during this admission? A. Appendicitis, COPD, and diabetic neuropathy B. COPD and diabetic neuropathy C. COPD with exacerbation and diabetic neuropathy D. COPD, diabetic neuropathy, and prostate cancer

B. COPD and diabetic neuropathy

Thoracentesis is removing fluid or air from the: A. Lung B. Chest cavity C. Thoracic vertebrae D. Heart

B. Chest cavity

What does oligospermia mean? A. Presence of blood in the semen B. Deficiency of sperm in semen C. Having sperm in urine D. Formation of spermatozoa

B. Deficiency of sperm in semen

When listing both CPT and HCPCS modifiers on a claim, you: A. List the HCPCS modifier first B. Do not list the HCPCS modifier at all C. Only list the CPT modifier D. List the CPT modifier first

B. Do not list the HCPCS modifier at all

Testing chloride can be found in both basic metabolic panels. Which other organ/Disease Oriented panels also test for chloride? A. General Health, Electrolyte B. Electrolyte, Renal function C. Lipid, Obstetric D. Electrolyte, Lipid

B. Electrolyte, Renal function

After Many episodes of anxious behavior, a patient's PCP diagnoses them with GAD. How would this diagnoses be billed? A. F40.8 B. F41.1 C. F41.9 D. F43.0

B. F41.1

True or False: You can use a general diagnosis code (Z00.00) for an in-depth procedure test, such as TSH screening panel. A. True B. False

B. False

Intentional billing of services not provided is considered A. Deceptive Billing B. Fraud C. Abuse D. Common practice

B. Fraud

Patient is going back to the OR for a re-exploration L5-S1 laminectomy for a presumed cerebrospinal fluid leak following a decompression procedure. A small partial laminectomy was slightly extended, however revealed no real evidence of leak. Valsalva maneuver was performed several times, no evidence of leak. There was a hematoma, which was drained. What ICD-10-CM code(s) is (are) reported by the physician? A. G96.0 B. G97.61 C. G96.8 D. G96.0, T81.4XXA

B. G97.61

Ventral, umbilical, spigelian and incisional are types of: A. Surgical approaches B. Hernias C. Organs found in the digestive system D. Cardiac catheterizations

B. Hernias

Guidelines from which of the following code sets are included as part of the code set requirements under HIPAA? A. CPT® Category III codes B. ICD-10-CM C. HCPCS Level II D. ADA Dental Codes

B. ICD-10-CM

Ms. Gardose is a 75-year-old woman who presented to emergency department with sharp pain during inhalation. The physician diagnosed her with pneumonia and flare up of COPD. Diagnosis code(s) to report this patient's condition are: A. J44.0, J18.9 B. J44.0, J18.9, J44.1 C. J44.1, J18.9 D. J18.9

B. J44.0, J18.9, J44.1

A 35-year-old-female is getting a Levonorgestrel implant system with supplies. The HCPCS Level II code is: A. S4989 B. J7306 C. A4264 D. J7301

B. J7306

What is another term for when a physician performs a reduction on a displaced fracture? A. Casting B. Manipulation C. Skeletal traction D. External fixation

B. Manipulation

Dr. Torrey is a teaching physician in a large metropolitan medical center. She has four medical students attached to her services. Resident Dr. Colavito performed an E/M service in the pediatric clinic, carefully documenting all encounter data in the EHR. The service was performed on 2/1/2018 at 9:30 a.m. Dr. Torrey reviewed his work and agreed with the findings on 2/2/2018 at 10 a.m. Does this meet CMS' requirements for billing E/M services? A. Yes: The EHR automatically adds her name and date stamp. B. No: The teaching physician must be present at the time the patient is examined.

B. No: The teaching physician must be present at the time the patient is examined.

Complete this series: Frontal lobe, Parietal lobe, Temporal lobe, ____________. A. Medulla lobe B. Occipital lobe C. Middle lobe D. Inferior lobe

B. Occipital lobe

Which of the following is not considered PHI. A. Patient's insurance ID number B. Patient's driver's license number C. Patient's date of birth D. Patient's first and last name

B. Patient's driver's license number

Diaphragmatic hernia repair codes are divided based upon what? A. The age of the patient and whether or not mesh was used B. The age of the patient and whether or not the hernia is acute or chronic C. The stage of the hernia and the site of the hernia D. The age of the patient and the site of the hernia

B. The age of the patient and whether or not the hernia is acute or chronic

When selecting an evaluation and management code, what is the first thing that the coder needs to determine? A. The time the provider spent with the patient B. The appropriate category of E&M service C. Whether the patient was new or established D. How long the discharge took

B. The appropriate category of E&M service

Which statement is TRUE when reporting pregnancy codes (O00-O9A): A. These codes can be used on the maternal and baby records. B. These codes have sequencing priority over codes from other chapters. C. Code Z33.1 should always be reported with these codes. D. The seventh character assigned to these codes only indicate a complication during the pregnancy.

B. These codes have sequencing priority over codes from other chapters.

What do the prefixes staped/o and myring/o have in common? A.They are both related to the nervous system B. They are both parts of the ear C. They are both parts of the eye D. They are both related to the respiratory system.

B. They are both parts of the ear

What is medical coding? A. Reporting services on a CMS - 1500 B. Translating medical documents into codes C. Programming and EHR D. Creating a 5010 electronic file for transmission

B. Translating medical documents into codes

Patient with corneal degeneration is having a cornea transplant. The donor cornea had been previously prepared by punching a central corneal button with a guillotine punch. This had been stored in Optisol GS. It was gently rinsed with BSS Plus solution and was then transferred to the patient's eye on a Paton spatula and sutured with 12 interrupted 10-0 nylon sutures. Select the HCPCS Level II code for the corneal tissue. A. V2790 B. V2785 C. V2628 D. V2799

B. V2785

When should an ABN be signed? A. When a service is considered medically necessary by Medicare. B. When a service is not expected to be covered by Medicare. C. Routinely for any service given to Medicare patient. D. After service is denied and the patient should be billed.

B. When a service is not expected to be covered by Medicare.

Which one is NOT a covered entity of HIPAA? A. Medicare B. Worker's Compensation C. Dentists D. Pharmacies

B. Worker's Compensation

If a patient is having abdominal ultrasound of just the liver and gallbladder, how would it be billed? A.76700 B.76705 C.78201 D.78215

B.76705

Osteoblast

Bone forming cell

Metacarpal

Bones of the hand

A 6-month-old patient is administered general anesthesia to repair a cleft palate. What anesthesia code(s) is (are) reported for this procedure? A. 00170, 99100 B. 00172 C. 00172, 99100 D. 00176

C. 00172, 99100

A 42-year-old with renal pelvis cancer receives general anesthesia for a laparoscopic radical nephrectomy. The patient has controlled type 2 diabetes otherwise no other co-morbidities. What is the correct CPT® and ICD-10-CM code for the anesthesia services? A. 00860-P1, C64.9, E11.9 B. 00840-P3, C65.9, E11.9 C. 00862-P2, C65.9, E11.9 D. 00868-P2, C79.02, E11.9

C. 00862-P2, C65.9, E11.9

A patient is having knee replacement surgery. The surgeon requests that in addition to the general anesthesia for the procedure that the anesthesiologist also insert a continuous lumbar epidural infusion for postoperative pain management. The anesthesiologist performs postoperative management for two postoperative days. A. 01400-AA, 62326, 01996 x 2 B. 01402-AA, 62327, 01966 x 2 C. 01402-AA, 62326, 01996 x 2 D. 01404-AA, 62327

C. 01402-AA, 62326, 01996 x 2

A healthy 32-year-old with a closed distal radius fracture received monitored anesthesia care for an ORIF of the distal radius. What is the code for the anesthesia service? A. 01830-P1 B. 01860-QS-P1 C. 01830-QS-P1 D. 01860-QS-G9-P1

C. 01830-QS-P1

A 24-year-old patient had an abscess by her vulva which burst. She has developed a soft tissue infection caused by gas gangrene. The area was debrided of necrotic infected tissue. All of the pus was removed and irrigation was performed with a liter of saline until clear and clean. The infected area was completely drained and the wound was packed gently with sterile saline moistened gauze and pads were placed on top of this. The correct CPT® code is: A. 56405 B. 10061 C. 11004 D. 11042

C. 11004

A 30-year-old female is having 15 sq cm debridement performed on an infected ulcer with eschar on the right foot. Using sharp dissection, the ulcer was debrided all the way to down to the bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the metatarsal. After debriding the area, there was minimal bleeding because of very poor circulation of the foot. It seems that the toes next to the ulcer may have some involvement and cultures were taken. The area was dressed with sterile saline and dressings and then wrapped. What CPT® code should be reported? A. 11043 B. 11012 C. 11044 D. 11042

C. 11044

A 46-year-old female had a previous biopsy that indicated positive malignant margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8 cm lesion. Layered closure was performed after the removal. The specimen was sent for permanent histopathologic examination. What are the CPT® code(s) for this procedure? A. 11626 B. 11626, 12004-51 C. 11626, 12044-51 D. 11626, 13132-51, 13133

C. 11626, 12044-51

A patient presents to the urgent care after accidently cutting two fingers with a bagel knife. The laceration on the index finger is 1 cm and the laceration on the middle finger is 2 cm. Simple repairs are performed on each laceration with 5-0 nylon. How should you code these repairs? A. 12001 x 2 B. 12001 C. 12002 D. 12042

C. 12002

A patient presents to the urgent care after accidently cutting two fingers with a bagel knife. The laceration on the index finger is 1 cm, and 2 cm on the middle finger. Simple repairs are performed on each laceration with 5-0 nylon. Which is proper coding? A. 12001 x 2 B. 12001 C. 12002 D. 12042

C. 12002

A 76-year-old has dermatochalasis on bilateral upper eyelids. A blepharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT® code(s) is/are? A. 15822, 15823-51 B. 15823-50 C. 15822-50 D. 15820-LT, 15820-RT

C. 15822-50

A patient has a panniculectomy, as well as a coring out and relocation of the umbilicus. Which is correct coding assignment for this surgery? A. 15830 B. 15830, 14301, 14302 C. 15830, 15847 D. 15830, 15877

C. 15830, 15847

UOD excludes all of the following, except: A. Hospice member B. Sickle cell disease patient C. 18 years and older who received prescription opioids for 15 days or more during the measurement year at a high dose D. Cancer patient

C. 18 years and older who received prescription opioids for 15 days or more during the measurement year at a high dose

A 52-year-old female has a mass growing on her right flank for several years. It has finally gotten significantly larger and is beginning to bother her. She is brought to the Operating Room for definitive excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous tissue and the surgeon encountered a well encapsulated lipoma approximately 4 centimeters. This was excised primarily bluntly with a few attachments divided with electrocautery. What CPT® and ICD-10-CM codes are reported? A. 21932, D17.39 B. 21935, D17.1 C. 21931, D17.1 D. 21925, D17.9

C. 21931, D17.1

After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped away from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT® codes for this visit? A. 22612, 22614 x 2, 22842, 20938, 20930 B. 22533, 22534 x 2, 22842 C. 22630, 22632 x 2, 22842, 20938, 20930 D. 22554, 22632 x 2, 22842

C. 22630, 22632 x 2, 22842, 20938, 20930

Which place of service code is reported on the physician's claim for a surgical procedure performed in an ASC? A. 21 B. 22 C. 24 D. 11

C. 24

This is a 32-year-old female who presents today with sacroilitis. On the physical exam there was pain on palpation of the left and right sacroiliac joint and fluoroscopic guidance was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left and right sacroiliac joint with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up will be as needed. The correct CPT® code(s) is (are): A. 20611 B. 27096-50, 77012 C. 27096-50 D. 27096, 27096-51, 77012

C. 27096-50

PREOPERATIVE DIAGNOSIS: Medial meniscus tear, right knee POSTOPERATIVE DIAGNOSIS: Medial meniscus tear, extensive synovitis with an impingement medial synovial plica, right knee TITLE OF PROCEDURE: Diagnostic operative arthroscopy, partial medial meniscectomy and synovectomy, right knee The patent was brought to the operating room, placed in the supine position after which he underwent general anesthesia. The right knee was then prepped and draped in the usual sterile fashion. The arthroscope was introduced through an anterolateral portal, interim portal created anteromedially. The suprapatellar pouch was inspected. The findings on the patella and the femoral groove were as noted above. An intra-articular shaver was introduced to debride the loose fibrillated articular cartilage from the medial patellar facet. The hypertrophic synovial scarring between the patella and the femoral groove was debrided. The hypertrophic impinging medial synovial plica was resected. The hypertrophic synovial scarring overlying the intercondylar notch and lateral compartment was debrided. The medial compartment was inspected. An upbiting basket was introduced to transect the base of the degenerative posterior horn flap tear. This was removed with a grasper. The meniscus was then further contoured and balanced with an intra-articular shaver, reprobed and found to be stable. The cruciate ligaments were probed, palpated and found to be intact. The lateral compartment was then inspected. The lateral meniscus was probed and found to be intact. The loose fibrillated articular cartilage along the lateral tibial plateau was debrided with the intra-articular shaver. The knee joint was then thoroughly irrigated with the arthroscope. The arthroscope was then removed. Skin portals were closed with 3-0 nylon sutures. A sterile dressing was applied. The patient was then awakened and sent to the recovery room in stable condition. What CPT® and ICD-10-CM codes should be reported? A. 29880-RT, M23.203, M65.80, M94.261, M22.41 B. 29881-RT, M23.211, M65.861, M94.261, M22.41 C. 29881-RT, M23.221, M65.861, M94.261, M22.41 D. 29880-RT, 29877-59-RT, M23.621, M65.80, M94.261, M22.41

C. 29881-RT, M23.221, M65.861, M94.261, M22.41

Which of the following CPT Codes is Modifier 51 exempt? A. 49500- Repair initial inguinal hernia, age 6 mos to younger than 5 years, with/without hydrocelectomy reducible B. 33218- Repair of single transvenous electrode, permanent pacemaker or implant defibrillator C. 31500- Intubation, endotracheal, emergency procedure D. 50100 Transection/repositioning of aberrant renal vessels

C. 31500- Intubation, endotracheal, emergency procedure

Patient has lung cancer in his upper right and middle lobes. Patient is in the operating suite to have a video-assisted thorascopy surgery (VATS). A 10-mm-zero-degree thoracoscope is inserted in the right pleural cavity through a port site placed in the ninth and seventh intercostal spaces. Lung was deflated. The tumor is in the right pleural. Both lobes were removed thorascopically. Port site closed. A chest tube was placed to suction and patient was sent to recovery in stable condition. Which CPT® code is reported for this procedure? A. 32482 B. 32484 C. 32670 D. 32671

C. 32670

The patient is a 67-year-old gentleman with metastatic colon cancer recently operated on for a brain metastasis, now for placement of an Infuse-A-Port for continued chemotherapy. The left subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and the power port line was placed with the introducer and the introducer was peeled away. The tip was placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the appropriate length and secured to the power port device. The locking mechanism was fully engaged. The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically. It was secured to the underlying soft tissue with 2-0 silk stitch. What CPT® code(s) is (are) reported for this procedure? A. 36556, 77001-26 B. 36558 C. 36561, 77001-26 D. 36571

C. 36561, 77001-26

The patient is a 51-year-old gentleman who has end-stage renal disease. He was in the OR yesterday for a revision of his AV graft. The next day the patient had complications of the graft failing. The patient was back to the operating room where an open thrombectomy was performed on both sides getting good back bleeding, good inflow. Select the appropriate code for performing the procedure in a post-operative period: A. 36831-76 B. 36831 C. 36831-78 D. 36831-58

C. 36831-78

A 50-year-old female has recurrent lymphoma in the axilla. Ultrasound was used to localize the lymph node in question for needle guidance. An 11 blade scalpel was used to perform a small dermatotomy. An 18 x 10 cm Biopence needle was advanced through the dermatotomy to the periphery of the lymph node. A total of 4 biopsy specimens were obtained. Two specimens were placed an RPMI and 2 were placed in formalin and sent to laboratory. The correct CPT® code(s) is (are): A. 10005 B. 38500, 77002-26 C. 38505, 76942-26 D. 38525, 76942-26

C. 38505, 76942-26

A 15 year-old female is to have a tonsillectomy performed for chronic tonsillitis and hypertrophied tonsils. A McIver mouth gag was put in place and the tongue was depressed. The nasopharynx was digitalized. No significant adenoid tissue was felt. The tonsils were then removed bilaterally by dissection. The uvula was a huge size because of edema, a part of this was removed and the raw surface oversewn with 3-0 chromic catgut. Which CPT® code(s) is (are) reported? A. 42821 B. 42825, 42104-51 C. 42826, 42106-51 D. 42842

C. 42826, 42106-51

An 82-year-old female had a CAT scan which revealed evidence of a proximal small bowel obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made, excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the small bowel. The omentum and bowel were stuck up to the anterior abdominal wall. Time consuming, tedious and spending an extra hour to lysis the adhesions to free up the entire length of the gastrointestinal tract from the ligament to Treitz to the ileocolic anastomosis. The correct CPT® code is: A. 44005 B. 44180-22 C. 44005-22 D. 44180-59

C. 44005-22

A 16-day-old male baby is in the OR for a repeat circumcision due to redundant foreskin that caused circumferential scarring from the original circumcision. Anesthetic was injected and an incision was made at base of the foreskin. Foreskin was pulled back and the excess foreskin was taken off and the two raw skin surfaces were sutured together to create a circumferential anastomosis. Select the appropriate code for this surgery: A. 54150 B. 54160 C. 54163 D. 54164

C. 54163

A 55-year-old female has a symptomatic rectocele. She had been admitted and taken to the main OR. An incision is made in the vagina into the perineal body (central tendon of the perineum). Dissection was carried underneath posterior vaginal epithelium all the way over to the rectocele. Fascial tissue was brought together with sutures creating a bridge and the rectocele had been reduced with good support between the vagina and rectum. What procedure code should be reported? A. 45560 B. 57284 C. 57250 D. 57240

C. 57250

A 23-year-old who is pregnant at 39-weeks and 3 days is presenting for a low transverse cesarean section. An abdominal incision is made and was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the lower uterine segment incised in a transverse fashion with the scalpel. The bladder blade was removed and the infant's head delivered atraumatically. The nose and mouth were suctioned with the bulb suction trap and the cord doubly clamped and cut. The placenta was then removed manually. What CPT® and ICD-10-CM codes are reported for this procedure? A. 59610, O34.211, Z37.0, Z3A.39 B. 59510, O64.1XX0, Z37.0, Z3A.39 C. 59514, O82, Z37.0, Z3A.39 D. 59515, O82, Z37.0, Z3A.39

C. 59514, O82, Z37.0, Z3A.39

A physician performed craniotomy on a patient with a severe head trauma and intracerebral hematoma. Due to the patient's condition the procedure was extremely difficult, requiring a significant amount of extra time and effort. What is the correct code for this procedure? A. 61315 B. 61313 C. 61313 -22 D. 61315 -23

C. 61313 -22

A craniectomy is being performed on a patient who has Chiari malformation. Once the posterior inferior scalp was removed a C-1 and a partial C-2 laminectomy was then performed. The right cerebellar tonsil was dissected free of the dorsal medulla and a gush of cerebrospinal fluid gave good decompression of the posterior fossa content. Which CPT® code is reported? A. 61322 B. 61345 C. 61343 D. 61458

C. 61343

The patient is a 64 year-old female who is undergoing a removal of a previously implanted Medtronic pain pump and catheter due to a possible infection. The back was incised; dissection was carried down to the previously placed catheter. There was evidence of infection with some fat necrosis in which cultures were taken. The intrathecal portion of the catheter was removed. Next the pump pocket was incised and the pump was dissected from the anterior fascia. A 7-mm Blake drain was placed in the pump pocket through a stab incision and secured to the skin with interrupted Prolene. The pump pocket was copiously irrigated with saline and closed in two layers. What are the CPT® and ICD-10-CM codes for this procedure? A. 62365, 62350-51, T85.898A, Z46.2 B. 62360, 62355-51, T85.79XA C. 62365, 62355-51, T85.79XA D. 36590, I97.42, T85.898A

C. 62365, 62355-51, T85.79XA

What is the CPT® code for the decompression of the median nerve found in the space in the wrist on the palmar side? A. 64704 B. 64713 C. 64721 D. 64719

C. 64721

An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacomulsicfication unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex allowing the insertion of the intraocular lens. What CPT® code is reported? A. 66985 B. 66984 C. 66982 D. 66983

C. 66982

A 35-year-old male sees his primary care physician complaining of fever with chills, cough and congestion. The physician performs a chest X-ray taking lateral and AP views in his office. The physician interprets the X-ray views and the patient is diagnosed with walking pneumonia. Which CPT® code is reported for the chest X-rays performed in the office and interpreted by the physician? A. 71046-26 B. 71047-26 C. 71046 D. 71045-26-TC

C. 71046

56-year-old female is having a bilateral mammogram with computer aid detection conducted as a screening because the patient has a family history of breast cancer. She does not presently have signs or symptoms of breast disease. What radiological services are reported? A. 77065 x 2 B. 77065, 77066 C. 77067 D. 77066

C. 77067

A CT density study is performed on a post-menopausal female to screen for osteoporosis. Today's visit the bone density study will be performed on the spine. Which CPT® code is reported? A. 77075 B. 77080 C. 77078 D. 72081

C. 77078

A patient uses Topiramate to control his seizures. He comes in every two months to have a therapeutic drug testing performed to assess serum plasma levels of this medication. What lab code(s) is (are) reported for this testing? A. 80305 B. 80375 C. 80201 D. 80306, 80375

C. 80201

A 4-year-old is getting over his cold and will be getting three immunizations in the pediatrician's office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next vaccination is the live influenza (LAIV3) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and vaccines? A. 90713, 90658, 90716, 90460, 90461 x 2 B. 90713, 90660, 90716, 90460, 90461 x 1 C. 90713, 90660, 90716, 90471, 90472, 90474 D. 90713, 90658, 90716, 90471, 90472, 90473

C. 90713, 90660, 90716, 90471, 90472, 90474

A patient who is a singer has been hoarse for a few months following an upper respiratory infection. She is in a voice laboratory to have a laryngeal function study performed by an otolaryngologist. She starts off with the acoustic testing first. Before she moves on to the aerodynamic testing she complains of throat pain and is rescheduled to come back to have the other test performed. What CPT® code is reported? A. 92520 B. 92700 C. 92520-52 D. 92614-52

C. 92520-52

A new patient is having a cardiovascular stress test done in his cardiologist's office. Before the test is started the physician documents a comprehensive history and exam and moderate complexity medical decision making. The physician will be supervising and interpreting the stress on the patient's heart during the test. What procedure codes are reported for this encounter? A. 93015-26, 99204-25 B. 93016, 93018, 99204-25 C. 93015, 99204-25 D. 93018-26, 99204-25

C. 93015, 99204-25

A cardiologist pediatrician sends a four week-old baby to an outpatient facility to have an echocardiogram. The baby has been having rapid breathing. He is sedated and a probe is placed on the chest wall and images are taken through the chest wall. A report is generated and sent to the pediatrician. The interpretation of the report by the pediatrician reveals the baby has an atrial septal defect. Choose the CPT® code the cardiologist pediatrician should report. A. 93303 B. 93315-26 C. 93303-26 D. 93315

C. 93303-26

A progress note with one to three elements of HPI for a new patient office visit will result in an E/M level no higher than: A. 99203 B. 99214 C. 99202 D. 99213

C. 99202

Documentation of a new patient in a doctor's office setting supports a detailed history in which there are four elements for an extended history of present illness (HPI), three elements for an extended review of systems (ROS) and a pertinent Past, Family, Social History (PFSH). There is a detailed examination of six body areas and organ systems. The medical making decision making is of high complexity. Which E/M service supports this documentation? A. 99205 B. 99204 C. 99203 D. 99202

C. 99203

The patient is here to follow up on her atrial fibrillation. Her primary care physician is not in the office. She will be seen by the partner physician that is also in the same group practice. No new problems. A problem focused history is performed. An expanded problem focused physical exam is documented with the following, Blood pressure is 110/64. Pulse is regular at 72. Temp is 98.6F Chest is clear. Cardiac normal sinus rhythm. Medical making decision is straightforward. Diagnosis: Atrial fibrillation, currently stable. What E/M code is reported for this service? A. 99201 B. 99202 C. 99212 D. 99213

C. 99212

Patient was in the ER complaining of constipation with nausea and vomiting when taking Zovirax for his herpes zoster and Percocet for pain. His primary care physician came to the ER and admitted him to the hospital for intravenous therapy and management of this problem. His physician documented a detailed history, comprehensive examination and a medical decision making of moderate complexity. Which E/M service is reported? A. 99285 B. 99284 C. 99221 D. 99222

C. 99221

A patient was admitted yesterday to the hospital for possible gallstones. The following day the physician who admitted the patient performed a detailed history, a detailed exam and a medical decision making of low complexity. The physician tells her the test results have come back positive for gallstones and is recommending having a cholecystectomy. What code is reported for this evaluation and management service for the following day? A. 99253 B. 99221 C. 99233 D. 99234

C. 99233

Which of the follow describes a procedure to remove fluid from the amniotic sac? A. Arthrocentesis B. Paracentesis C. Amniocentesis D. Pericardiocentesis

C. Amniocentesis

Question 9 Code +34709 for placement of an extension may be assigned for which scenario? A. An extension is placed in the common iliac artery. B. A docking limb is placed in the common iliac artery. C. An extension is placed in the external iliac artery. D. A docking limb is placed in the external iliac artery.

C. An extension is placed in the external iliac artery.

If a ST elevation myocardial infarction (STEMI) converts to a non ST elevation myocardial infarction (NSTEMI) due to thrombolytic therapy, how is it reported, according to ICD-10-CM guidelines? A. As unspecified AMI B. As a subendocardial AMI C. As STEMI D. As a NSTEMI

C. As STEMI

A patient has a standard, rubberized gastrostomy tube placed during the procedure. How would just the tube be billed(HCPCS)? A. B4081 B. B4083 C. B4087 D. B4088

C. B4087

An angiogram is a study to look inside: A. Female Reproductive System B. Urinary System C. Blood Vessels D. Breasts

C. Blood Vessels

Bob was referred to an OT status post left index finger arthroplasty. The patient's goal is to decrease pain and return to pre-morbid functional status with use of hand. The OT should look to which G codes for reporting therapy sessions? A. Changing and maintaining body positions G code set B. Other PT/OT subsequent G code set C. Carrying, moving, and handling objects G code set D. Mobility G code set

C. Carrying, moving, and handling objects G code set

An entity that processes non standard health information they receive from another entity into a standard format is considered what? A Billing Company B. Electronic Heath Record Vendor C. Clearinghouse D. Practice Management Vendor

C. Clearinghouse

Local Coverage Determinations (LCDs) are: A. Applicable across the United States B. Issued by CMS C. Contain information about standards for "reasonable and necessary" items and services D. Not enforceable by the Medicare administrative contractor (MAC)

C. Contain information about standards for "reasonable and necessary" items and services

___________________ is an example of a disease interaction. A. Hypertension and osteoporosis B. PVD and CHF C. Diabetes with macular degeneration D. Diabetes and respirator dependence

C. Diabetes with macular degeneration

An electric breast pump is provided to a pregnant patient through her insurance. She receives the pump and an AC/DC adapter. How would this be billed? A. E0570 B. E0602 C. E0603 D. E0604

C. E0603

A 66-year-old Medicare patient, who has a history of ulcerative colitis, presents for a colorectal cancer screening. The screening is performed via barium enema. What HCPCS Level II code is reported for this procedure? A. G0104 B. G0105 C. G0120 D. G0121

C. G0120

What is the ICD-10-CM code for a diagnosis of "cyclic vomiting syndrome?" A. R11.2 B. R11.12 C. G43.A0 D. G43.A1

C. G43.A0

Patient comes into see her primary care physician for a productive cough and shortness of breath. The physician takes a chest X-ray which indicates the patient has double pneumonia. Select the ICD-10-CM code(s) for this visit. A. J18.9, R05, R06.2 B. R05, R06.2, J18.9 C. J18.9 D. J15.9

C. J18.9

A patient that has cirrhosis of the liver just had an endoscopy performed showing hemorrhagic esophageal varices. The ICD-10-CM codes are reported: A. I85.01, K74.69 B. I85.11, K74.60 C. K74.60, I85.11 D. I85.00, K74.69

C. K74.60, I85.11

Which is an NCD interpreted at the MAC level considered? A.MAC adjusted NCD B. ABN C. LCD D. MAC's cannot interpret and NCD

C. LCD

A patient sustains an injury to her great saphenous vein would have sustained an injury to which of the following anatomical sites? A. Neck B. Arm C. Leg D. Abdomen

C. Leg

A 9-year-old female presents to this office today with continued bed wetting. She is here with her mom, who states the child has never been able to go through the night without wetting the bed. She has used alarms, cutting off fluids at 6 p.m., and using bathroom before bed. Denies dysuria or frequency. Mom states the urine is often dark. Which is the ICD-10-CM code to report this condition? A. N39.4 B. N39.41 C. N39.44 D. N39.498

C. N39.44

A 47-year-old male patient with advanced cancer of the lower left mandible presented to the hospital for surgical removal of the lower left jawbone with secondary insertion of mandibular prosthesis. In order to perform surgery, the patient had to be intubated through a tracheostomy. After anesthesia, the surgeon performed the tracheostomy by incising the cricothyroid membrane horizontally along the trachea and inserting the intubation device. The surgeon completed the primary surgical procedure on the patient's mandible. What is the correct code for the intubation? A. 31605 B. 31600 C. No code would be used for the intubation D. 31603

C. No code would be used for the intubation

Fracturing the acetabulum involves what area? A. Skull B. Shoulder C. Pelvis D. Leg

C. Pelvis

What is PHI? A. Physician-health care interchange B. Private health insurance C. Protected health information D. Provider identified incident-to

C. Protected health information

What is the correct way to code a patient having bradycardia due to Demerol that was correctly prescribed and properly administered? A. T40.2X1A, R00.1 B. T40.2X3A, R00.1 C. R00.1, T40.2X5A D. R00.1, T40.2X2A

C. R00.1, T40.2X5A

A 44-year-old had a history of adenocarcinoma of the cervix on a conization in March 20XX who has been followed with twice-yearly endocervical curettages and Pap smears that were all negative for two years, per the recommendation of a GYN oncologist. Her Pap smear results from the last visit noted atypical glandular cells. In light of this, she underwent a colposcopy and the biopsy of the normal-appearing cervix on colposcopy was benign. The endocervical curettage was benign endocervical glands, and the endometrial sampling was benign endometrium. In light of the fact that she had had previous atypical glandular cells that led to diagnosis of adenocarcinoma and the concerns that this may have recurred, she had been recommended for a cone biopsy and fractional dilatation and curettage, which she is undergoing today. What ICD-10-CM code(s) should be reported? A. R87.619, C53.9 B. C55 C. R87.619, Z85.41 D. Z12.4, Z85.41

C. R87.619, Z85.41

What is NOT included in CPT® surgical package? A. Typical postoperative follow-up care B. One related Evaluation and Management service on the same date of the procedure C. Returning to the operating room the next day for a complication resulting from the initial procedure D. Evaluating the patient in the post-anesthesia recovery area

C. Returning to the operating room the next day for a complication resulting from the initial procedure

A 27-year-old was frying chicken when an explosion of the oil had occurred and she sustained second-degree burns on her face (5%), third degree burns on both hands (5%). There was a total of 10 percent of the body surface that was burned. Select which ICD-10-CM codes are reported. A. T20.20XA, T23.301A, T23.302A, T31.10, X10.2XXA, Y93.G3 B. T23.301A, T23.302A, T20.20XA, T31.11, X10.2XXA, Y93.G3 C. T23.301A, T23.302A, T20.20XA, T31.10, X10.2XXA, Y93.G3 D. T23.601A, T23.602A, T20.60XA, T31.10, X10.2XXA, Y93.G3

C. T23.301A, T23.302A, T20.20XA, T31.10, X10.2XXA, Y93.G3

When coding an adverse effect for a drug that was correctly prescribed and properly administered, what should be coded first? A. The drug B. The underlying condition treated C. The side effect of the drug D. The activity the patient was involved in when the drug was taken

C. The side effect of the drug

CMS changed the rule regarding teaching physicians re-documenting medical students' physical examinations because: A. They want less documentation for auditors to review. B. They want to reduce the reimbursement for E/M services. C. They want to reduce administrative burdens for teaching physicians. D. They intend to change evaluation and management CPT® codes in 2019.

C. They want to reduce administrative burdens for teaching physicians.

Glomerulonephritis is an inflammation affecting which system? A. Digestive B. Nervous C. Urinary D. Cardiovascular

C. Urinary

Which health plan does NOT fall under HIPAA? A. Medicaid B. Medicare C. Workers' compensation D. Private plans

C. Workers' compensation

Which statement is TRUE about Z codes: A. Z codes are never reported as a primary code. B. Z codes are only reported with injury codes. C. Z codes may be used either as a primary code or a secondary code. D. Z codes are always reported as a secondary code.

C. Z codes may be used either as a primary code or a secondary code.

Center for Medicare and Medicaid Services

CMS

Yes

Can medical records serve as a legal document?

Osteocarcinoma

Cancerous tumor of bone

Mitosis

Cells divide and multiply to form two cells

CMS

Centers for Medicare and Medicaid Services, formerly HCFA, Health Care Financing Administration

CRNA

Certified Registered Nurse Anesthetist

delivery

Childbirth

Stratum Spinosum

Composed of prickle cells

Ecchymosis

Condition in which blood seeps into the skin causing discoloration

Osteoporosis

Condition resulting in reduction of bone mass

synovial membrane

Connective tissue that lines the joint cavities

The procedure known as blepharoplasty is performed to: A. Correct the muscle misalignment caused by strabismus B. Correct vision loss due to glaucoma C. Plastic repair a droopy eyelid D. Repair the lens of the eye caused by cataracts

D - Repair the lens of the eye caused by cataracts

A patient undergoes a procedure for intermediate repair of various wounds on the left arm and hand. The total size of the wounds is 8 cm and 3 cm respectively. How would this be billed? A. 12034 B. 12031, 12041 C. 12004, 12001 D. 12034, 12042

D. 12034, 12042

Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon. No tumor was identified after the final stage of the microscopically controlled surgery. What procedure codes are reported? A. 17313, 17314, 17314 B. 17313, 17315 C. 17260, 17313, 17314 D. 17313,17314, 17315

D. 17313,17314, 17315

A 76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o'clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology. Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0 Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What CPT® and ICD-10-CM codes describe this procedure? A. 19100, N63.20 B. 19285, C50.912 C. 19120, R92.8 D. 19125, D24.2

D. 19125, D24.2

A 61-year-old gentleman with a history of a fall while intoxicated suffered a blow to the forehead and imaging revealed a posteriorly displaced odontoid fracture. The patient was taken into the Operating Room, and placed supine on the operating room table. Under mild sedation, the patient was placed in Gardner-Wells tongs and gentle axial traction under fluoroscopy was performed to gently try to reduce the fracture. It did reduce partially without any change in the neurologic examination. More manipulation would be necessary and it was decided to intubate and use fiberoptic technique. The anterior neck was prepped and draped and an incision was made in a skin crease overlying the C4-C5 area. Using hand-held retractors, the ventral aspect of the spine was identified and the C2-C3 disk space was identified using lateral fluoroscopy. Using some pressure upon the ventral aspect of the C2 body, we were able to achieve a satisfactory reduction of the fracture. Under direct AP and lateral fluoroscopic guidance, a Kirschner wire was advanced into the C2 body through the fracture line and into the odontoid process. This was then drilled, and a 42 millimeter cannulated lag screw was advanced through the C2 body into the odontoid process. What procedure code is reported? A. 22505 B. 22326 C. 22315 D. 22318

D. 22318

A 68-year-old, Medicare patient was woodworking in his basement workshop in his single-family home, preparing a new finish to a coffee table. He lost his grip on a powered sander and suffered a crushing injury into the capitate and hamate bones of his right wrist as well as a Gustilo-Anderson Type I open fracture of the hamate body. In the hospital, an orthopedic surgeon performed a flexor tendon decompression fasciotomy with extensive debridement of muscle, nerve tissue and bone as well as a 2-bone carpectomy. An ORIF of the fracture was also done. The surgery took place in the hospital the day after admission at Level 2 subsequent hospital care. This procedure was actually done in consult, but Medicare does not pay for consultation CPT® codes. The patient is placed in an extension control cock-up wrist splint. Code the encounter. A. 25023-RT, 25628-51-RT, 25210-51-RT B. 25023-RT, 25628-51-RT, 25210-51-RT x 2 C. 25023-RT, 11012-51, 25645-51-RT, 25210-51-RT x 2 D. 25023-RT, 25645-51-RT, 25210-51-RT x 2, 99232-57

D. 25023-RT, 25645-51-RT, 25210-51-RT x 2, 99232-57

An infant with genu valgum is brought to the operating room to have a bilateral medial distal femur hemiepiphysiodesis done. On each knee, the C-arm was used to localize the growth plate. With the growth plate localized, an incision was made medially on both sides. This was taken down to the fascia, which was opened. The periosteum was not opened. The Orthofix® figure-of-eight plate was placed and checked with X-ray. We then irrigated and closed the medial fascia with 0 Vicryl suture. The skin was closed with 2-0 Vicryl and 3-0 Monocryl®. What procedure code is reported? A. 27470-50 B. 27475-50 C. 27477-50 D. 27485-50

D. 27485-50

A 42-year-old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes, about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The rotator interval was very thick and contracted. Adhesions were destroyed with electrocautery and the Bovie. The superior glenohumeral ligament, the middle glenohumeral ligament and the tendinous portion of the subscapularis were released. The arthroscope was placed anteriorly, adhesions were destroyed and the shaver was used to debride some of the posterior capsule and the posterior capsule was released in its posterosuperior and then posteroinferior aspect. What CPT® code(s) is (are) reported? A. 23450-LT B. 23466-LT C. 29805-LT, 29806-51-LT D. 29825-LT

D. 29825-LT

The patient is a 58-year-old white male, one month status post pneumonectomy. He had a post pneumonectomy empyema treated with a tunneled cuffed pleural catheter which has been draining the cavity for one month with clear drainage. He has had no evidence of a block or pleural fistula. Therefore a planned return to surgery results in the removal of the catheter. The correct CPT® code is: A. 32440-78 B. 32035-58 C. 32036-79 D. 32552-58

D. 32552-58

This 67-year-old man presented with a history of progressive shortness of breath. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general area. Both of these holes were closed with a single pericardial patch. What CPT® and ICD-10-CM codes are reported? A. 33675, Q21.0 B. 33647, Q21.1, R06.02 C. 33645, Q21.2, R06.02 D. 33641, Q21.1

D. 33641, Q21.1

A catheter is placed in the left common femoral artery which was directed into the right the external iliac (antegrade). Dye was injected and a right lower extremity angiogram was performed which revealed patency of the common femoral and profunda femoris. The catheter was then manipulated into the superficial femoral artery (retrograde) in which a lower extremity angiogram was performed which revealed occlusion from the popliteal to the tibioperoneal artery. What are the procedure codes that describe this procedure? A. 36217, 75736-26 B. 36247, 75716-26 C. 36217, 75756-26 D. 36247, 75710-26

D. 36247, 75710-26

A physician orders 90 minutes of HBOT. The documentation for the HBOT treatment indicates the patient was in the chamber at 100 percent oxygen for 90 minutes. Additional time of 10 minutes for descent, a 10-minute air break, and 10 minutes for ascent was also documented. How many units of G0277 are billed by the hospital? A. 3 units B. 5 units C. 2 units D. 4 units

D. 4 units

A 34-year-old male developed a ventral hernia when lifting a 60 pound bag. The patient is in surgery for a ventral herniorrhaphy. The abdomen was entered through a short midline incision revealing the fascial defect. The hernia sac and contents were able to easily be reduced and a large plug of mesh was placed into the fascial defect. The edge of the mesh plug was sutured to the fascia. What procedure code(s) is (are) reported? A. 49560 B. 49561, 49568 C. 49652 D. 49560, 49568

D. 49560, 49568

This gentleman has localized prostate cancer and has chosen to have complete transrectal ultrasonography performed for dosimetry purposes. Following calculation of the planned transrectal ultrasound, guidance was provided for percutaneous placement of 1-125 seeds. Select the appropriate codes for this procedure. A. 55920, 76965-26 B. 55876, 76942-26 C. 55860, 76873-26 D. 55875, 76965-26

D. 55875, 76965-26

5 year-old female has a history of post void dribbling. She was found to have extensive labial adhesions, which have been unresponsive to topical medical management. She is brought to the operating suite in a supine position. Under general anesthesia the labia majora is retracted and the granulating chronic adhesions were incised midline both anteriorly and posteriorly. The adherent granulation tissue was excised on either side. What code should be used for this procedure? A. 58660 B. 58740 C. 57061 D. 56441

D. 56441

A 25-year-old female in the OR for ectopic pregnancy. Once the trocars were place a pneumoperitoneum was created and the laparoscope introduced. The left fallopian tube was dilated and was bleeding. The left ovary was normal. The uterus was of normal size, shape and contour. The right ovary and tube were normal. Due to the patient's body habitus the adnexa could not be visualized to start the surgery. At this point the laparoscopic approach was terminated. The pneumoperitoneum was deflated, and trocar sites were sutured closed. The trocars and laparoscopic instruments had been removed. Open surgery was performed incising a previous transverse scar from a cesarean section. The gestation site was bleeding and all products of conception and clots were removed. The left tube was grasped, clamped and removed in its entirety and passed off to pathology. What code(s) is (are) reported for this procedure? A. 59150, 59120 B. 59151 C. 59121 D. 59120

D. 59120

MRI reveals patient has cervical stenosis. It was determined he should undergo bilateral cervical laminectomy at C3 through C6 and fusion. The edges of the laminectomy were then cleaned up with a Kerrison and foraminotomies were done at C4, C5, and,C6. The stenosis is central; a facetectomy is performed by using a burr. Nerve root canals were freed by additional resection of the facet, and compression of the spinal cord was relieved by removal of a tissue overgrowth around the foramen. Which CPT® code(s) is (are) used for this procedure? A. 63045-50, 63048-50 B. 63020-50, 63035-50, 63035-50 C. 63015-50 D. 63045, 63048 x 2

D. 63045, 63048 x 2

Under fluoroscopic guidance an injection of a combination of steroid and analgesic agent is performed on T2-T3, T4-T5, T6-T7 and T8-T9 on the left side into the paravertebral facet joints. The procedure was performed for pain due to thoracic root lesions. What are the procedure codes? A. 64479, 64480x3, 77003 B. 64490, 64491, 64492x2, 77003 C. 64520x4, 77003 D. 64490, 64491, 64492

D. 64490, 64491, 64492

A 2-year-old male has a chalazion on both upper and lower lid of the right eye. He was placed under general anesthesia. With a #11 blade the chalazion was incised and a small curette was then used to retrieve any granulomatous material on both lids. What CPT® code should be used for this procedure? A. 67801 B. 67805 C. 67800 D. 67808

D. 67808

A patient undergoes a bilateral limited breast ultrasound after a compliant of a palpable lump on both sides. How would this be billed? A. 76604 B. 76800 C. 76641-50 D. 76642-50

D. 76642-50 In the index of the CPT book, you will look up ultrasound breast. This gives you the codes 76641 and 76642, which can be found in the Radiology section. Turning to this section, you will see that these codes differ depending on whether the study was limited or complete. The question states the patient went through a limited ultrasound, so code 76642 will be the correct answer. Also, since the patient had a bilateral ultrasound done, you will add the 50 modifier to the code. Code 76641 is also for a breast ultrasound but is a complete study, not limited. Since this is not what the question is asking for, this is incorrect. Code 76604 is for ultrasound of the chest. This is also not what the question is asking or so this would be incorrect. Code 76800 is for an ultrasound of the spinal canal and contents within. This is not what the question is asking for either, so this is correct. AMA. CPT Professional Pg 494

Physician orders a basic (80047) and comprehensive metabolic (80053) panels. Select the code(s) on how this is reported. A. 80053, 80047 B. 80053 C. 80047, 82040, 82247, 82310, 84075, 84155, 84460, 84450 D. 80053, 82330

D. 80053, 82330

Patient that is a borderline diabetic has been sent to the laboratory to have an oral glucose tolerance test. Patient drank the glucose and five blood specimens were taken every 30 to 60 minutes up to three hours to determine how quickly the glucose is cleared from the blood. What code(s) is (are) reported for this test? A. 82947 x 5 B. 82946 C. 80422 D. 82951, 82952 x 2

D. 82951, 82952 x 2

A patient with chronic renal failure is in the hospital being evaluated by his nephrologist after just placing a catheter into the peritoneal cavity for dialysis. The physician is evaluating the dwell time and running fluid out of the cavity to make sure the volume of dialysate and the concentration of electrolytes and glucose are correctly prescribed for this patient. What code should be reported for this service? A. 90935 B. 90937 C. 90947 D. 90945

D. 90945

Patient with hemiparesis on the dominant side due to having a CVA lives at home alone and has a therapist at his home site to evaluate meal preparation for self-care. The therapist observes the patient's functional level of performing kitchen management activities within safe limits. The therapist then teaches meal preparation using one handed techniques along with adaptive equipment to handle different kitchen appliances. The total time spent on this visit was 45 minutes. Report the CPT® and ICD-10-CM codes for this encounter. A. 97530 x 3, I67.89, G81.91 B. 97535 x 3, G81.90, I69.959 C. 97530 x 3, I69.959, I67.89 D. 97535 x 3, I69.959

D. 97535 x 3, I69.959

A 2-year-old is coming in with his mom to see the pediatrician for fever, sore throat, and pulling of the ears. The physician performs an expanded problem focused history. An expanded problem focused exam. A strep culture was taken for the pharyngitis and came back positive for strep throat. A diagnosis was also made of the infant having acute otitis media with effusion in both ears. The medical decision making was of moderate complexity with the giving of a prescription. What CPT® and ICD-10-CM codes are reported? A. 99212, J02.9, H66.93 B. 99213, J02.0 H65.93 C. 99212, J02.0 H65.193 D. 99213, J02.0 H65.193

D. 99213, J02.0 H65.193

A 64-year-old female who has multiple sclerosis fell from her walker and landed on a glass table. She lacerated her forehead, cheek and chin and the total length of these lacerations was 6 cm. Her right arm and left leg had deep cuts measuring 5 cm on each extremity. Her right hand and right foot had a total of 3 cm lacerations. The ED physician repaired the lacerations as follows: The forehead, cheek, and chin had debridement and cleaning of glass debris with the lacerations being closed with one layer closure, 6-0 Prolene sutures. The arm and leg were repaired by layered closure, 6-0 Vicryl subcutaneous sutures and Prolene sutures on the skin. The hand and foot were closed with adhesive strips. Select the appropriate procedure codes for this visit. A. 99283-25, 12014, 12034-59, 12002-59, 11042-51 B. 99283-25, 12053, 12034-59, 12002-59 C. 99283-25, 12014, 12034-59, 11042-51 D. 99283-25, 12053, 12034-59

D. 99283-25, 12053, 12034-59

What documentation indicates a "rupture" when coding for an endovascular repair? A. Pseudoaneurysm B. Chronic rupture C. Dissection D. Acute hemorrhage

D. Acute hemorrhage

When comparing the review of systems and physical examination to the chief complaint and HPI in an EHR, the auditor is looking for: A. A comprehensive level B. A detailed level C. The number of HPI elements D. Agreement

D. Agreement

For Presumptive drug class screenings which drugs are represented? A. Cocaine, ampethamines1-5, and barbiturates only, per monthly testing period B. All Drugs listed in the old class lists A and B only, per date of service. C. Opioids and tramadol only, per date of service. D. All Drugs and drug classes performed by the respective methodology per date of service.

D. All Drugs and drug classes performed by the respective methodology per date of service.

For presumptive drug class screenings, which drugs are represented? A. Cocaine, amphetamines 1-5, and barbiturates only, per monthly testing period B. All Drugs listed in the old class lists A and B only, per date of service C. Opioids and Tramadol only, per date of service. D. All drugs and drug classes performed by the respective methodology per date of service.

D. All drugs and drug classes performed by the respective methodology per date of service.

Guard against insurance and patient check payment theft by: A. Using insurance company direct deposit options B. Using bank check scanners in your office for depositing checks C. Using a bank lock box to avoid checks coming to the office D. All of the above

D. All of the above

You may want to consider being an out-of-network provider if all of your referrals come from the following marketing sources: A. Word of mouth B. Other colleagues C. Independent marketing D. All of the above

D. All of the above

OP-25 is the measure for Safe Surgery Checklist Use (outpatient). Which should be done to ensure patient safety? A. Mark the site of the body area to be operated on. B. Confirm the patient's identity before initiating the procedure. C. Identify the allergy(ies) the patient has prior to initiating the procedure. D. All of the above.

D. All of the above.

The Sessions and Brand memos are: A. New policies on how the DOJ should proceed regarding agency guidance B. Effective upon their date of issue C. Applied to guidance documents such as LCDs, CMS' Medicare manuals, and OIG advisory opinions D. All the above

D. All the above

Atherosclerosis: A. Is a significant risk factor for AAA B. May cause muscle weakness in the legs C. May cause tears in the inner layer of the aorta D. Both a and b

D. Both a and b

Tina was referred to a PT for low back pain that radiates to her left, lower extremity. Pain increases when she ascends/descends stairs, goes from sitting to standing or vice versa, and when she lies down. The patient's goal is to reduce her pain and be more comfortable. The PT should look to which G codes for reporting therapy sessions? A. Other PT/OT primary G code set B. Self-care G code set C. Mobility G code set D. Changing and maintaining body positions G code set

D. Changing and maintaining body positions G code set

In the Cardiovascular system section of the CPT book, there is a chart that helps coders code ECMO and ECLS procedures. Within the chart, there are four different procedures. Which of these is not one of them? A. Additional procedures B. Decannulation C. Initiation D. Exteracorporeal Membrane oxygenation

D. Exteracorporeal Membrane oxygenation

Which statement is TRUE for reporting external cause codes of morbidity (V00-Y99)? A. All external cause codes do not require a seventh character. B. Only report one external cause code to fully explain each cause. C. Report code Y92.9 if the place of occurrence is not stated. D. External cause codes should never be sequenced as a first-listed or primary code

D. External cause codes should never be sequenced as a first-listed or primary code

In the Cardiovascular system section of the CPT book, there is a chart that helps code ECMO and ECLS procedures. Within this chart, there are four different procedures. Which of these is not one of them? A. Additional Procedure B. Decannulation C. Initation D. Extracorporeal membrane oxygenation

D. Extracorporeal membrane oxygenation

Mr. Valdez arrives in the emergency department with complaints of shortness of breath and wheezing. After study, he is found to have an exacerbation of COPD. He has a history of emphysema. ICD-10-CM code(s) are: A. R06.02, R06.2 B. J44.1 C. J44.1, J43.9 D. J43.9

D. J43.9

The excision of benign lesions includes what service? A. MAC B. Skin Graft C. Follow-up care D. Local anesthesia

D. Local anesthesia

The excision of benign lesions includes what services? A. MAC B. Skin Graft C. Follow up care D. Local anesthesia

D. Local anesthesia

A 27-year-old male presents for evaluation of left elbow pain. It started two weeks ago after picking up a heavy box. There is no snapping or popping. Pain is aching, located on the left lateral elbow. It's worse with gripping. He has never experienced this pain before, and there are no alleviating/aggravating factors. He has been putting heat on the area with short term relief. Proper diagnosis is: A. M77.0 B. M77.02 C. M77.11 D. M77.12

D. M77.12

Question 10 Which diagnostic test or procedure can be used to diagnose a patient with CVS? A. Abdominal X-ray B. Abdominal ultrasound C. Upper GI endoscopy D. None of the above

D. None of the above

What OIG document should a provider review for potential problem areas that will receive special scrutiny in the upcoming year? A. Compliance Program Guidance B. Safe Harbor Regulations C. Red Flag Rules D. OIG work plan

D. OIG Work Plan

What is the term used for inflammation of the bone and bone marrow? A. Chondromatosis B. Osteochondritis C. Costochondritis D. Osteomyelitis

D. Osteomyelitis

A Medicare patient is receiving chemotherapy at her oncologist's office. While the patient is receiving chemotherapy, the oncologist called in a prescription for pain medication to a pharmacy in the same building. The pharmacy delivers the medication to the patient and the oncologist's office for the patient to take home. What part of Medicare should be billed for this pain medication by the pharmacy? A. Part A B. Part B C. Part C D. Part D

D. Part D

What is PHI? A. Personal History Information B. Problem with History of infection C. Partial Health Information D. Protected Health Information

D. Protected Health Information

A 55-year-old-patient had a fracture of his left knee cap six months ago. The fracture has healed but he still has staggering gait in which he will be going to physical therapy. What ICD-10-CM codes are reported? A. S82.002A, R26.81 B. R26.0, S82.002A C. S82.092S, R26.0 D. R26.0, S82.002S

D. R26.0, S82.002S

A patients comes into the PCP's office complaining of pain while urinating. After a quick urine sample tested negative, and the patient has no other concerning symptoms, the physician gives the patient a cautionary antibiotic and state that, if he should develop a fever, to come back to the office. Which ICD-10 code would best fit this visit?. A. R41 B. R06.4 C. R10.9 D. R30.0

D. R30.0

Local Coverage Determinations (LCD) are published to give providers information on which of the following? A. Information on modifier use with procedure codes B. CPT® codes that are bundled C. Fee schedule information listed by CPT® code D. Reasonable and necessary conditions of coverage for an item or service Question 49

D. Reasonable and necessary conditions of coverage for an item or service

A patient is having pyeloplasty performed to treat an uretero-pelvic junction obstruction. What is being performed? A. Surgical repair of the bladder B. Removal of the kidney C. Cutting into the ureter D. Surgical reconstruction of the renal pelvis

D. Surgical reconstruction of the renal pelvis

From a documentation standpoint, which is most useful in determining whether a patient has a true drug allergy or just a drug intolerance? A. The underlying condition treated B. The place of occurrence C. The activity the patient was involved in when the drug was taken D. The reaction the patient experienced and the drug that caused the reaction

D. The reaction the patient experienced and the drug that caused the reaction

Put a policy in place that requires a scribe to sign and date all medical records entries: A. When the practice is under the jurisdiction of a MAC that requires it B. Never, since a signature is not required by a scribe C. When the scribe is certified by a national organization D. When the practice/organization may be surveyed by The Joint Commission

D. When the practice/organization may be surveyed by The Joint Commission

Stratum Basale (Stratum Germinativum)

Deepest of the 5 layers of Epidermis; made of basal cells

DHHS

Department of Health and Human Services

Electronic Health Record

EHR

Medicare

Federal health insurance administered by CMS

Stratum Granulosum

Granular layer of cells

5

How many body cavities does the body have

4

How many parts of Medicare are there

Pediculosis

Infestation with lice

Osteochondritis

Inflammation of bone or cartilage

Onychitis

Inflammation of nail matrix

aneurysm

Is an abnormal weakening of a vessel wall with outpouching beyond the normal confines of the vessel

Proper code assignment

Is determined by content of the medical record and by the unique rules that governs each code set

Coding

Is the process of translating written or dictated medical record into a series of numeric or alpha-numeric characters

Serous Membrane

Line cavities

Mucous Membranes

Line the interior walls of the organs and tubes opening to the outside of the body, such as those of the digestive, respiratory, urinary, and reproductive systems

Chromosomes

Linear strand made of DNA carrying genetic information

Lunula

Little moon area of nail

Alopecia

Loss of hair

Osteopenia

Lower than average bone density, can be a precursor to osteoporosis

assignment

Medicare's payment for the service, which participating physicians agree to accept as payment in full

Subcutaneous

Pertaining to below the skin

Cutaneous

Pertaining to the skin

Hypodermic

Pertaining to under the skin

Intradermal

Pertaining to within the skin

Dermatologist

Physician specializing in diseases of the skin and subcutaneous tissue

Melanin

Pigment giving color to the skin.

Melanoma

Pigmented tumor of the skin

PPO

Preferred Provider Organization

Decubitus

Pressure ulcer/bed sore

Tinea

Ringworm (a fungal infection of the skin)

antrum

Sinus

Nucleus

Small, round structure within the cell containing chromosomes and nucleoplasm (DNA and RNA)

Gene

Specific segment of base pairs of chromosomes; functional unit of heredity

Cytology

Study of cells, including the formation, structure and function of cells

Cell Membrane

Surrounds and protects the individual cell

Osterraphy

Suture of bone

Dermatology

The study of skin

Dermatology

The study of the skin

Stratum Reticulare (Dermis)

Thick layer of dense, irregular connective tissue

Stratum Papillare (Dermis)

Thin superficial layer interlocked with the epidermis

anterior (ventral)

Toward the front of the body

Connective tissue

What is synovial membrane composed of

Subcutaneous layer

What layer is not considered a layer of skin

Jaundice

Yellowing of the skin

Jaundice

Yellowness of skin

carcinoma in situ

a cancerous tumor in its original place that has not invaded neighboring tissues

combination coding

a code from the Radiology section as well as a code from one of the other sections must be used to fully describe the procedure

component coding

a code from the Radiology section as well as a code from one of the other sections must be used to fully describe the procedure

CPT (Current Procedural Terminology)

a coding system developed by the American Medical Association (AMA) to convert widely accepted, uniform descriptions of medical, surgical, and diagnostic services rendered by health care providers into five-digit codes

conscious sedation

a decreased level of consciousness in which the patient is not completely asleep

counseling

a discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of treatment instructions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education

DRGs (Diagnosis Related Groups)

a disease classification system that relates the type of inpatients a hospital treats (case mix) to the costs incurred by the hospital (now MS-DRGs)

Cloquet's node

a gland; it is the highest of the deep groin lymph nodes

Allogenic

a graft that is from the same species, but genetically different

paranoia

a mental disorder, often includes delusions involving persecution

Demerol

a narcotic analgesic

APC (Ambulatory Payment Classification)

a patient classification that provides a payment system for outpatients

cardiologist

a physician specializing in diseases of the heart

nephrologist

a physician treating diseases of the kidney

blood patch

a procedure in which a cerebrospinal fluid leak is closed by means of an injection of the patient's blood into the area used during spinal anesthesia

carina

a projection of the lowest tracheal cartilage where the trachea separates into two bronchi

atherosclerosis

a type of arteriosclerosis characterized by lipid deposits causing fibrosis and calcification

lordosis

abnormal anterior curvature of spine, usually lumbar

rales (crackles)

abnormal chest sounds heard when air enters small airways or alveoli containing fluid typically during inspiration

kyphosis

abnormal curvature of thoracic spine (humpback)

bradykinesia

abnormal or slowness of motion

anomaly

abnormality

Superior (Cranial)

above; toward the head

aphakia

absence of lens of the eye

amenorrhea

absence of menstruation

aphakia

absence of the lens of the eye

anterior synechiae

adhesions of the iris to the cornea

psychosis

an abnormal condition of the mind, gross disorganization, or distortion of mental capacity

late effect

an inactive, residual effect or condition produced after the acute portion of an injury or illness has passed

biometry

application of a statistical measure to a biologic fact

colostomy

artificial opening between the colon and the abdominal wall

constitutional examination element

assessment of the patient's general condition and the recording of the vital signs

Admission

attention to an acute illness or injury resulting in admission to a hospital

caudal

away from the head, or the lower part of the body; same as inferior

bacteriuria

bacteria in the urine

antepartum

before childbirth

sublingual

below or beneath the tongue

subdural

below the dura mater

Inferior (caudal)

below; toward the lower end of the spine

hemangioma

benign tumor of a blood vessel

CVS (chorionic villus sampling)

biopsy of the outermost part of the placenta

cystorrhagia

blood bursting forth from the bladder

cardiopulmonary bypass

blood bypasses the heart through a heart-lung machine during open-heart surgery

thrombus

blood clot formed within a blood vessel

embolism

blood clot traveling through a blood vessel to another part of the body

hematuria

blood in urine

hematocrit

blood test measuring red blood cell volume

cyanosis

bluing of skin and mucous membranes caused by oxygen deficiency

osteoblast

bone-forming cell

phalangeal

bones of the fingers and toes

central nervous system (CNS)

brain and spinal cord

transverse fracture

breaks shaft of bone across the longitudinal axis

osteocarcinoma

cancerous tumor of bone

atrium

chamber in the upper part of the heart

cycloplegia

ciliary muscle paralysis

debridement

cleansing of or removal of dead tissue from a wound

Stratum Lucidum

clear layer - palms of hands and soles of feet

cyst

closed sac containing matter or fluid

Deep (internal)

closer to the center of the body

Superficial (external)

closer to the surface of the body

pneumothorax

collection of air in the chest or pleural cavity

calculus

concretion of mineral salts, also called a stone

thyrotoxicosis

condition caused by excess thyroid hormone, often to hyperactivity of the thyroid gland

astigmatism

condition in which the refractive surfaces of the eye are unequal

hydronephrosis

condition in which urine collects in the renal pelvis due to obstructed outflow, results in dilation of the renal pelvis and calices.

ankylosis

condition of stiffening of a joint

osteoporosis

condition resulting in reduction of bone mass

chordee

condition resulting in the penis' being bent downward

aural atresia

congenital absence of the external auditory canal

hypospadias

congenital defect in which the urethra opens on the underside of the penis or in the perineum

epispadias

congenital defect in which the urethra opens on the upper aspect (dorsum) of the penis

cystic hygroma

congenital deformity or benign tumor of the lymphatic system

hemostasis

control of bleeding

corneosclera

cornea and sclera of the eye

contributory factors

counseling, coordination of care, nature of the presenting problem, and time of an E/M service

ileostomy

creating an opening throughout the abdominal wall into the ileum

cavernosa-corpus spongiosum shunt

creation of a connection between a cavity of the penis and the urethra

cavernosa-glans penis fistulization

creation of a connection between a cavity of the penis and the glans penis, which overlaps the penis cavity

cavernos-saphenous vein shunt

creation of a connection between the cavity of the penis and a vein

cholecystoenterostomy

creation of a connection between the gallbladder and intestine

Frontal (coronal)

cuts at a right angle to the midline cut, from side to side, and divides the body into front (anterior) and back (posterior) sections

Transverse (horizontal) (axial)

cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections.

Sagittal

cuts throughout he midline of the body from front to back and divides the body into right and left sections

ametropia

defect in the refractive power of the eye

hypoglycemia

deficient amount of sugar in the blood

hypothyroidism

deficient secretion of the thyroid hormone

Addiction

dependence on a drug

electrodesiccation

destruction of a lesion by the use of electric current radiated through a needle

cryosurgery

destruction of lesions using extreme cold

neurolysis

destruction of nerve tissue or lysis (braking up) perineural adhesions

hemolysis

destruction of red blood cells

cauterization

destruction of tissue by the use of cautery

dysuria

difficult or painful urination

dyspnea

difficulty breathing

orthopnea

difficulty breathing unless upright or in a straight position

dysphagia

difficulty in swallowing

arteriovenous fistula

direct communication (passage) between an artery and vein

rhinorrhea

discharge from the nose

mononucleosis

disease of excessive mononuclear leukocytes in the blood due to infection with the Epstein-Barr virus

erythropathy

disease of red blood cells

glaucoma

disease of the eye characterized by increased intraocular pressure

nephropathy

disease of the kidney

communicable disease

disease that can be transmitted from one person to another or one species to another

closed fracture

does not involve a break in the skin

diplopia

double vision

astigmatism

due to an abnormal curve of the cornea, rays of light do not focal on the retina, but are spread over area causing out of focus vision

cardioversion

electric shock to the heart to restore normal rhythm

electrocardiogram

electrical tracing of the heart and heart muscle activity

dual-chamber pacemaker

electrodes of the pacemaker are placed in both the atria and the ventricle of the heart

neurosis

emotional condition or disorder; anxiety is a primary characteristic

splenomegaly

enlarged spleen

cardiomegaly

enlargement of the heart

colonoscopy

examination of the colon and the distal small bowel with an endoscope

uremia

excess urea and other nitrogenous waste in blood

hyperlipemia

excessive amount of fat in the blood

hypercalcemia

excessive amounts of calcium in the blood

hyperkalemia

excessive amounts of potassium in the blood

hyperglycemia

excessive amounts of sugar in the blood

menorrhagia

excessive blood flow during menstruation

hyperthyroidism

excessive secretion of thyroid hormone

polyuria

excessive urination

nephrectomy

excision of a kidney

apicectomy

excision of a portion of the temporal bone

cystolithectomy

excision of a stone from the bladder

colectomy

excision of part of the colon

cystectomy

excision of the bladder or part of the bladder

vasectomy

excision of the vas deferens surgically

laminectomy

excision of the vertebral posterior arch or spinal process

congenital

existing from birth

dilation

expansion (of the cervix)

auricle

external ear

presbyopia

farsightedness associated with aging and progressive

Distal

farther from the point of attachment or from a given reference point

distal

farther from the point of attachment or origin

tachypnea

fast or rapid breathing

vertigo

feeling you or your environment is moving or spinning, caused by a disturbance of equilibrium in the labyrinth

colonoscopy

fiberscopic examination of the entire colon that may include part of the terminal ileum

Cutaneous Membrane

forms the outer covering of the body

closed treatment

fracture site that is not surgically opened and visualized

drainage

free flow or withdrawal of fluids from a wound or cavity

anteroposterior

from front to back

autogenous

from oneself

autologous

from oneself

block

frozen piece of a sample

bariatric surgery

gastric restrictive procedures that are used to treat morbid obesity and are accomplished by placing a restrictive device around the stomach to decrease its functional size

Adrenal

glands, located at the top of the kidneys, that produce steroid hormones

arteriosclerosis

hardening of an artery

nephrosclerosis

harding of the kidney

cephalgia/cephalagia

headache

audiometry

hearing testing

cystocele

hernia of the bladder protruding into the vagina

diaphragmatic hernia

hernia of the diaphragm

cystocele

herniation of the bladder into the vagina

rectocele

herniation of the rectum into the vagina

diverticula of colon

herniations of mucosa and submucosa of the colon, which can cause episodes of bleeding and inflammation

benign hypertension

hypertensive condition with a continuous, mild blood pressure elevation

dysphasia

impairment of speech

incontinence

inability to hold urine

aphagia

inability to swallow

herniotomy

incision into a hernia

arteriotomy

incision into an artery

cystotomy

incision into the bladder

thoracotomy

incision into the chest wall

consultation

includes those services rendered by a physician whose opinion or advice is requested by another physician or agency concerning the evaluation and/or treatment of a patient; a consultant is not an attending physician

busitis

inflammation of a bursa

arthritis

inflammation of a joint

nephritis

inflammation of a kidney

neuritis

inflammation of a nerve

osteochondritis

inflammation of bone and cartilage

poliomyelitis

inflammation of gray matter of the spinal cord

angiocarditis

inflammation of heart and vessels

tendonitis

inflammation of tendon

cystitis

inflammation of the bladder

pyelocystitis

inflammation of the bladder and renal pelvis

keratitis

inflammation of the cornea

diverticulitis

inflammation of the diverticula in the colon

blepharitis

inflammation of the edges of the eyelids

cholecystitis

inflammation of the gallbladder

carditis

inflammation of the heart

pyelonephritis

inflammation of the kidney and renal pelvis

labyrinthitis

inflammation of the labyrinth

meningitis

inflammation of the meninges or the membranes covering the spinal cord or brain

stomatitis

inflammation of the mucous membrane of the mouth

myometritis

inflammation of the muscular wall of the uterus

pancreatitis

inflammation of the pancreas

pericarditis

inflammation of the pericardium

myelitis

inflammation of the spinal cord

radiculitis

inflammation of the spinal nerve roots

Orchitis

inflammation of the testes

baginitis

inflammation of the vagina

trichiasis

ingrown eyelashes, can rub against the cornea irritating the eye

cannulation

insertion of a tube into a duct or cavity

bronchoscopy

inspection of the bronchial tree using a bronchoscope

tonometer

instrument to measure intraocular pressure

otoscope

instrument used to examine the ear and ear drum

anomaloscope

instrument used to test color vision

arthropathy

joint disease

destruction

killing of tissue by means of electrocautery, laser, chemicals, or other means

scoliosis

lateral curvature of spine

amblyopia

lazy eye causing dullness of vision

electrode

lead attached to a generator that carries the electric current from the generator to the atria or ventricles

Synovial Membranes

line joint cavities

Abcess

localized collection of pus that will result in the disintegration of tissue over time

metacarpal

long bones of the hand that form the skeletal structure of the palm

amnesia

loss of memory

ataxia

loss of muscle coordination

osteopenia

lower than average bone density

axillary nodes

lymph nodes located in the armpit

cavernosometry

measurement of the pressure in a cavity, e.g., the penis

cystometrogram (CMG)

measurement of the pressures and capacity of the urinary bladder

Abuse

misuse of substance

comminuted fracture

more than two separate bone components-segmental fracture, bony fragments

bulbocavernosus

muscle that constricts the vagina in a female and the urethra in a male

diaphragm

muscular wall that separates the thoracic and abdominal cavities

CF (conversion factor)

national dollar amount that is applied to all services paid on the Medicare Fee Schedule basis

Proximal

nearer to the point of attachment or to a given reference point

retinopathy

non-inflammatory degenerative disease of the retina

apexcardiography

noninvasive graphic recording of the movement of the chest wall from the cardiac pulsations from the region of the apex of the heart, usually of the left ventricle

menorrhea

normal menstruation

euthyroid

normal thyroid gland activity

Acquired

not genetic

benign

not progressive

asymptomatic

not showing any of the typical symptoms of a disease or condition

bilateral

occurring on two sides

Colles' Fracture

occurs in wrist and affects the distal radius bone

epiphyseal fracture

occurs when matrix is calcifying and chondrocytes are dying; usually seen in children

chronic

of long duration

Acute

of sudden onset and short duration

distinct procedure

one service or procedure that has no relationship to another service or procedure

A-mode

one-dimensional ultrasonic display reflecting the time it takes a sound wave to reach a structure and reflect back; maps the structure's outline

greenstick fracture

only one side of shaft is broken, and other is bent; common in children

cataract

opaque covering on or in the lens

leukemia

overproduction of leukocytes resulting in a malignant, acute, or chronic disease

chondralgia

pain around and in the cartilage

prostatalgia

pain in the prostate

gastralgia

pain in the stomach

urethalgia

pain in the urethra

dysmenorrhea

painful or difficult menstruation

quadriplegia

paralysis of all four extremities

hemiparesis

paralysis on one side of the body

component

part

septicemia

pathogenic bacteria present in the blood

comparative conditions

patient conditions that are documented as "either/or" in the medical record

amniocentesis

percutaneous aspiration of amniotic fluid

hypertension

persistent excessive pressure int he arteries

epidural

pertaining to above or outside the dura mater

biliary

pertaining to bile

chondral

pertaining to cartilage

femoral

pertaining to femur and thigh bone

dactylic

pertaining to finger or toe

cardiopulmonary

pertaining to heart and lungs

patellar

pertaining to patella

cerebrospinal

pertaining to the brain and spinal cord

buccal

pertaining to the cheek

coccygeal

pertaining to the coccyx

corneal

pertaining to the cornea

esophageal

pertaining to the esophagus

ocular

pertaining to the eye

iliac

pertaining to the ilium

cervical

pertaining to the neck or to the cervix of the uterus

pharyngeal

pertaining to the pharynx

carpal

pertaining to the wrist bones

otolaryngologist

physician specializing in diagnosis and treatment of disease of the ear and larynx

otologist

physician specializing in diagnosis and treatment of diseases of the ear

arthralgia

pin in joint

dislocation

placement in a location other than the original location

chole-

prefix meaning bile

cycl/o-

prefix meaning ciliary body or eye muscle

aur-

prefix meaning ear

blephar(o)-

prefix meaning eyelid

audi-

prefix meaning hearing

dacryocyst/o-

prefix meaning pertaining to the lacrimal sac

dacry/o-

prefix meaning tear or tear duct

ectopic

pregnancy outside the uterus also known as in the fallopian tube

diverticulosis

presence of a number of diverticula of the intestine

hemothorax

presence of blood in the pleural space

albuminuria

presence of serum protein in the urine

CT or CAT (computed axial tomography)

procedure by which selected planes of tissue are pinpointed through computer enhancement, and images may be reconstructed by analysis of variance in absorption of the tissue

displacement therapy

procedure in which the physician flushes saline solution into the sinuses to remove mucus or pus

anoscopy

procedure that uses a scope to examine the anus

cordocentesis

procedure to obtain a fetal blood sample; also called a percutaneous umbilical blood sampling

biofeedback

process of giving a person self-information

CDI (Clinical Documentation Improvement)

programs used by medical providers to improve documentation keyed to the quality of coding, medical necessity, and denial standards

compound fracture

projects through the skin with a possibility of infection

Meninges

protect the brain and spinal cord

parenteral

provided intravenously

otopyorrhea

pus draining from the ear

pyuria

pus in urine

barium enema

radiographic contrast medium-enhanced examination of the colon

ERCP (cholangiopancreatography)

radiographic recording of the biliary system and pancreas

cavernosography

radiographic recording of a cavity, e.g., the pulmonary cavity or the main part of the penis

arthrography

radiographic recording of a joint

diskography

radiographic recording of an intervertebral joint

aortography

radiographic recording of the aorta

cholangiography

radiographic recording of the bile ducts

duodenography

radiographic recording of the duodenum, or first part of the small intestine

cholecystography

radiographic recording of the gallbladder

echocardiography

radiographic recording of the heart or heart walls or surrounding tissues

dacryocystography

radiographic recording of the lacrimal sac or tear duct sac

bronchography

radiographic recording of the lungs

cystography

radiographic recording of the urinary bladder

rhonchus

rale or rattling sound in throat or bronchial tube caused by obstructed or inflamed bronchi

hyperpnea

rapid or excessive breathing

calyx

recess of the renal pelvis

cardiopulmonary

refers to the heart and lungs

epigastric

region above the stomach

Crohn's disease

regional enteritis

Ablation

removal by cutting or destruction

cystolithectomy

removal of a calculus (stone) from the urinary bladder

biopsy

removal of a small piece of living tissue for diagnostic purposes

thoracentesis

removal of fluid from the pleural cavity via surgical puncture

neurorrhaphy

repair of a severed nerve by suture, graft or with synthetic conduit

myringoplasty

repair of the tympanic membrane

arthroplasty

reshaping or reconstruction of a joint

tinnitus

ringing in the ear

bulbourethral gland

rounded mass of the urethra

cervix uteri

rounded, cone-shaped neck of the uterus

dosimetry

scientific calculation of radiation emitted from various radioactive sources

curettage

scraping of a cavity using a spoon-shaped instrument

dermis

second layer of skin, holding blood vessels, nerve endings, sweat glands, and hair follicles

dialysis

separation of waste material from blood to maintain fluid, electrolyte, and acid-base balance in impaired kidney function or in the absence of a kidney.

neuralgia

severe or stabbing pain int he course or distribution of a nerve

combination code

single ICD-10-CM/ICD-9-CM code used to classify two diagnoses

nail bed

skin below the nail (sterile matrix)

bradycardia

slow heartbeat

encephalomalacia

softening of the brain often due to ischemia or infarction

backbench work

special preparation of an organ before organ transplantation

spiral fracture

spread along length of bone and produced by twisting stress

electrocochleography

stimulation of the cochlea to measure electrical activity

audiology

study of hearing disorders

angioscopy

studying the capillaries of the eyes

-centesis

suffix meaning puncture of a cavity

-ectomy

suffix meaning removal of part or all of an organ of the body

anastomosis

surgical connection of two tubular structures, such as two pieces of the intestine

cystostomy

surgical creation of an opening into the bladder

lobectomy

surgical excision of a lobe of the lung

orchiectomy

surgical excision of a testicle

discectomy

surgical excision of an intervertebral disc

salpingectomy

surgical excision of fallopian tubes

cholecystectomy

surgical excision of the gallbladder

arthrodesis

surgical fixation of a joint

cystopexy

surgical fixation of the bladder to the abdominal wall

arthrodesis

surgical immobilization of a joint

laparotomy

surgical incision into the abdomen

craniotomy

surgical incision into the skull

sternotomy

surgical incision of sternum

vagotomy

surgical incision of the vagus nerve

cesarean

surgical opening through abdominal wall for delivery

angioplasty

surgical or percutaneous procedure in a vessel to dilate the vessel opening; used in the treatment of atherosclerotic disease

chromotubation

surgical procedure to open obstructed fallopian tubes

amniocentesis

surgical puncture of the amniotic sac to obtain a sample of amniotic fluid

cardiocentesis

surgical puncture of the heart

calycoplasty

surgical reconstruction of a recess of the renal pelvis

cystoplasty

surgical reconstruction of the bladder

cystourethroplasty

surgical reconstruction of the bladder and urethra

cholecystectomy

surgical removal of the gallbladder

cordectomy

surgical removal of the vocal cord(s)

bilobectomy

surgical removal of two lobes of a lung

cystoplasty

surgical repair of the bladder

bronchoplasty

surgical repair of the bronchi

dermatoplasty

surgical repair of the skin

angioplasty

surgical repair of vessels

osteorrhaphy

suture of bone

cystorrhaphy

suture of the bladder

colporrhaphy

suture or repair of the vaginal wall

angiography

taking of x-ray films of vessels after injection of contrast material

lacrimal

tears

Abortion

termination of pregnancy

diagnostic

that done to identify the cause, origin, or extent of a condition

cranium

that part of the skeleton that encloses the brain

critical care

the care of critically ill patients in medical emergencies that requires the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, respiratory failure); critical care is usually, but not always, given in a critical care area, such as the coronary care unit (CCU) or the intensive care unit (ICU)

conjunctiva

the lining of the eyelids and the covering of the sclerae

contralateral

the opposite side

attending physician

the physician with the primary responsibility for care of the patient

concurrent care

the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. Each physician provides services for a separate condition, not reasonably expected to be managed by the attending physician. When concurrent care is provided, the diagnosis must reflect the medical necessity of different specialties

hemoglobin

the red respiratory protein of RBCs, transports oxygen to the tissues

corpora cavernosa

the two cavities of the penis

brachytherapy

therapy using radioactive sources that are placed inside the body

anterior segment

those parts of the eye in the front of and including the lens, orbit, extraocular muscles, and eyelid

antepartum

time period during pregnancy before onset of labor

connective

tissue connecting or binding together

Allograft

tissue graft between individuals who are not of the same genotype

bypass

to go around

Posterior (dorsal)

toward the back of the body

Anterior (ventral)

toward the front of the body

Medial

toward the midline of the body

Lateral

toward the side of the body

Allotransplantation

transplantation between individuals who are not of the same genotype

Actinotherapy

treatment of acne using ultraviolet rays

enteral

tube feeds by way of intestine or gastrointestinal tract

catheter

tube placed into the body to put fluid in or take fluid out

entropion

turning inward (eyelid)

ectropion

turning outward (eyelid)

bifocal

two focuses in eyeglasses, one usually for close work and the other for improvement of distance vision

B-scan

two-dimensional display of tissues and organs

Doppler

ultrasonic measure of blood movement

echoencephalography

ultrasound of the brain

echography

ultrasound procedure in which sound waves are bounced off an internal organ and the resulting image is recorded

aspiration

use of a needle and a syringe to withdraw fluid

electrohydraulic fragmentation

use of a probe containing two electrodes that are applied, one on each side, of the calculus

cystoscopy

use of a scope to view the bladder

cystourethroscopy

use of a scope to view the bladder and urethra

corpus uteri

uterus

compression fracture

vertebrae collapse due to trauma, tumor or osteoporosis

artery

vessel that generally carries oxygenated blood from the heart to body tissues (pulmonary artery carries un-oxygenated blood)

nail body

visible part of nail

hematemesis

vomiting blood

wheeze

whistling sound usually caused by air passageway obstruction, common in asthmatics

intraocular

within the eye

intracranial

within the skull

ECG (electrocardiogram)

written record of the electrical activity of the heart

EEG (electroencephalogram)

written record of the electrical activity of the brain