CCS Exam Study Guide 2017
By manipulation, under general anesthesia a 6 year old left tarsal's dislocation was reduced. Correct alignment was confirmed by a two-view intraoperative x-rays. A short leg cast was then applied to the left leg. Code only the reduction service. a. 28545-LT b. 28545-LT, 29405-LT, 73620 c. 28545-LT, 29405-LT-51 d. 28540-LT, 7360
a. 28545-LT key words: under general anesthesia, dislocation, left tarsal.
Because of frequent headaches, this 50 year old females doctor ordered a CT scan of her head, without contrast materials. a. 70450 b. 70460 c. 70470 d. 70496
a. 70450, Computed tomography, head and brain; without contrast material.
Code a complex brachytherapy isodose calculation for a patient with prostate cancer: a. 77318, C61 b. 77317-22, C62.90 c. 77772, C52 d. 77300, C52
a. 77318, Brachytherapy isodose plan complex. C61, Malignant neoplasm of the prostate.
An 81 year old female patient presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein(direct measurement, HDL) and triglycerides. a. 80061 b. 80061-52 c. 82465, 83718, 84478 d. 82465-52, 83718, 84478
a. 80061, lipid panel includes cholesterol, serum, total lipoprotein, direct measurement, high density cholesterol.
The 67 year old female suffers from Chronic liver disease and needs a hepatic function panel performed every six months. Tests include total bilirubin(82274), direct bilirubin(82248), total protein (84155), alanine aminotransferases (ALT and SGPT)(84460), aspartate aminotransferases (AST and SGOT)(84450) and what other lab tests? a. 82040, 84075 b. 80061, 83718 c. 82040, 82247 d. 84295, 84450
a. 82040, Albumin: serum, plasma or whole blood. 84075, phosphatase, alkaline.
Code for the supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport including data interpretation and report; first 30 minutes: a. 99485 b. 99486 c. 99487 d. 99489
a. 99485. On E & M codes be sure to circle and highlight location, type(critically ill, pediatric) limiting phrases (before transport) and time.
A 5 year old boy was brought to the ER by a social worker who discovered him alone in spasms and seizures. The social worker relates that the child's older sister told her the boy was bitten on the had by a raccoon he played with 11 days ago. No treatment was sought for the injury at the time, but the area was inflamed and hot. Social worker said mother is a drug addict and often leaves the children unattended, illness actually began 2 days ago with a headache and restlessness and inflammation at the wound site. The child expired due to cardiorespiratory failure before any effective treatment could administered. CPR was performed not successfully. Physician diagnosis was listed as Phadbovirus form infected raccoon bite, not treated due to child neglect. Critical care was provided for 60 minutes. Which code sets will be provided? a. A82.9, S61.429A, W55.51xA, Y07.12, T76.92xA, 99291, 92950 b. B97.89, 99285 c. R09.2, R56.9, R50.9, S61.429A, W55.51xA, Y07.12, 92950 d. A82.9, R56.9, R50.9, 92950
a. A82.9, S61.429A, W55.51xA, Y07.12, T76.92xA, code manifestation and cause codes. 99291, key word critical care for 60 minutes. 92950, key word; CPR. Be sure to read the guidelines and highlights what is included in critical care services.
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is: a. pathology report b. operative report c. discharge summary d. recovery room record
a. Although a gross description of tissue removed my be mentioned on the operative note or discharge summary, only the pathology report will contain a microscopic description.
A separate procedure is coded per CPT guidelines: a. Is considered to be an integral part of a larger service b. Is coded when it is performed as a part of another larger procedure c. Is never coded under any circumstances d. both a and b above
a. Because a separate procedure is considered a part of, and integral to, another, larger procedure, it is not coded when performed as part of the more extensive procedure. See Surgery Guidelines. It may, however, be coded when it is not performed as part of another, large service.
Excision lesion on left shoulder, 2.5 x 1.0 x .5 cm, including circumferential margins. Excision lesion, skin of right cheek, 1.0 x 1.0 x .5 cm including margins. Pathology report states that the skin lesion on the left shoulder is a lipoma and the lesion of the right cheek is a squamous cell carcinoma. The physician progress note states that the left shoulder was sutured with a layered closure and the cheek was repaired with a simple repair. What are the correct code sets? a. C44.329, D17.22, 11641-RT, 11403-51-LT,12031-51-LT b. C44.329, D17.22, 11641-RT, 12031-51-LT c. C44.329, D17.21, 11641-RT, 12031-51-LT d. C44.329, 11643-RT, 12031-51-LT
a. C44.329, keyword: carcinoma, squamous cell. D17.22, Lipomas are benign and coded by site. 11641-RT, malignant lesion removals are coded separately by site. 11403-51-RT, 12031-51-LT skin lesion removal includes simple repair, code intermediate or layered closures. Both codes are required. See surgery guidelines.
A 5 year old patient is seen by a physician in an outpatient clinic for chronic lymphoid leukemia in remission and Shiga toxin-producing Escherichia coli: a. C91.11, B96.21 b. C91.Z1, A04.4 c. C92.21, A41.51 d. C91.Z1, B96.20
a. C91.11; key; in remission. 04141: Shiga toxin producing Escherichia Coli (Ecoli) (STEC)
ICD-10-CM codes are composed of 3-7 alpha and numeric digit codes, when using them: a. Code to the greatest detail b. It's appropriate to code the 3 digit code when the category is further defined c. Code to the 4th digit when you don't have the information in your notes d. b and c is correct
a. Code to the greatest detail.
Discharged with pneumonia, klebsiella pneumonia, COPD with emphysema, multifocal atrial tachycardia, middle dementia a. J15.0, J43.9, I49.8, F06.8 b. J15.20, J43.9, I49.8, F06.8 c. J18.9, J43.9, I49.8, F06.8 d. J18.9, J43.9, I49.8, F02.81
a. J15.0, pneumonia due to klebsiella pneumonia; J43.9, other emphysema; I49.8, other specified cardiac dysrhythmia; F06.8 other specified mental disorders due to known physiological condition.
A 50 year old female patient had two separate carbuncles removed from the left axilla. Pathology report indicated staphylococcal infection. a. L02.432, B95.8 b. L02.92, B95.5 c. L02.92, B95.4 d. L02.432, B95.7
a. L02.432, B95.8; when coding L02 also identify the infective organism such as staphylococcus.
AN HIM educator speaks on department design and legislative act or agency that was created to ensure that workers have a safe and healthy work environment. Which of the following topics will be discussed? a. OSH Act b. Wagner Act c. Labor Management Relations Act d. Taft-Hartley Law
a. OSH Act
Erin, a 45 year old, asymptomatic female comes in for her annual bilateral screening mammography. Her physician ordered a computer aided detection along with the mammography. The procedure was performed in a hospital. How would you report the professional services for this study? a. 77057-26, 77067-26 b. 77056-26, 70051-26-59 c. 77059-26, 77057-51 d. 77057, 77067-51
a. Report a screening mammography with 77057 and the computer aided detection with 77067-26.
A new patient presents to the urgent care center with a laceration to the left elbow that happened 10 days ago and was not treated. An infected gaping wound was found, with resulting cellulitis to the forearm and upper left arm. Extensive irrigation and debridement using sterile water were performed but closure was not attempted pending resolution of the infection. Culture of the wound revealed streptococcus. The patient received 1,200,000 units of Bicillian CR IM and is to return in 3 days for follow up. The history and physical examination were problem focused. a. S51.012A, L03.114, B95.5, 99201, 96372, J0561x12 b. L03.114, B95.5, 96372-LT, J0561x12 c. S41.009A, B95.5, 99201 d. S51.012A, 99281, 96372, J0561x12
a. S51.012A, L03.114, cellulitis secondary to superficial injury, always code the additional injury or ulcer code B95.5, always code bacterial agents after the disease manifestation. 99201 minimal E & M visit for a new patient. Injection, IM, 96372, J0561x12, always code the drug and administration of the drug times amount of drug used.
Andrea, a 52 year old patient, had a hysterectomy on Monday morning. That afternoon, after returning to her hospital room, she suffered a cardiac arrest. A cardiologist responded to the call and delivered one hour and 35 minutes of critical care. During this time the cardiologist ordered a single view chest x-ray and provided ventilation management. How should you report the cardiologist's services? a. 99291, 99292 b. 99291, 99292, 71010, 94002 c. 71010, 94002, 99231 d. 99291, 99292, 99292-52
a. The guidelines for critical care have a list of services that are included with critical care when performed by the physician providing the critical care and these services should not be reported separately.
Which is true of the CPT codes? a. They describe both physician and non physician services b. They are numeric. c. Only physicians can report them. d. All of the above are correct.
a. They describe both physician and non-physician services. Category I are numeric ranging from 00100-99499 and correspond to a procedure or service. Category II and III CPT codes are alphanumeric with a T or F at the end.
Larry is being managed for his warfarin therapy on an outpatient basis. Dr. Nancy continues to review Larry's INR tests, gives patient instructions dosage adjustment as needed, and ordered additional test. How would you report the initial 90 days of therapy including 8 INR measurements? a. 99363 b. 99363, 99471 c. 99214 d. This service is bundled with evaluation and management services
a. This question deals with outpatient anticoagulant management. The code 99363 gives specific parameters for reporting.
In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to.... a. use of prohibited or "dangerous" abbreviations b. prohibited use of any abbreviations c. use of abbreviations used in the final diagnoses d. flagrant use of specialty-specific abbreviations
a. Use of prohibited or dangerous abbreviations.
When one or more hospitals are organized around a medical school they are referred to as an _____________________. a. academic medical center b. learning hospital c. teaching hospital d. primary care facility
a. academic medical center
When some computers are used primarily to enter data and others to process data, this architecture is called? a. client/server b. LAN c. mainframe d. web services
a. client/server allows for the sharing of a database, printers, disc space, etc. across a network.
One of the responsibilities of a Chief Privacy Officer for a hospital is to ___________________. a. develop a plan for reporting privacy complaints b. back up data c. writing policies on protecting hardware d. writing policies on encryption standards
a. develop a plan for reporting privacy complaints. The others are a job of the Chief Security Officer.
This committee is responsible for developing guidelines and standards for ethical decision making in the delivery of health care. a. ethics committee b. regulatory committee c. human resource committee d. oversight committee
a. ethics committee
When a patient presents for outpatient surgery (same day surgery) and develops complications requiring admission for observation, what should be coded first: a. reason for the original encounter b. reason for the complications c. initial diagnosis b. reason for admission
a. reason for the original encounter
For patients receiving ________________ services only during a visit, sequence first the diagnosis, condition, problem, shown in the medical record to be chiefly responsible for the outpatient services provided. a. therapeutic b. non-therapeutic c. psychological d. basic
a. therapeutic
Brandon comes into the orthopedic department today with his father after falling from the top bunk bed, where he and his sister were playing. He is having pain in his lower left leg and is unable to bear weight on it. Brandon is taken to the x-ray department. After the physician talks with the radiologist regarding the diagnosis of sprained ankle, the physician decides to apply a short leg cast, designed for walking, just below the knee to his toes. a. 29405-LT, S93.402A, W06.xxxA, Y92.013 b. 29425-LT, S93.402A, W06.xxxA, Y92.013 c. 29515-LT, S93.402A, W19.xxxA, Y92.013 d. 29405-LT, S93.402A, W06.xxxA
b. 29425-RT application of walking cast; S93.402A sprain left lower leg; W06.xxxA fall from bed. Code location as bedroom of single family (private) house:Y92.013.
Urban hospitals are in a county that is part of a metropolitan statistical area, population of _____________________. a. 25,000 or more b. 50,000 or more c. 100,000 or more d. 250,000 or more
b. 50,000 or more. When the Health Care Financing Administration implemented the Medicare prospective payment system (PPS), the payment rates for inpatient hospital operating costs ere derived on an urban and rural basis within each region.
Strabismus correction involving the lateral rectus muscle. a. 67314 b. 67311 c. 67318 d. 67312
b. 67311, keyword lateral
The 62 year old female who suffers from treatment- resistant schizophrenia comes into the lab today to have a quantitative drug assay performed for the anti-psychotic medication clozapine, a regular white blood cell and absolute neutrophil count due to concern with agranulocytosis. a. 80159 b. 80159, 85048 c. 80159, 85048, 85004 d. 80159, 85025
b. 80159: Clozapine; therapeutic drug assay for Clozapine. In CPT, 85048 is listed as: Blood count; leukocyte(WBC) automated. The CBC, 85058, and adding code 85004 would be unnecessary.
This male is status post kidney transplant and comes into the clinic for a follow up creatinine clearance. a. 82540, Z94.0 b. 82575, Z94.0 c. 82565, N19 d. 82570, N18.6
b. 82575, Creatinine; clearance, Z94.0 kidney replaced by transplant.
Code for a tetravalent, preservative free, flu vaccine for a three-year old girl, injected intramuscularly. a. 90686 b. 90686, 90471 c. 90687, 90460 d. 90688, 90460
b. 90868: Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use. Quadrivalent (aka tetravalent) means the vaccine is a mixture of four flu-types. A "split virus" is chemically disrupted using a non ionic surfactant, which is futher purified. Bivalent is two and trivalent is three. Report the vaccine admin codes 90471-74 in addition to cods 90476-90749.
How does CPT Professional Edition define a new patient? a. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 2 years. b. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belong to the same group practice, within the past 3 years. c. A new patient is one who has received professional services from the physician or another physician of the dame specialty within the last 2 years for the same problem. d. A new patient is one who has received hospital services but has never been seen in the clinic by the reporting physician.
b. A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.
When using the ICD-10-CM a. Always use the index when coding b. Check the tabular before assigning a code c. It is perfectly appropriate to memorize codes d. b and c are correct
b. ALWAYS check the tabular before assigning a code.
A surgeon performed a cervical approach esophagoplasty with repair of a tracheosophageal fistula under general anesthesia. The surgeon performed both the procedure and the anesthesia. How would you report these services? a. 00500, 43305 b. 43305-47 c. 00500-47 d. both a and c
b. According to the anesthesia guidelines; To report regional or general anesthesia provided by a physician also performing the services for which the anesthesia is being provided, see modifier -47.
AS a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review the elements from which data set? a. MDS b. DEEDS c. UHDDS d. ORYX
b. DEEDS. It is designed to provide uniform specifications for data elements that decision makers may choose to retain, revise, or add to their ED record system.
Asymptomatic, non-sustained, ventricular tachycardia, there are no prolonged pauses; predominant rhythm is atrial fibrillation with well controlled ventricular rate. a. I48.92, I42.8 b. I48.91, I42.8 c. I49.01, I42.8 d. I42.8, I48.91
b. I48.91; unspecified atrial fibrillation, always cod the reason for the encounter first. I42.8, other primary cardiomyopathies.
A 55 year old female with spinal stenosis of the cervical disk C4-5 and C5-6 with inter-vertebral disk displacement had a cervical discectomy, corpectomy, allgraft from C4 to C6 and placement of arthrodesis (a 34 mm plate from C4 to C6) a. M50.90 b. M48.02, M50.221, M50.222 c. M48.02, M51.26 d. M50.90, M51.35
b. M48.02, M50.221, M50.222 mid cervical region; key word: displacement
When operating under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), what is a basic tenet in information security for health care professionals to follow? a. The information system encourages mass copying, printing, and downloading of patient records. b. Security training is provided to all levels of staff. c. Patients are not educated about their right to confidentiality of health information. d. When paper-based records are no longer needed, they are bundled and sent to a recycling center.
b. Security training is provided to all levels of staff.
The Black Triangle symbol before a code in the CPT manuals means? a. The code is exempt from bundling requirements. b. The code has been revised in some way. c. The code is exempt from unbundling requirements. d. The code can be used as an add-on code, never reported alone or first.
b. The code description has been revised. You will see this throughout the book.
Adam, a 48 year old patient, presented to Dr. Crampton's office with complaints of fever, malaise, chills, chest pain and a severe cough. Crampton took a history, did an exam and ordered a chest x-ray. After reviewing the x-ray, Crampton admitted Adam to the hospital for treatment of pneumonia. After his regular office hours, Crampton visited Adam in the hospital where he dictated a comprehensive history, comprehensive exam, and decision-making of moderate complexity. How would you report Dr. Crampton's services? a. 99214 b. 99222 c. 99204, 99222-51 d. 99223, 99214-21
b. The subcategory guidelines for Initial Hospital Care state, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service all evaluation and management services provided by that physician in conjunction with the admission are considered part of the initial hospital services are reported with the initial hospital care code only. The office visit is a bundled service.
Mr. Johnson, a 38 year old established patient is being seen for management of his hypertension, diabetes, and weight control. On his last visit, he was told he had a diabetic foot ulcer and needed to be hospitalized for this condition. He decided to get a second opinion and went to see Dr. Myers. This was the first time Myers had seen Johnson. Myers documented a comprehensive history, comprehensive examination, and decision-making of high complexity. He concurred with hospitalization for the foot ulcer and sent a report back to Johnson's primary care doctor. How would you report Dr. Myers visit? a. 99245 b. 99205 c. 99215 d. 99255
b. This is a new patient visit not a consultation. "A consultation initiated by a patient and/or family, and not requested by a physician or other appropriate source, is not reported using the consultation cods but may be reporting using the office visit, home service, or domiciliary/rest home care codes". Report a consultation code only when a request is made by another physician or appropriate source, an opinion is rendered, and a written report is sent back to the "requestor". In this case the patient initiated the visit.
An anesthesiologist provides general anesthesia for a 72 year old patient with mild systemic disease who is undergoing a ventral hernia repair. How would you report the anesthesia service? a. 00834-P2, 99100 b. 00832-P2, 99100 c. 49560, 00834, 91000-P2 d. 00832
b. You should report the anesthesia services with modifier -P2 for mild systemic disease and qualifying circumstances due to the patient's age.
What code would you assign for encounters for routine laboratory or radiology testing in the absence of any signs, symptoms, or associated diagnosis? a. Z01.812 b. Z01.89 c. Z01.84 d. Z01.818
b. Z01.89, encounter for other specified special examinations.
A patients wishes regarding continuation or withdrawal of treatment when patient lacks decision making capacity is called______________________? a. life support b. advance healthcare directive c. continuation or withdrawal agreement d. power of attorney
b. advance healthcare directive. Also known as a living will, personal directive, advance directive, medical directive and advance decision.
A special type hospital that must have all ALOS greater than 25 days serves patients with complex medical needs, and may suffer from multiple chronic problems. a. special care hospital b. long term care hospital c. teaching hospital d. extended care hospital
b. long term care hospital. Long term care hospitals are certified as acute care hospitals, but LTCHs focus on patients who on average stay more than 25 days.
For ambulatory surgery code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from preoperative diagnosis at the time the diagnosis is confirmed, select the _________________ for coding since it is the most definitive. a. preoperative diagnosis b. postoperative diagnosis c. best match d. most expensive
b. postoperative diagnosis
Which of the following stores data in predefined tables consisting of rows and columns? a. spreadsheet b. relational database c. hierarchical database d. network database
b. relational databases store data in predefined tables similar to a spreadsheet and are often used in healthcare applications.
A patient is taken to the operating room for a ruptured spleen. A partial splenectomy and repair of a rupture was done. a. 38101, S36.032A b.38101-58, 38115-51, D73.5 c. 38115, D73.5 d. 38120, S36.032A
c. 38115, repair ruptured spleen D73.5, infarction of spleen includes splenic rupture non-traumatic. There is no mention that it is laparoscopic.
Excisional transverse blepharotomy with one-quarter lid margin rotation graft. a. 67966 b. 67950 c. 67961 d. 67961, 15576
c. 67961, keyword: one fourth
A patient presents for an MRI of the pelvis with contrast materials. a. 72125 b. 72198 c. 72196 d. 72159
c. 72196, Magnetic resonance imaging, pelvis; with contract materials
Code an endoscopic catheterization of the biliary ductal system for the professional radiology component only. a. 74330-TC b. 74330-26 c. 74328-26 b. 74300-26
c. 74328-26 interpretation of , Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation.
Marcy is a 29 year old pregnant female in for a follow-up ultrasound with image documentation of the uterus. a. 76856 b. 74740 c. 76816 d. 74710
c. 76816, Ultrasound, pregnant uterus, real time with image documentation, follow-up.
A patient presents to the laboratory in the clinic for the following tests: TSH, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count(CBC). How would you code this lab? a. 84445, 80551, 85025 b. 84443 c. 80050 d. 84443, 80053, 85027, 85007
c. 80050, general health panel, includes DBD, comprehensive metabolic profile, CBC automated and appropriate manual differential WBC count TSH.
Thomas has end stage renal failure and comes to the clinic lab today for his monthly urinalysis(qualitative, microscopic only). a. 81015, N19 b. 81001, N17.9 c. 81015, N18.6 d. 81003, N18.6
c. 81015, Urinalysis, microscopic only, N18.6, end stage renal disease.
The patient presented to the laboratory at the clinic for the following blood tests ordered by her physician: albumin (serum), bilirubin(total), and Urea nitrogen(BUN) (quantitative) a. 82044, 82248, 84520 b. 82040, 82252, 84525 c. 82040, 82247, 84520 d. 82044, 82247, 84540
c. 82040, Albumin: serum, plasma or whole blood, 82247, Bilirubin, total, 84520, Urea nitrogen(BUN): quantitative.
This patient presents to the clinic lab for a prothrombin time measurement because of long-term use of Coumadin a. 85210, Z79.01 b. 85210, Z79.2 c. 85610, Z79.01 d. 85230, Z79.2
c. 85610, Prothrombin time Z79.01 encounter for long term(current) use of anticoagulants.
This 70 year old male is taken to the emergency room with severe chest pain. The physician provided an expanded problem-focused history and examination. While the physician is examining the patient, his pressures drop and he goes into cardiac arrest. Cardiopulmonary resuscitation is given to the patient, and his pressure returns to normal; he is transferred to the intensive care unit in critical condition. Code the cardiopulmonary resuscitation and the diagnosis. The medical decision making was of low complexity. a. 99282, 92950, I46.9 b. 99283, 92970, I46.9 c. 92950, I46.9 d. 92960, I46.9
c. 92950, Cardiopulmonary resuscitation (eg, in cardiac arrest) I46.9 cardiac arrest, cause unspecified.
Postoperative Diagnosis: Basal Cell Carcinoma of the forehead. Procedure: Excision of basal cell carcinoma with split-thickness skin graft. Patient was given a local IV sedation and taken to the operating room. Face and right thigh were prepped with pHisoHex soap. The cancer was outlined for excision. Cancer measured approx. 2.5 cm in diameter. Forehead was in filtrated with 1% xylocaine with 1:1,000,000 epinephrine. The cancer was excised and carried sown to the frontalis muscle. The area of the excision measured 5x4cm in total. A suture was placed at the 12 o'clock position. Specimen sent to pathology for frozen section. Attention was then turned to the skin graft. Pattern of the defect was transferred to the left anterior thigh using a new needle. Using a free hand knife a split thickness skin graft was harvested. a. C76.0, 15120 b. C44.319, 15120 c. C44.319, 15120, 11646 d. C76.0, 15002, 15120
c. C44.319, carcinoma, basal cell of skin of other parts of face. 15120, keyword split thickness. 11646 excision of a malignant lesion.
The hospital survey and construction act of 1946, referred to as the Hill-Burton Act, provided federal grants to states for the construction of new ___________________________. a. long term care facilities b. emergency rooms c. community hospital beds d. all of the above
c. Community hospital beds. The Hill Burton Act gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization.
The patient, a 55 year old male. This was a follow up for POAG. The patient had IOP of 22 OD and 24 OS, The Optometrist added TImolol Maleate to the patient's Xalatan prescription. The OD performed a Comprehensive Eye Exam, which included ExtraOcular Motility(EOM) Confrontation Fields and a Dilated Fundus Exam, No ROS was taken. The provider performed a refraction exam and GDX of the retina of both eyes. a. 99215, 92132 b. 92004, 92250, 92015 c. 92014, 92134, 92015 d. 92014, 92134
c. Key hints here: 55 year old is not a Medicare patient, POAG is Primary Angel Glaucoma, IOP is Intraocular Pressure the Comprehensive eye exam is a 92014 code and not an E & M code. Clues are the two included tests (EOM and CF) and the no ROS was done (not need for 92xxx codes) GDX HRT and OCT are all diagnostic tests coded as Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 9213X, 92134 is the correct code. Code 92015 for the refraction services. Determination of refractive state.
In long term care the residents care plan is based on data collected in what system? a. UHDDS b. OASIS c. MDS d. HEIDS
c. MDS-minimum data set
A patient was placed under general anesthesia for a simple incision and removal of a foreign body from the subcutaneous tissue. This procedure usually requires local anesthesia. Due to unusual circumstances, which required general anesthesia, what modifier would best describe this situation? a. 47 b. 22 c. 23 d. P6
c. Modifier -23
Dr. Member performed a transesophageal echocardiography for a congenital cardiac condition on a 16 year old patient. Prior to the probe placement, moderate conscious sedation was administered. The probe was placed, images acquired, interpretation and reports were completed in the provider's office. This procedure lasted 45 minutes. What codes capture the services performed by Dr. Member? a. 93315, 99144, 99145 b. 00320, 99144, 99145 c. 93315 d. 93315-P1
c. Refer to appendix G in the CPT edition. This appendix lists the codes that include moderate conscious sedation along with guidelines to assist with reporting these services. Additionally, code 99315 has a bulls-eye symbol that indicates moderate conscious sedation is included with the service.
A skilled nursing home patient with an indwelling Foley catheter is diagnosed with a serious urinary tract infection due to E. coli caused by the catheter. The catheter is removed. A temporary catheter id placed through the urethra, and aggressive antibiotic therapy is begun in the emergency room of the hospital. Which of the following codes sets will be reported by the ER physician? No medical evaluation was performed because the patient was evaluated by the primary care physician via telephone with the nursing home staff, and orders were called into the hospital. a. N39.0, B96.20, 51701 b. T83.511A, Y84.6, 51703, 99281 c. T83.511A, N39.0, B96.20, Y84.6, 51702 d. N39.0, T83.511A, Y83.8, 51020
c. T83.511A, 599.0, B96.20, always code reason for the encounter and any manifestations. Y84.6, code the cause 51702 insertion of temporary indwelling catheter simple.
A patient presents to a freestanding radiology center and had ultrasonic guidance needle placement with imaging supervision and interpretation of two separate lesions in the left breast. The procedure required several passes to complete. How would you report the imaging procedure? a. 76930x2 b. 76941 c. 76942x2-LT d. 76942-LT
c. The code 76942 is the correct code to report this procedure according to the CPT. Code 76942 should be reported per distinct lesion that requires separate needle placement. therefore if passes are made into two separate lesions in the same organ then code 76942 would be reported twice.
Brandon was seen in Dr. Shaw's office after falling off his bunk bed. Brandon's mother reported that Brandon and his sister were jumping on the beds when she heard a "thud". Brandon complained of knee pain and had trouble walking. Shaw ordered a knee x-ray that was done at the imaging center across the street. The x-ray showed no fracture or dislocations. Shaw had seen Brandon for his school physical six months ago. Today, Shaw documented a detailed examination and decision-making of moderate complexity. He also instructed Brandon's mother that if Brandon had any additional pain or trouble walking he should see an orthopedic specialist. How should Dr. Shaw report her services from today's visit? a. 99204 b. 99394, 99214 c. 99214 d. 99203
c. This is an established patient visit and meets two of the three key components for a 99214 level visit.
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a ____________ has not been established (confirmed) by the provider. a. record b. encounter c. diagnosis d. procedure
c. diagnosis
Do not code diagnoses documented as "probable, suspected, questionable, ruled out or working diagnosis". Instead, code the condition to _____________ for the encounter. a. The highest level of clarity b. The lowest level of clarity c. The highest level of certainty d. The lowest level of certainty
c. the highest level of certainty
Postoperative Diagnosis: Full thickness burn wound to anterior left lower leg. Operation: Split thickness graft, approximately 35 cm.; preparation of the wound. Procedure: left lower leg was prepped and draped in the usual sterile fashion. The ulcer, which measured approximately 8x4 to 4.5cm, was debrided sharply with Goulian knife until healthy bleeding was seen. Split thickness skin graft was harvested from the left lateral buttock area approximately 4.5x5cm x 8 cm at the depth of 14/1000 of an inch. THe graft was meshed to 1 to 1.5 cm fashion and placed over the prepared wound, stabilized with staples and then Xeroform dressing and dry dressings, wrapped with Kerlix and finally immobilized in a posterior splint. The donor site was covered with Xeroform and dry dressings. What are the correct procedure codes reported by, the physician for this procedure performed in the hospital outpatient surgical suite? a. 15220-LT, 15221-51-LT, 15002-51-LT b. 15100-LT c. 14021-LT, 15002-51-LT D. 15100-LT, 15002-51-LT
d. 15100-LT, 15002-51-LT. code both the wound preparation and the any intermediate graft.
A 69 year old male is admitted for coronary ASHD. A prior cardiac catheterization showed numerous native vessels to be 70% to 100% blocked. The patient was then taken to the operating room. After opening the chest and separating the rib cage, a coronary artery bypass was performed using five venous grafts and four coronary arterial grafts. Code the graft procedures and the diagnosis: a. 33514, I25.10 B. 33536, 33517-51, I25.9 c. 33533, 33522, I25.810 d. 33536, 33522, I25.10
d. 33536, 4 or more coronary arterial grafts, 33522 an add on code primary procedure first. I25.10, native coronary artery without angina pectoris.
A 60 year old female comes to the clinic with shortness of breath. The doctor orders a chest x-ray, frontal and lateral. a. 71020x2, R06.2 b. 71035x2, R06.89 c. 71015, R06.09 d. 71020, R06.02 d. 71020, R06.02
d. 71020, radiologic examination, chest, 2 views, frontal and lateral. R06.02, shortness of breath.
Surgical pathology , gross examination, or microscopic examination is most often required when a sample of an organ, tissue, or body fluid id taken from the body.. What codes would you use to report biopsy of the colon, hematoma, pancreas, and a tumor of the testis? a. 88307, 88304, 88309 b. 88305, 88304, 88307 c. 88305, 88302, 88307, 88309 d. 88305, 88304, 88307, 88309
d. 88305, 88304, 88307, 88309, surgical pathology code location from which biopsy was taken.
An elderly man comes in for his flu (split virus, IM) and pneumonia (23-valent, IM) vaccines. Code only the immunization administration and diagnoses for the vaccines. a. 90658, 90632, Z23, Z23 b. 90471, 90658, 90472, 90732, Z23, Z23 c. 90471x2, 90658, 90632, Z23 d. 90471, 90472, Z23, Z23
d. 90471, 1st administration. 90472, 2nd administration, Z23, need for influenza, Z23, need for pneumococcal vaccine.
The established patient is seen for a comprehensive eye exam (not E & M), fundus photography and the application of corneal bandage lenses for Keratoconus. Code for this encounter. a. 99215, 92250, 92082 b. 92004, 92250, 92072 c. 92014, 92250, 92071 d. 92014, 92250, 92072
d. 92014 comprehensive eye exam. 99250 Fundus photography. Note: for keratoconus. 92072 Fitting of contact lens for management of keratoconus, initial fitting.
The provider performed a 120 minute E & M service of a critically ill neonate plus selective head hypothermia reported as two days. a. 99291, 99184 b. 9929x4, 99184 c. 99291x2, 99184x1 d. 99291, 99292x2, 99184
d. 99291, 99292x2; for 120 minutes. 99184 combines total and selective hypothermia in a critically ill neonate per day. Quantity is 2 days.
Lucas, a 3 year old new patient is seen for a well-child exam. The doctor documents an age appropriate history, examination, anticipatory guidelines, risk factor reduction intervention and indicates Lucus immunizations are up to date. How would you report this service? a. 99392 b. 99213-25, 99385 c. 99203 d. 99382
d. 99382, keywords, age 1-4. Preventive medicine services are based on new vs. established patient and age.
A 50 year old male has staphylococcal septicemia with systemic inflammatory response syndrome and respiratory and hepatic failure a. A41.2, J96.00, K72.00 b. A41.2, J96.00, R65.20 c. J96.00, K72.00, A40.8, R65.20 d. A41.2, R65.20, J96.00, K72.00
d. A41.2, R65.20, J96.00, K72.00; always code organism first then SIRS, followed by other manifestations.
Katherine is a 77 year old patient with a severe hypertensive disease. She underwent a cataract surgery to both eyes under general anesthesia. Dr. Sharon, the anesthesiologist, performed the anesthesia. Prior to induction of anesthesia Sharon completed a preoperative visit and documented a detailed history, detailed examination, and low complexity decision-making on this new patient. How would you report Dr. Sharon's services? a. 99203, 00142-P2, 99100 b. 66820, 00144 c. 0140-P1, 99116-59 d. 00142-P3, 99100
d. According to the anesthesia guidelines in the CPT, the preoperative visit is bundled or included in the anesthesia services.
James, a 35 year old new patient, received 45 minutes of counseling and risk factor reduction intervention services from Dr. Kelly. Dr Kelley talked to James about how to avoid sports injuries. Currently, James does not have any symptoms or injuries and wants to maintain this status. This was the only service rendered. How would you report this service? a. 99213 b. 99203 c. 99385 d. 99403
d. Counseling and/or risk factor reduction intervention services are provided to patients with symptoms or established illness. 45 minutes.
Dr. Jane admitted a 67 year old woman to the coronary care unit for an acute myocardial infarction. The admission included a comprehensive history, comprehensive examination, and high complexity decision-making. Jane visited the patient on days 2 and 3 and documented (each day) an expanded problem focused examination and decision-making of moderate complexity. On day four, Jane moved the patient to the medical floor and documented a problem focused examination and straight forward decision-making. Day 5, Jane discharged the patient to home. The discharge took over an hour. How would you report the services from day on to day five? a. 99213, 99232, 99231, 99239x2 b. 99221, 99222, 99223, 99238 c. 99231, 99232, 99355, 99217 d. 99223, 99232, 99232, 99231, 99239
d. Day one admission or initial hospital care is 99223. Days two and three are subsequent hospital care services at 99232 and you should report them separately. Day four is subsequent hospital care at level 99231. Day five is the discharge service, which is based on time and code 99239 is reported for services of more than 30 minutes, regardless of the actual time. Report this code only once.
A patient with a history of myocardial infarction is admitted for cardiac catheterization. It is also noted the patient has unstable angina, hypertension, and diabetes with hypoglycemia. a. I20.0, I10, E13.9, D10.9 b. I20.8, I10, E11.69, I25.2 c. I20.0, I10, E11.69, I25.2 d. I20.0, I21.3, E11.69, I25.2
d. I20.0, unstable angina; I10, Essential (primary) hypertension; I21.3 acute myocardial infarction, episode of care unspecified; E11.69 type 2 diabetes mellitus with other specified complication, code also the manifestation; I25.2 old myocardial infarction.
This includes rights to patients such as confidentiality, consent, and the right to make decisions regarding medical care. a. admittance form b. patient confidentiality clause c. living will d. patients bill of rights
d. Patients bill of rights.
12 year old female was chasing her friend when she fell through a sliding glass door sustaining three lacerations. Left knee 5.5 cm laceration involving deep subcutaneous tissue and fascia, was repaired with layered closure using 1% lidocaine anesthetic. Right knee: 7.2 cm laceration was repaired under local anesthetic with a single layer closure. Right hand : 2.5 cm laceration of the dermis was repaired with simple closure using Dermabond tissue adhesive. What are the correct CM and CPT procedure codes? Do not code anesthesia. a. S81.012A, S81.011A, S61.411A, W01.110A, Y92.009, 12005 b. S81.012A, S81.011A, S61.411A, 12002-RT, 12032-51-LT, 17999-51-LT c. S71.009A, 12032, 12002-LT, A4364 d. S81.012A, S81.011A, S61.411A, W01.110A, Y92.099, 12032-LT, 12004-51-RT
d. S81.012A, keyword laceration, knee. S61.411A, keyword laceration, right hand. W01.110A, Y92.099, Code location and instrument. 12032, 12004-51 code location and size adding together the wounds in the dame location regardless how many. Remember that simple closure and single layer are considered the same type of closure.
The patient, a 21 year old female, has acute laryngitis, chronic fatigue syndrome and presents for both FLU and pneumococcal vaccine. a. Z23, Z23, J04.0, R53.83 b. Z23, Z23, J37.0, R53.81 c. Z23, Z23, J37.0, R53.81 d. Z23, Z23, J04.0, R53.82
d. Z23 is correct for influenza, Z23 is the pneumococcal vaccine. R53.82 is chronic fatigue. J40.0 is acute laryngitis without mention of obstruction.
A hospital that has no more than 25 acute care or swing beds and must provide 24 hour emergency medical services. a. rural hospital b. emergency medical center c. academic medical center d. critical access hospital
d. critical access hospital. CAHs is a designation given to certain rural hospitals by the CMS. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve the access to healthcare by keeping essential services in rural communities.
CPT has been developed and maintained by a. AMA b. CMS c. The Cooperating Parties d. WHO
a. American Medical Association. CPT codes were first published in 1996 and are developed, maintained and copyrighted by the AMA.
Acute bacterial endocarditis due to AIDS. a. B20, I33.0 b. B20, I39 c. B20, I33.9 d. A80.39, I39
a. B20, HIV. I33.0 acute and subacute infective endocarditis (use additional code to identify organism)
Which service is not included with anesthesia services? a. Swan-Ganz monitoring b. Administration of blood c. Blood pressure d. mass spectrometry
a. Swan-Ganz monitoring
The patient, 4 year old child, complained of pain from inside the ear. The doctor found retained glass fragment in the child's ear. a. H92.09, H74.8x9, Z18.83 b. H92.09, H74.8x9, Z18.81 c. H92.09, H74.43, Z18.81 d. H92.09, H69.80, Z18.81
b. H92.09: otogenic pain- of or originating within the ear, especially from inflammation of the ear. For H74.8x9 see Notes Z18.81 retained glass fragments
Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets. a. Joint Commission standards b. HL-7 standards c. CMS standards d. NHIN standards
c. CMS standards.
This group performs the daily operations for CMS. a. OIG b. PRO c. FI (and carriers) d. WHO
c. FI and carriers. A fiscal intermediary is a private company contracted by Medicare to pay bills like hospital expenses for Medicare Part A and Part B.
What data entry software system do home health agencies use? a. incidence-only population-based registry b. Home Health Agency c. HAVEN (Home Assessment Validation and Entry) d. a release of information company
c. HAVEN
The factors influencing health status and contact with health service codes (Z00-Z99) are used when circumstances other than____________________ are recorded as the diagnosis or problem. a. a drug overdose b. an evaluation or diagnosis c. a disease or injury d. a surgical procedure
c. a disease or injury.
This patient received a prescription for a therapeutic radiology for a cancerous neoplasm of the adrenal gland. What code would you use for complex treatment planning? a. 60520 b. 77307 c. 77401 d.77263
d. 77263, keyword; therapeutic radiology treatment planning, complex.
This 34 year old female had been suffering from chronic fatigue. Her physician has ordered a TSH test. a. 80418, R53.81 b. 80438, R53.82 c. 84146, R53.81 d. 84443, R53.82
d. 84443, Thyroid simulating hormone(TSH), R53.82, chronic fatigue syndrome.
When Acute and Chronic Conditions are noted: a. Always code the Chronic condition first b. Always coed the Acute condition first c. Code both and sequence the acute (sub-acute) code first d. b and c are correct
d. B and C are correct
Which below are not included with subsequent intensive care codes 99478-99480? a. Cardiac and respiratory monitoring b. Vital sign monitoring c. Enteral nutritional adjustments d. None of the answers are correct
d. These services are all included. Exceptions and inclusions in the guidelines should be highlighted or added to the margins for quick reference.
What code would be used should a general medical examination for an adult result in an abnormal finding? a. Z00.121 b. Z00.110 c. Z00.00 d. Z00.01
d. Z00.01, encounter for general adult medical exam with abnormal findings. use an additional code to identify the abnormal findings.
