Ambulatory Coding {assessments}

The correct code for Arthrocentesis of the left elbow:

20605-LT

Arthroscopy of left wrist with repair of triangular fibrocartilage and joint debridement.

29846-LT

Left nasal endoscopy for control of epistaxis.

31238-LT

Bilateral nasal endoscopy with total ethmoidectomy.

31255-50

Indirect laryngoscopy with biopsy.

31510

Direct laryngoscopy for removal of lesion.

31540

Direct layrngoscopy with stripping of vocal chords.

31540

Colposcopy of the cervix with a loop electrode biopsy.

57460

Dilation and curettage of cervical stump.

57558

Code the vaginal removal of a 252-gram uterus.

58290

Diagnostic maxillary sinusoscopy, bilateral.

31233-50

Nasal endoscopy with polypectomy.

31237

Fitting and insertion of a pessary.

57160

With the use of Surgery Guidelines in the CPT manual, match the following information to the heading under which it appears:

- Evaluating the patient in the post-anesthesia recovery area → CPT Surgical Package Definitions -"Special Services and Reports" is presented in the Medicine Section → Physicians' Services -List drugs, trays, supplies, and materials provided → Materials Supplied by Physician - Complexity of service → Special Report

With the use of the Surgery subsection indexes in the CPT manual, match the following code titles to the correct code range:

- Hand Joint: Arthrodesis → 26843-26844 - Excision--Malignant Lesions → 11600-11646 - Endovascular Repair of Abdominal Aortic Aneurysm → 34800-34834 - Transcatheter Procedures → 37184-37216

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

-25

Mr. White presented to the physician's office for his yearly physical. During the exam, Mr. White requested that the physician remove a mole on his shoulder. The mole was removed during the same office visit. The physician bills both an E/M code and a procedure code. Which modifier would you use on the E/M code?

-25

What modifier would you use if you were coding only for the professional component of a diagnostic procedure?

-26

The surgeon performed carpal tunnel release on Mrs. Shaw's left and right wrist. Which modifier would you use?

-50

The modifier that indicates multiple procedures is:

-51

The modifier that indicates that a physician provided only postoperative care

-55

Mr. Jones is admitted to the hospital by the orthopedic surgeon for severe hip pain. The ortho surgeon provides an initial hospital visit during which it is determined that Mr. Jones has a fractured hip that will require surgical intervention. Mr. Jones is taken later that day to the OR where Dr. Ortho performs the surgical procedure to repair Mr. Jones' hip. Which modifier would you use for the hospital visit?

-57

A surgeon performed an esophageal dilation on a 4-week-old newborn who weighed 3.1kg. What modifier would you use on this special circumstance?

-63

Modifier ________ is used to indicate a repeat laboratory test on the same day to obtain multiple test results.

-91

Multiple modifiers are indicated with which modifier?

-99

Anesthesia for corneal transplant. CPT Code:

00144

Assign a CPT anesthesia code for repair of cleft palate. CPT Code: Answer

00172

Anesthesia for lumbar puncture. CPT Code:

00635

Assign a CPT anesthesia code for upper gastrointestinal endoscopy. CPT Code:

00731

Anesthesia for vaginal hysterectomy. CPT Code:

00944

Anesthesia for diagnostic arthroscopic procedure of the knee joint. CPT Code:

01382

Assign a CPT anesthesia code for anesthesia services for an 76-year-old patient with mild systemic disease who receives anesthesia for total knee arthroplasty. CPT Code:

01402-P2, 99100

Assign a CPT anesthesia code for debridement of second-degree burns of left arm, 3% body surface area. CPT Code:

01951 (Here we would use the code for less than 4% since there was only 3% body surface. )

Anesthesia for Cesarean delivery only. CPT Code:

01961

Daily hospital management of epidural, continuous drug administration. CPT Code:

01996

Biopsy of a lymph node by fine needle aspiration without image guidance.

10021

An incision and drainage of a sebaceous cyst of back.

10060

Removal of 37 skin tags by electrosurgical destruction.

11200, 11201 X 3

Shaving of a 0.5 cm pyogenic granuloma of the neck.

11305

Shaving of 1.5 cm epidermal lesion, scalp.

11307

An asymmetric nevi, total excision size of 2.0 cm x 3.0 cm was removed from the patient's back. Pathology report identifies the specimen as "interdermal nevi." What is the correct CPT code assignment for this procedure?

11403

Excision of 0.5 cm solar keratosis of the cheek with no significant margins.

11440

Excision of basal cell carcinoma, abdominal wall, 1.2 cm in diameter, with 1-cm skin margin all around.

11604

A physician performs a simple avulsion of the nail plate, second and third digits of the left foot.

11730-T1, 11732-T2

Repair of nail bed, third digit-left hand.

11760-F2

Repair of 3.4 cm laceration of the left forearm, single-layer closure with 4-0 Dexon.

12002-LT

Repair of 3.0-cm laceration of the scalp, 2.5-cm laceration of the left foot, and 6.0-cm laceration of the left lower leg.

12004-LT

Repair of 5.2-cm laceration of the left hand, dorsum, with layered closure.

12042-LT

Repair of 16.0-cm complex laceration of the left chest wall, utilizing multilayered closure.

13101, 13102, 13102

Excision of 2-cm squamous cell carcinoma from chest with repair of resultant 8-cm2 defect using V-Y plasty.

14000

Patient presents for an excision of a sacral pressure ulcer with ostectomy, with primary suture.

15933

With the use of a YAG laser, the surgeon removed a 2.0 cm Giant congenital melanocytic nevus of the leg. Pathology confirmed that the lesion was premalignant.

17000

With the use of a laser, the physician removed two benign lesions on the right side of the back.

17110

The surgeon fulgurates a 0.5 cm superficial basal cell carcinoma of the back.

17260

Aspiration of one cyst, breast.

19000

Puncture aspiration of a cyst of the left breast.

19000-LT

What year was CPT first developed and published?

1966

Surgical exploration of stab wound of chest with included coagulation of blood vessels and enlargement of the wound.

20101

Open treatment of four rib fractures, with fixation.

21812

Removal of silver metal from deep tissue in the left shoulder.

23333-LT

Closed reduction of greater humeral tuberosity fracture, left.

23625-LT

Incision and drainage of hematoma of elbow.

23930

Repair of lateral collateral ligament of right elbow using local tissue.

24343-RT

Patient is diagnosed with right humeral shaft fracture. The orthopedic surgeon performs an open treatment of the fracture using an intramedullary implant and locking screws.

24516-RT

Open reduction of right radial shaft fracture.

25515-RT

The patient was diagnosed with a dislocated right patella. The surgeon performed a closed reduction with the patient under anesthesia.

27562-RT

Open reduction with internal fixation, fracture of distal end (medial condyle) of left femur.

27514-LT

The orthopedic surgeon reduces a fracture of the left proximal tibia. After closed treatment and skeletal traction, the physician applies a short leg cast.

27532-LT

Open reduction of fracture of right medial malleolus.

27766-RT

According to information in 99468, what is the age of a neonate?

28 days or younger

Excision of bone cyst, toe (third digit of left foot).

28108-T2

Repair of hammertoe, second digit of left foot.

28285-T1

Closed reduction of three metatarsal fracture of right foot.

28475-RT x 3

Arthroscopy of right shoulder with rotator cuff repair.

29827-RT

Arthroscopy of the left elbow with limited debridement.

29837-LT

Arthroscopy of the left wrist with partial synovectomy.

29844-LT

Arthroscopic synovectomy (limited) of the left knee.

29875-LT

Scalpel excision of polyp from inside the nose, performed in doctor's office.

30110

Partial excision of inferior turbinate.

30130

Submucous resection of the inferior turbinates, bilaterally.

30140-50

Removal of pebble from child's nasal passage, performed in the physician's office.

30300

Patient treated in the ER for severe epistaxis; doctor performs extensive anterior packing, bilateral.

30903-50

Flexible fiberoptic laryngoscopy with biopsy of tissue.

31576

FLexible fiberoptic laryngoscopy perfomed for removal of a dime lodged in the patient's larynx.

31577

Flexible bronchoscopy with cell washings, brushings, and biopsy.

31623, 31625

Flexible bronchoscopy with bronchial biopsies.

31625

Bronchoscopy with transbronchial biopsy of lung.

31628

Bronchoscopy with laser destruction of a lesion of the bronchus.

31641

Puncture aspiration of lung.

32405

Thoracoscopy with wedge resection of lung.

32666

Insertion of single chamber pacing cardioverter-defibrillator (transvenous electrode).

33216

Relocation of pacemaker pocket.

33222

Valvuloplasty of tricuspid valve with ring insertion.

33464

CABG using two arterial grafts and three venous grafts.

33534, 33519

Application of right and left pulmonary artery bands.

33620

Repair of ductus arteriosus by division (18 year old patient).

33824

Removal of intra-aortic balloon pump, percutaneous.

33968

Aortobifemoral bypass graft.

35540

Catheter placement into the brachiocephalic artery (first order).

36215

Blood transfusion.

36430

Centrally inserted tunneled central venous access device with a subcutaneous pump on a 6-year-old patient.

36563

Complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient).

36582

Creation of Brescia-Cimino fistula for chronic hemodialysis.

36821

Open revision of AV fistula without thrombectomy, patient receiving hemodialysis.

36832

Percutaneous thrombectomy of AV graft.

36904

Percutaneous transluminal femoropopliteal artery balloon angioplasty with atherectomy.

37225

Bilateral ligation of femoral vein.

37650-50

Long saphenous vein stripping from saphenofemoral junction to below knee of left and right legs.

37722-50

Laparoscopic splenectomy.

38120

Bone marrow biopsy by needle aspiration.

38221

The physician performs an extensive drainage of a lymph node abscess.

38305

Suprahyoid lymphadenectomy.

38700

The physician performs a complete axillary lymphadenectomy.

38745

Injection for identification of sentinel node.

38792

Excision of a mediastinal tumor.

39220

The physician repairs a large laceration of the diaphragm that occurred during a car accident from the seat belt the patient was wearing through a transabdominal approach.

39501

Imbrication of the diaphragm for eventration, transabdominal, nonparalytic.

39545

Plastic repair of a bilateral cleft lip, primary, in one stage.

40701

Plastic repair of the cleft lip/nasal deformity primary bilateral, one of two stages.

40702

A direct ligation of esophageal varices.

43400

Transection of the esophagus with repair for esophageal varices.

43401

A physician is placing a nasogastric tube using fluoroscopic guidance.

43752

A morbidly obese patient's stomach is partitioned with a staple line on the lesser curvature. A short limb of small bowel 90 cm is divided and anastomosis was accomplished to the upper stomach pouch.

43846

Colotomy with removal of foreign body.

44025

The destruction by electrosurgery of fourteen papilloma lesions in the anal area.

46924

The gallbladder is removed under laparoscopic guidance.

47562

Surgical repair of reducible inguinal hernia of a 4-month-old male, initial repair.

49495

Repair of an initial reduced inguinal hernia; with a hydrocelectomy in a patient who is 28 months of age.

49500

A nephrectomy with a total ureterectomy and bladder cuff, through different incisions.

50236

OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Right staghorn calculus. POSTOPERATIVE DIAGNOSIS: Same. OPERATIVE PROCEDURE: Right ESWL (electric shock wave lithotripsy). CLINICAL NOTE: This gentleman had a failed percutaneous nephrolithotripsy. He now is stented. The procedure was unsuccessful because of inability to access the kidney because of the stone. I decided to proceed with lithotripsy to see if we can create some more room, and maybe we will get lucky, but I told the patient he will likely require either multiple ESWLs or secondary attempt at PCN. PROCEDURE NOTE: The patient was given a general laryngeal mask anesthetic, prepped and draped in the supine position on lithotripsy table, stone targeted, shock had engaged. Unfortunately, we had to do the procedure without the simulator. Therefore, it took a longer time, but the patient tolerated it well. A total of 3,000 shocks at a maximum kv of 24 were administered to the stone. Some fragmentation was noted. We will see the patient early next year to see how he is doing, to schedule further treatment as required.

50590-RT

Ureteral endoscopy through an established ureterostomy with irrigation and the removal of a foreign body.

50961

Complex cystometrogram with calibrated electronic equipment.

51726

Cystourethroscopy with insertion of permanent urethral stent.

52282

A complete transurethral electrosurgical resection of the prostate.

52601

Urethral biopsy.

53200

Fulguration of a urethral prolapse.

53275

Urethromeatoplasty with mucosal advancement.

53450

OPERATIVE REPORT PRE/POSTOPERATIVE DIAGNOSIS: Recurrent balanitis and phimosis. PROCEDURE PERFORMED: Circumcision. PROCEDURE: The child was given general mask anesthetic as well as caudal block for postoperative pain control. He was prepped and draped in the supine position, foreskin retracted, prepucial adhesions broken down. Circumcision was then performed using a dorsal slit technique. Hemostasis was achieved with judicious use of electrocautery and chromic ties. Prepuce was re-anastomosed to the penile skin using 5-0 chromic catgut. Vaseline gauze dressing was applied. The patient tolerated the procedure well and transferred to the recovery room in good condition.

54150

The patient requires the lysis of post-circumcision penile adhesions.

54162

Radical orchiectomy by inguinal approach due to a tumor.

54530

The patient had a 3.8 cm testicular laceration repair from a baseball injury.

54670

Bilateral vasectomy.

55250

A radical retropubic prostatectomy with nerve sparing.

55840

The marsupialization of a Bartholin's gland cyst.

56440

Colposcopy of the vulva with five biopsies.

56821

Colpocentesis.

57020

Complete removal of the vaginal wall, vaginectomy.

57110

OPERATIVE REPORT PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram. OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region. Otherwise, benign uterine cavity. PROCEDURE: The patient was taken to the operating room and a general anesthetic was administered. The patient was then prepped and draped in the usual manner in lithotomy position and the bladder was emptied with a straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single toothed tenaculum. The uterus was then sounded to 9 cm in depth. The cervix was dilated to allow for insertion of the diagnostic hysteroscope. The uterine cavity was then inspected. Immediately apparent was a polyp arising from the left cornual region. Remainder of uterine cavity was inspected and appeared to be benign. Minimal endometrial tissue was otherwise present. At this point then, the hysteroscope was removed and polyp forceps was placed within the uterus. Attempt was made to grasp the polyp but this could not be grabbed with the polyp forceps. Therefore, a sharp curet was used and the polyp was thereby obtained and removed. A small amount of endometrial tissue was also obtained by curettage. Once this had been completed, the hysteroscope was reinserted and the cavity was re-inspected. It was confirmed that the polyp was removed. Otherwise, the endometrial canal then appeared normal. At this point, the procedure was terminated. Tenaculum was removed and good hemostasis was ensured at the cervix. The patient tolerated this procedure well. There were no complications. Fluid in was 325 cc and was equal to fluid out at the end of the procedure. Estimated blood loss was minimal.

58558

Surgical hysteroscopy with removal of leiomyomata.

58561

Patient presents for a laparoscopic salpingostomy.

58673

Amniocentesis.

59000

Intrauterine cordocentesis. Do not code the radiological portion of the procedure.

59012

Vaginal delivery with episiotomy and use of forceps, including postpartum care.

59410

Antepartum care only after vaginal delivery by another physician, five visits.

59425

Assign a code for a cesarean delivery with postpartum care and a ligation of fallopian tubes performed at the same operative session.

59515, 58611

A patient who has delivered twice by means of cesarean section receives complete obstetrical care and vaginal delivery services that include the postpartum care.

59610

Code the treatment of a septic abortion that was completed surgically.

59830

Induced abortion by dilation and evacuation.

59841

Removal of cerclage sutures under general anesthesia.

59871

Incision and drainage of an infected thyroglossal duct cyst.

60000

The physician removes the entire thyroid.

60240

The physician drills a burr hole in the cranium to drain a subdural hematoma.

61154

Complex repair of intracranial arteriovenous malformation, supratentorial.

61682

The physician resects an easily accessible arteriovenous malformation (AVM) in the infratentorial region of the brain.

61684

The physician biopsies an intracranial lesion using stereotaxis.

61750

The physician irrigates an existing ventricular catheter.

62225

Diagnostic lumbar spinal puncture.

62270

Posterior hemilaminectomy with herniated discectomy L2 thru L4.

63030, 63035 x2

OPERATIVE REPORT PRE/POSTOPERATIVE DIAGNOSIS: Herniated disc L4-5 on the left. PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc at L4-5 on the left. ANESTHESIA: General. DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in the prone position. The back was prepped and draped in the usual manner. Incision was made in the skin and extended through subcutaneous tissue. The lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The interspace was localized via x-ray. We then performed a generous laminectomy/foraminotomy and saw the problem. There was sequestered disc on the body of L4-L5. I entered the disc space and removed much degenerating material both medially and laterally. Having cleaned out the disc space, I was satisfied the root was decompressed. We passed a hockey-stick down the foramen and laterally there were no free fragments. We then irrigated the wound and closed the wound in layers utilizing double knotted 0 Chromic on the lumbodorsal fascia with 0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room in stable condition.

63030-LT

Laminectomy for excision of intraspinal lesion, extradural, lumbar.

63267

The physician anesthetizes the vagus nerve.

64408

Anesthetic injection of sphenopalatine ganglion.

64505

Destruction of infraorbital nerve with neurolytic agent.

64600

Removal of a superficial foreign body in the external left eye.

65205-LT

Sclera lesion excision, left eye.

66130-LT

Bilateral repair of blepharoptosis with frontalis muscle technique.

67901-50

Removal of impacted cerumen from both ears.

69209-50

Otoplasty of the right ear, with size reduction.

69300-RT

OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Chronic otitis media with effusion POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: Bilateral tympanostomies with placement of ventilation tubes PROCEDURE: After the patient was placed under general anesthetic, the right canal was cleared of wax and prepped with Betadine. A radial incision was made in the anterior-inferior quadrant and thick mucoid fluid was suctioned from behind this drum. A 0.39-mm ventilation tube was inserted. The left canal was then cleared of wax and prepped with Betadine. A radial incision was made in the anterior-inferior quadrant and thick mucoid fluid was suctioned from behind this drum. A 0.39-mm ventilation tube was inserted. The canal was then filled with Ciprodex on both sides and cotton in the external auditory meatus. The patient was awakened from her anesthetic and returned to the recovery room in stable condition. Prognosis immediate/remote is good. Blood loss is 0.

69436-50

Urography, retrograde with KUB.

74420

Supervision and interpretation of a hysterosalpingography.

74740

RADIOLOGY REPORT EXAMINATION OF: Retroperitoneal sonogram, kidneys CLINICAL SYMPTOMS: Elevated creatinine RETROPERITONEAL SONOGRAM, KIDNEYS: Findings: The right kidney measures 12.6 5.4 5.0 cm. The cortex is thinned diffusely. The left kidney is smaller measuring 10.0 5.1 3.9 cm. The cortex is preserved. There is a 1.5 cm cyst seen anteriorly in the interpole region on this side. Bladder not well evaluated as the catheter is in place. There is mild prominence of the right proximal collecting system relative to the contralateral side in spite of the empty bladder. Cannot exclude mild caliectasis on this side. Also, cortical thinning suggests chronic renal insufficiency.

76770-26

Follicular study, ultrasound of the pelvis nonobstetric, B-scan, and real time with image documentation follow-up.

76857

Unlisted ultrasound procedure.

76999

Unlisted codes are assigned to identify procedures for which there is no more specific code.

True

RADIOLOGY REPORT BILATERAL SCREENING MAMMOGRAM: The tissue of both breasts is heterogeneously dense. This may reduce the sensitivity of mammography. No significant masses, calcifications, or other findings are seen in either breast. IMPRESSION: NEGATIVE MAMMOGRAM There is no mammographic evidence of malignancy. A 1-year screening mammogram is recommended.

77067

An 18 MeV radiation treatment, single treatment area.

77402

Parathyroid imaging.

78070

Liver imaging with vascular flow.

78202

Vitamin B12 absorption study with intrinsic factor.

78271

Cardiac blood pool imaging, first pass technique, multiple studies, with stress, with wall motion study plus ejection fraction without quantification.

78483

Cerebrospinal fluid leakage detection and localization.

78650 Hint: Cerebrospinal fluid, nuclear imaging

Hepatic function panel.

80076

Drug screening, confirmation, one procedure.

80305

Alkaloids, quantitative, urine.

80323

Fecal occult blood, three determinations by guaiac.

82272

Three specimens for total gastric acid.

82930x3

Blood analysis for HGH.

83003

Sodium, urine.

84300

Peripheral blood smear interpretation by physician with a written report.

85060

The semen analysis including Huhner test.

89300

The usual global surgery period for a major procedure is:

90 days

DIALYSIS PROGRESS NOTE: The patient was seen during CAPD while using 1.5% two liter fill volumes. She is on IV fluids. She appears dry. She doesn't have much edema but she is feeling much better. She still has some pain and tenderness on examination, but her spirits are better today and she is eating better. She finished all her breakfast. Her cultures so far are negative. The patient is on vancomycin and gentamicin for peritonitis, and we will continue that with pharmacy. Meanwhile, we will continue current dialysis prescription. We will keep her in the hospital for a couple more days, hopefully discharge either Sunday or Monday. The patient agrees with the plan.

90947

ESRD-related services per day for one encounter (less than a month), for a patient who is 17 years old.

90969

The patient presents for a serial tonometry with multiple measurements of intraocular pressure over an extended time period, same day, with interpretation and report.

92100

Fitting and prescription of contact lens for one eye with medical supervision of adaptation of corneal lens.

92310-52

Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision, corneal lens for aphakia, both eyes.

92312

Audiologic function screening test for pure tone, air only.

92551

Hearing test using pure tone audiometry; air only.

92552

Hearing aid check, one ear.

92592

Electrocardiogram with 15 leads including the interpretation and report.

93000

Electronic analysis of dual-chamber pacemaker system with reprogramming including the evaluation of parameters at rest and during activity.

93280

Catheter placement into the coronary arteries for coronary angiography with injections, imaging, supervision, and interpretation.

93454

Transcranial Doppler study of the intracranial arteries, limited study.

93888

Simple pulmonary stress test.

94618

Plethysmography for determination of lung volumes.

94726

Electroencephalogram recording for a patient in a coma.

95822

Neurofunctional testing during brain mapping, by physician with test review.

96020

Therapeutic IV infusion under the direct supervision of the physician of 45 minutes' duration.

96365

The global surgery period includes:

all routine preoperative and postoperative care

This patient is diagnosed with psoriasis and presents to the clinic for laser treatment to 375 sq cm.

96921

Hot packs applied to two areas.

97010

What code is used to report routine postoperative care?

99024

The CPT code that is used to report materials and supplies by the physician for which no other more specific CPT code exists is:

99070

A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM.

99205

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

99213

A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101°F yesterday. Mom treated her with Tylenol. The fever this AM is 99°F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with Otitis Media and an Upper Respiratory Infection and prescribed an antibiotic. The MDM is stated to be moderate.

99214

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

99232

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

99233

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

99253

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

99284

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome.

99291, 99292

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

99341

A 40-year-old established patient presents to the physician office for a preventive care exam.

99396

CLINIC NOTE CC: Established patient presents for routine examination SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits. ASSESSMENT: 1. Normal BP. 2. Normal pelvic exam. PLAN: Return in 1 year or as needed.

99396

History and exam of the normal newborn infant born in a hospital setting.

99460

Home visit for stoma care and maintenance of a patient's colostomy.

99505

Who publishes CPT?

AMA

When a physician performs a preventive care service, the extent of the exam is determined by the:

Age

Codes from the E/M subsection Nursing Facilities Service are used to report services provided in nursing facilities that used to be known as:

All are correct (skilled nursing facility, long-term care facility, intermediate care facility)

In which CPT appendix would all modifiers be found?

Appendix A

In which CPT appendix would additions, deletions, and revisions be found?

Appendix B

The universal health insurance form for submission of outpatient services is the:

CMS-1500

Which punctuation mark between codes in the index of the CPT manual indicates two codes are available?

Comma

Information given in the notes preceding a subsection is also contained in the section Guidelines.

False

A list of the unlisted procedures for use in a specific section of the CPT manual is contained in:

Guidelines

Where is specific coding information about each section located?

Guidelines

This act mandated the adoption of national uniform standards for electronic transmission of financial and administrative health information.

HIPAA

Which punctuation mark between codes in the index of the CPT manual indicates a range of codes is available?

Hyphen

Level II codes are not used in which setting?

Inpatient

Health care providers are ____ based on the codes submitted on a claim form for procedures and services rendered.

Reimbursed

Which term reflects the technologic advances made in medicine that are incorporated into the CPT manual?

Revisions

These elements would be part of the ____ history: employment, education, use of drugs.

Social

A code that has all of the words that describe the code that follows is what type of code?

Stand alone

Modifier -58, related procedure or service by the same physician during the postoperative period, is used on what type of service?

Surgery

The HPI must be documented in the medical record by:

The physician

When the words "separate procedure" appear after the descriptor of a code, you know which of the following about that code?

The procedure was a minor procedure that would only be reported if it was the only service provided.

Who requires a special report with the use of unlisted codes?

Third party payers

An established patient is one who has received face-to-face professional services from the physician or another physician of the same specialty in the same group within the past _________ years.

Three

Critical care codes are reported based on:

Time

Parenthetical phrases that sometimes follow a code or code group provide further information about codes that may be applicable.

True

Third-party payers determine the contents of a surgical package.

True

How often are Category III codes released?

Twice a year

Procedures that are experimental, newly approved, or seldom used are reported with what type of code?

Unlisted/Category III

Excision including simple closure of benign lesions of the skin includes this type of anesthesia:

local

Local anesthesia is defined in the CPT guidelines as:

all are correct

What are the divisions of the Surgery section based on?

body system

Which of the following represents three of the six elements that a special report must contain?

nature, extent, need

Endoscopic procedures within the Urinary subsection, Kidney subheading, are often divided based on this unique factor:

existence of a stoma

Endoscopic procedures within the Urinary subsection, Kidney subheading, are often divided based on this unique factor:

initial or subsequent

This information is placed after some codes in the CPT manual and contains helpful information.

parenthetical information

Within the Male Genital System, the greatest numbers of codes fall under what category?

penis

Which of the following represents the contents of a surgical package?

preoperative, intraoperative, and postoperative services

The words that follow a code number in the CPT manual are called

procedure/service descriptor

A modifier:

provides additional information to the third-party payer

A triangle before a code indicates that the code description is or has been:

revised

When using an unlisted code a(n) ____ must accompany the claim.

special report

The surgical package includes:

typical follow-up care

The term that describes the study of the motion and flow of urine is:

urodynamics