A patient is diagnosed with a pressure ulcer on her right heel that is currently being treated.

What ICD-10-CM code is reported?

A comatose patient is seen in the ER. The patient has a history of depression. Drug testing confirm she overdosed on tricyclic antidepressant drugs doxepin, amoxapine, and clomipramine.

What CPT® code is reported?

A 47-year-old male with a history of peripheral artery disease presents with worsening claudication of the left leg. A diagnostic angiography confirms stenosis in the left iliac artery. To restore blood flow to the left leg, the vascular surgeon plans to perform angioplasty, using a balloon to dilate the vessel lumen followed by placement of an expandable stent in the left iliac artery.

What CPT® coding is reported for the procedure?

A 7-year-old boy was brought 10 the ED by his mother after he had been playing with small beads and one got lodged in his right external ear canal. After examination, the physician decided to remove the foreign body from the external auditory canal using alligator forceps without anesthesia.

What CPT® code is reported?

(A patient with abnormal growth had asuppression studythat includedfive glucose testsandfive human growth hormone tests. What CPT® coding is reported?)

(A male patient passes out while jogging in the park. Upon examination at the hospital, he is found to have a wide complex tachycardia and undergoes anelectrophysiologic study and radiofrequency ablation. For this procedure he is placed undergeneral anesthesia. What is the anesthesia coding for this otherwise healthy 35-year-old?)

A therapeutic colonoscopy is performed, where the scope goes beyond the splenic flexure, but not to the cecum. Using the Colonoscopy Decision Tree illustrated in the CPT® code book, what coding is reported?

(What modifier is appended to indicate that during thepostoperative period, a procedure is performed that wasplanned,more extensivethan the original procedure, or done fortherapeutic reasons?)

(A 1-year-old patient was born with twosupernumerary digits, one extending from the right pinky and one extending from the left pinky. The digit from his left pinky is larger and includes themetacarpal bone with a jointand is amputated. The one on the right is anubbinand containsno bony structure. The hand surgeon removes the extra digit containingsoft tissueby a simple excision. What is the CPT® coding for the procedures performed?)

(A patient is seen by her podiatrist to treat a painfulleft ingrown toenailon the big toe. The podiatrist performs awedge excisionof the skin of the nail fold at the lateral margin. Local anesthetic is administered, and an elliptical incision is made through subcutaneous tissue of the affected nail groove. A wedge-shaped piece of soft tissue from the nail margins is removed. What CPT® code is reported?)

Four malignant peritoneal tumors are excised, the largest measuring 15 cm.

What CPT® and ICD-10-CM coding is reported?

(What is the ICD-10-CM code for amedial meniscus tearof theleft kneedue to arecent football injury?)

Patient is diagnosed with dacryocystitis, which is the inflammation of?

What modifier is appended to indicate when a procedure performed during the postoperative period is unrelated to the original surgery?

A 57-year-old woman with a physical status of 3 received general endotracheal anesthesia for a panniculectomy. The anesthesiologist personally performed the entire anesthesia service.

What CPT@ coding is reported for the anesthesia?

(The documentation states: “A punch is placed and pushed downward to obtain a tissue sample for a biopsy of thelunula.” What anatomical structure is being biopsied?)

A patient with multiple atypical lesions on the face and trunk is in the office to perform a biopsy. A punch tool was used to obtain a full-thickness tissue sample for two lesions on the trunk.

Partial-thickness tissue sample was taken from one lesion on the forehead using a curette.

What CPT® coding is reported?

(A patient is in the operating room for a planned partial meniscectomy of the temporomandibular joint. However, after general anesthesia was administered and the oral surgeon made the incision, the patient experienced respiratory distress. The oral surgeon decides tocancel the procedure. What CPT® coding is reported for the oral surgeon?)

(Day 1: Provider admits patient toobservation carefor type 2 diabetes with hyperglycemia, orders labs, consults endocrinologist, starts IV insulin drip, keeps overnight. Day 2: orders glucose test, dietitian, documents total time 25 minutes. Day 3: glucose normal, documents 15 minutes, discharges patient. What E/M coding is reported by the physician for the patient in observation care?)

(Which punctuation is used in the ICD-10-CM Tabular List to denotesynonyms, alternative wording, or explanatory phrases?)

A 56-year-old female patient with a history of degenerative disc disease at levels T2-T3 and T4-T5 underwent a surgical repair procedure. Two surgeons will be working together as primary surgeons

Surgeon X: Carried out the anterior exposure of the spine and mobilized the great vessels, assisted Dr. Z. and performed the closure.

Surgeon Z: Performed a minimal anterior discectomy and fusion at T2-T3 and T4-T5 levels using an anterior interbody technique and solely performed utilizing a structural allograft.

What is the CPT® coding for the two surgeons?

(Chief Complaint: Palpable lump in the left breast. Adiagnostic mammogram (unilateral)was performed on theleft breastusingdigital imaging with CAD, with standard and additional views. What CPT® codes are reported for the radiological services?)

(A 5-year-old patient has a fractured radius. The orthopedist providesmoderate sedationand the reduction. The intra-service sedation time is documented as21 minutes. What CPT® code is reported for the moderate sedation?)

Patient with erectile dysfunction is presenting for same day surgery in removal and replacement of an inflatable penile prosthesis.

What CPT® code is reported for this service?

Which statement is FALSE in reporting a personal history ICD-10-CM code?

Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1

Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.

Operation performed: Excision of right thigh benign congenital>1

nevus, excision size with margins 4.5 cm and closure size 5 cm.

Anesthesia: General.0

Intraoperative antibiotics: Ancef.0

Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general

anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.

Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.

This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.

The patient was then cleaned and turned over to anesthesia for S extubation.

She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.

What CPT® and ICD-10-CM codes are reported?

An air bag deployed when a driver lost control of the car and crashed into a guardrail on the side of the highway. The driver suffers partial impact resulting in a skull fracture of the anterior

cranial base. The fracture is diagnosed using the MRI scanner and cerebrospinal fluid is noted dripping via the sphenoid sinus into the right nasal passage. The patient requires a surgical nasal

sinus endoscopy to assess and repair the injury.

What is the correct procedure and diagnosis coding combination to report this service?

A patient's left eye is damaged beyond repair due to a work injury. The provider fabricates a prosthesis from silicon materials and makes modifications to restore the patient's cosmetic appearance.

What CPT® code is reported?

A 26-year-old male presents with a deep laceration from a kitchen knife to his right hand. The surgeon washes the open wound with sterile saline. Clamps are applied. The provider cleans the

vessel and prepares the edges of thee wound. She then repairs the bleeding vessel with sutures. The clamps are removed and the provider uses a Doppler probe to check the blood flow pattern

through the repaired vessel.

What CPT® code is reported?

The CPT® code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.

What is the full description of CPT® code 44361?

Which statement is TRUE for an Excludes2 note that is under a code in the Tabular List for ICD-10-CM?

A patient with compression fractures of L5 and the sacrum undergoes vertebroplasty, with cement injected into two vertebral bodies, performed bilaterally.

What CPT® coding is reported?

The evisceration of ocular contents was performed using a surgical microscope for enhanced visualization. The procedure was performed on the left eye and an implant was not placed in the ocular cavity.

What CPT® coding is reported?

(In the ICD-10-CM code book, which instructional note given in the Tabular List indicates whentwo conditions cannot be reported together?)

View MR 001394

MR 001394

Operative Report

Procedure: Excision of 11 cm back lesion with rotation flap repair.

Preoperative Diagnosis: Basal cell carcinoma

Postoperative Diagnosis: Same

Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.

Location: Back

Size of Excision: 11 cm

Estimated Blood Loss: Minimal

Complications: None

Specimen: Sent to the lab in saline for frozen section margin control.

Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.

Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.

What CPT® coding is reported for this case?

(A patient arrives with pain due to a chest injury from blunt force. The provider takes X-ray imaging with6 views of the chest. What CPT® coding is reported?)

In medical terminology, suffixes indicate the procedure, condition, disorder, or disease.

Which term contains a suffix?

Refer to the supplemental information when answering this question:

View MR 000281

What anesthesia and diagnosis codes are reported for this case?

What does the prefix “sub-” signify in medical terminology?

Patient is admitted in observation care on 12/2/20XX in the morning for acute asthma exacerbation. The ED physician requires the patient to stay overnight. Next day, 12/3/20XX the patient is

discharged from observation care in the afternoon. Patient's total stay in observation was 16 hours.

What E/M categories and code ranges are appropriate to report?

A patient with end-stage renal disease (ESRD) receives hemodialysis 3x weekly in the office for one month. The nephrologist performs a comprehensive exam and supervises dialysis.

What CPT® and ICD-10-CM codes are reported?

A 4-year-old, critically ill child is admitted to the PICU from the ED with respiratory failure due to an exacerbation of asthma not manageable in the ER. The PICU provider takes over the care of the patient and starts continuous bronchodilator therapy and pharmacologic support with cardiovascular monitoring and possible mechanical ventilation support.

What is the E/M code for this encounter?

A 46-year-old female is admitted to the hospital by her urologist for a left ureteral calculus. The urologist visits her again on day two and performs a low for number and complexity of problems

addressed, minimal for amount and/or complexity of data to be reviewed and analyzed, and moderate for risk of complications.

What E/M service is reported for day two?

A patient is sent to the hospital by his family care provider for admission due to a high fever and neck pain The patient is admitted to the hospital to rule out bacterial meningitis. The hospitalist admits the patient and orders a CBC. CMR Blood culture, CT of the head and chest, and a lumbar puncture (spinal tap). After review of the results, he determines the patient has bacterial meningitis and starts the patient on IV antibiotics.

What CPT® and ICD-10-CM codes are reported for the admission?

(Which place of service code is submitted on the claim for a procedure that is performed in a patient’sprivate residence?)

911 is called by the physician for an ambulance with non-emergency basic life support to pick up a patient from his office that had fainted. The patient was taken to the hospital. What HCPCS

Level II coding is reported for the ambulance's service?

Which punctuation is used in the ICD-10-CM Alphabetic Index to identify manifestation codes?

A patient is diagnosed with sepsis due to enterococcus. What ICD-10-CM code is reported?

View MR 099405

MR 099405

CC: Shortness of breath

HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.

Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.

ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.

PMH: Asthma

SH: Lives with both parents.

FH: Family hx of asthma, paternal side

ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child’s family and no changes reported.

PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.

Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva

Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.

Lymph nodes: normal.

Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.

Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.

GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly

Skin: normal warm and dry. Pink well perfused

Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.

Assessment: Asthma, acute exacerbation

Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.

What E/M code is reported?

A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting

technique was used to repair the eardrum with ossicular chain reconstruction.

What CPT® code is reported for this surgery?

A patient undergoes a laparoscopic appendectomy for chronic appendicitis.

What CPT® and diagnosis codes are reported?

(The patient presents to the emergency department with chest pain. EKG showsNSTEMIand troponin is abnormal. The ED provider discusses the case with a cardiologist and the patient is admitted for heart catheterization/PCI. What is the E/M service and ICD-10-CM coding reported for the ED provider?)

(A 3-year-old is seen by his primary care physician for anannual exam. His last exam with the primary care physician wastwo years ago. He has no complaints. What CPT® code is reported?)

What is the HCPCS Level II code for a standard wheelchair?

A 52-year-old woman has been experiencing discomfort and itching In the vulvar area for several months. She has a history of abnormal Pap smears and a recent biopsy revealed vulvar intraepithelial neoplasia (VIN III). Decision has been made to perform a vulvectomy.

Procedure: Under general anesthesia, the surgeon made an incision in the vulvar area and removed the vulva (more than 80%), including the affected skin and deep subcutaneous tissue.

What CPT® and ICD-10-CM codes are reported?

A patient with severe diverticulitis in the sigmoid colon presents to surgery for a partial colectomy. The physician performs an exploratory laparoscopic laparotomy to verify the location of the diverticulitis. Once identified, it was noted that there was bleeding from the diverticulitis. The physician transects the descending colon and then transects at the line of the rectum.

The physician mobilizes the splenic flexure in order to create a colostomy with the proximal portion of the remaining colon. The distal portion of the colon is closed. The physician washes the patient's abdomen with saline, removes all trocars and instruments, and then closes the abdomen with sutures.

What CPT® and ICD-10-CM codes are reported?

A diagnostic mammogram is performed on the left and right breasts. Computer-aided detection is also used to further analyze the image for possible lesions.

What CPT® coding is reported for this radiology service?

(Full Case:Preoperative diagnosis:Recurrent dysphagia.Postoperative diagnosis:Hiatal hernia with obstruction.Procedure:EGD with dilation.Consent:PAR conference; informed consent signed; premedication given.Position/monitoring:left lateral decubitus; monitored with BP cuff and pulse oximeter throughout.Topical:Hurricaine spray to posterior pharynx.Scope passage:flexible endoscope passed under direct visualization through cricopharyngeus into esophagus; advanced with identification of EG junction into stomach; rugal folds visualized; advanced to antrum/pylorus; pylorus cannulated; duodenal bulb and second portion visualized; retroflexed views of cardia/fundus/lesser curvature.Dilation technique:guidewire placed in antrum; scope removed; wire positioned by markings;#14 French dilatorpassed into stomach area;esophageal dilation performed over guidewire.Findings:tortuous/shortened esophagus; large sliding hiatal hernia; EG junction ~30 cm; stomach abnormal with very large sliding hiatal hernia; duodenum normal.Question:What CPT® coding is reported?)

(A driver crashes into a guardrail and sustains a fracture of the anterior fossa cranial base with involvement of thesphenoid sinus, withno CSF leak. The patient undergoessurgical nasal sinus endoscopy with sphenoidotomyto evaluate and treat the sinus injury. No CSF leak repair is performed. What is the correct procedure and diagnosis coding combination to report this service?)

A 78-year-old patient experiencing intermittent asthma with exacerbation is in her pulmonologist's office for a pulmonary function test. The pulmonologist tests for spirometry, vital capacity,

breathing capacity, and flow volume capturing the measurements before and after administering a bronchodilator.

What CPT® and ICD-10-CM codes are reported?

A patient is going to have placement of a myringotomy tube. This tube is placed in the ______ to drain excess fluid.

A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.

What CPT® coding is reported?

A patient presents for planned sterilization via bilateral excisional vasectomy.

What CPT® and ICD-10-CM codes are reported?

An 8-day-old newborn (3 kg) undergoes circumcision using a scalpel (no clamp).

What CPT® coding is reported?

(What is the medical term for the study of the kidney?)

A male patient passes out while jogging in the park. Upon examination at the hospital, he is found to have a wide complex tachycardia and undergoes an electrophysiologic study and radiofrequency ablation. For this procedure he is placed under general anesthesia.

What is the anesthesia coding for this otherwise healthy 35-year-old?

A patient is taken to the radiology department for a radiological cardiac catheterization. An acute MI of the left anterior descending coronary artery is found. The cardiologist performs a suction thrombectomy, followed by atherectomy and a stent to the artery. A CRNA provides MAC for this patient, who is status P5.

What code/modifier combination would you report for the services of the CRNA?

A 45-year-old patient presents with right shoulder pain. The provider administers three trigger point injections in the trapezius muscle and two in the pectoralis muscle.

What CPT® coding is reported?

(What CPT® coding is reported for the insertion ofHeyman capsulesfor clinical brachytherapy?)

Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.

What diagnosis coding is reported for the second colonoscopy?

An 8-year-old undergoes tonsillectomy with adenoidectomy for chronic tonsillitis and adenoiditis with hypertrophy.

What CPT® and ICD-10-CM codes are reported?

A surgeon performs midface LeFort I reconstruction on a patient’s facial bones to correct a congenital deformity. The reconstruction is performed in two pieces in moving the upper jawbone forward and repositioning the teeth of the maxilla of the mid face.

What CPT® code is reported?

(A pathologist performs an analysis usingfluorescent microscopyto evaluate a specimen for inherited or acquiredchromosomal abnormalities. No specific CPT® code accurately describes this service. Which unlisted CPT® code is reported?)

A patient presents to the ER from a nursing home after the patient was found to have foul smelling, large sacral pressure ulcer during daily nursing rounds. The ER provider swabbed the wound

for culture (which measured at 7cm in largest diameter); then cleaned the site before painting with povidone around the entire sacrum to reduce cutaneous bacterial load. The provider made an

elliptical excision with 3mm margins around the outer edge of the ulcer and removed the lesion in its entirety. Further examination revealed deep tissue damage, prompting muscle and

segmental bone removal. The wound was then closed using a layered skin flap closure.

What CPT® coding and ICD-10-CM coding is reported?

(Which of the following is classified ascoronary arteries?)

A surgeon performed Mohs micrographic surgery on a lesion on the right arm. This required one stage with six tissue blocks.

What CPT@ codes are reported for the Mohs surgery?

(A provider orders a liquid chromatography mass spectrometry (LC-MS) definitive drug test for a patient suspected ofacetaminophen (analgesic) overdose. What CPT® code is reported for the test?)

Refer to the supplemental information when answering this question:

View MR 065174

What E/M code is reported for this encounter?

A patient has a 5 cm tumor in the left lower quadrant abdominal wall, excised through dermis and subcutaneous tissue. Pathology is pending to rule out cancer.

What CPT® and ICD-10-CM codes are reported?

Provider performs staged procedures for gender reassignment surgery converting female anatomy to male anatomy.

What CPT® code is reported?

Which is a malignant neoplasm originating in the skin?

A flexible sigmoidoscopy is performed with ablation of two sigmoid colon polyps.

What CPT® and ICD-10-CM codes are reported?

(A patient presents to the OR for removal of asubcutaneous cardiac rhythm monitor system14 months after the device was implanted. What is the CPT® code for this service?)

A business requires drug testing for cocaine and methamphetamines prior to hiring a job candidate. A single analysis with direct optical observation is performed, followed by a confirmation for cocaine.

Which codes are used for reporting the testing and confirmation?

A woman with vulvar intraepithelial neoplasia (VIN II) undergoes a partial vulvectomy (<80%) with removal of skin and deep subcutaneous tissue.

What CPT® and ICD-10-CM codes are reported?

(A 78-year-old patient withintermittent asthma with exacerbationis in her pulmonologist’s office for pulmonary function testing. The pulmonologist performs spirometry with flow volume loops, measuring before and after administering a bronchodilator. What CPT® and ICD-10-CM codes are reported?)

A retinal specialist diagnoses type 2 diabetic mild nonproliferative retinopathy with macular edema, bilateral. Diabetes is secondary to Cushing’s syndrome and controlled with oral hypoglycemics. What ICD-10-CM codes are reported?

The human shoulder is made of which three bones?

(Which one of the following is an anesthesiaphysical status modifier?)

A couple presents to the freestanding fertility clinic to start in vitro fertilization. Under radiologic guidance, an aspiration needle is inserted (by aid of a superimposed guiding-line) puncturing the ovary and preovulatory follicle and withdrawing fluid from the follicle containing the egg.

What is the correct CPT® code for this procedure?

A patient with coronary artery disease due to lipid-rich plaque undergoes coronary artery bypass grafting. The surgeon performs a left internal mammary artery graft to the left anterior descending artery. Then performs saphenous vein grafts to the obtuse marginal artery, ramus intermedius, and posterior descending artery. An endoscopic saphenous vein harvest is performed.

What CPT® coding is reported for the surgical procedure?

Which place of service code is submitted on the claim for a service that is performed in a skilled nursing facility?

(A patient visits her provider’s office because she is experiencing persistent headaches. Her provider sends her to a radiology facility to do aCT scan of the brain without contrast. The images are sent to the provider, and the providerreads and interpretsthe scan. What CPT® coding of the radiology service is reported by the provider?)

Mrs. Wilder presents with right and left leg swelling. Venous thrombosis imaging of each leg is done and shows deep venous embolism and thrombosis in each leg.

What CPT® and ICD-10-CM codes are reported?

View MR 099401

MR 099401

Established Patient Office Visit

Chief Complaint: Patient presents with bilateral thyroid nodules.

History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can “feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.

Review of Systems:

Constitutional: Negative for chills, fever, and unexpected weight change.

HENT: Negative for hearing loss, trouble swallowing and voice change.

Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting

Endocrine: Negative for cold Intolerance and heat intolerance.

Physical Exam:

Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97%

Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65”)

General Appearance: Alert, cooperative, in no acute distress

Head: Normocephalic, without obvious abnormality, atraumatic

Throat: No oral lesions, no thrush, oral mucosa moist

Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD

Lungs: Clear to auscultation, respirations regular, even, and unlabored

Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click

Lymph nodes: No palpable adenopathy

ASSESSMENT/PLAN:

1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).

What E/M code is reported for this encounter?

(A 6-month-old child was brought to the hospital with severe breathing difficulties. After testing, the child was diagnosed withtracheal stenosis present from birth. The pediatric surgeon performed atracheoplasty(surgical widening of the trachea). What CPT® and ICD-10-CM codes are reported?)

A 32-year-old is in the outpatient clinic for an esophagoscopy due to increased difficulty swallowing with his eosinophilic esophagitis. The flexible scope is inserted in the mouth and into the

esophagus. Examination of the esophagus noted narrowing in the distal esophagus. Following an injection of Kenalog, a transendoscopic balloon dilation was performed in the area of

stenosis. Inflation was repeated eventually reaching 18 mm in diameter. What CPT® coding is reported for this procedure?

(A physician performsexcisional debridementfor a patient with multiple wounds. A wound on thelower backmeasures12 cmand involves thefasciafor the debridement. A wound on theleft shouldermeasures8 cmand one on theleft lower legmeasures16 cminvolvessubcutaneous tissuefor the debridement. What CPT® codes are reported?)

A patient presents with recurrent spontaneous episodes of dizziness of unclear etiology. Caloric vestibular testing is performed irrigating both ears with warm and cold water while evaluating the patient’s eye movements. There is a total of three irrigations.

What CPT® coding is reported?

(A 60-year-old man presents for examination of the entire rectum andsigmoid colon. Two polyps are found in the sigmoid colon and removed usingablation. What CPT® and ICD-10-CM codes are reported?)

What CPT® coding is reported for a subtotal thyroidectomy for malignancy with radical neck dissection?

A 58-year-old male suffered an acute STEMI of the inferolateral wall while running a marathon on June 15 and had received treatment. Three weeks later, the patient presents to the ED complaining of SOB and left arm pain. An EKG is performed as well as blood tests. Patient is admitted for further evaluation.

What diagnosis code is reported for this encounter?

A 62-year-old with ventricular fibrillation comes to the outpatient surgery department for the replacement of a pacing cardioverter-defibrillator. The procedure is performed under MAC

anesthesia. The Certified Registered Nurse Anesthetist (CRNA), is working independently without medical direction.

What CPT® and ICD-10-CM codes are reported for the CRNA?

(Full Case:Established patient office visit.CC:Bilateral thyroid nodules.HPI:54-year-old evaluated for bilateral thyroid nodules; thyroid ultrasound last week showed multiple thyroid masses likely multinodular goiter; patient can “feel” left-sided nodules; denies dysphagia; denies unexplained weight loss/gain; family history thyroid cancer (maternal grandmother); otherwise no problems except palpable right-sided thyroid mass.ROS:Constitutional negative (chills/fever/weight change). ENT negative (hearing loss/trouble swallowing/voice change). GI negative (distention/pain/bleeding/bowel changes/N/V). Endocrine negative (cold/heat intolerance).PE:Vitals BP 140/72, P 96, R 16, T 97.6, SpO2 97%, wt 89.8 kg, ht 165.1 cm. General alert/cooperative/no distress. Head normocephalic. Throat moist/no lesions/no thrush. Neck: no adenopathy, supple, trachea midline,thyromegaly present, no carotid bruit, no JVD. Lungs clear. Heart regular rhythm/rate, normal S1/S2, no murmur/gallop/rub/click. Lymph nodes no palpable adenopathy.Assessment/Plan:Multinodular goiter; patient will have apercutaneous biopsy (minor procedure).Question:What E/M code is reported?)

A 63-year-old is seen by his. primary care physician for an annual exam. His last exam with the primary care physician was four years ago. He has no complaints.

What CPT code is reported?

The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.

What CPT® code is reported?

(A patient presents for an outpatient physical therapy evaluation due to chronic low back pain. The medical record documents that the patient has a current diagnosis oflumbar spine region cancer, which isactively being treatedat the time of therapy. Which lumbar spine associated conditionM codeis reported?)

A physician performs excisional debridement on multiple wounds:

Lower back: 12 cm, involving fascia

Left shoulder: 8 cm, involving subcutaneous tissue

Left lower leg: 16 cm, involving subcutaneous tissue

What CPT® codes are reported?

Refer to the supplemental information when answering this question:

View MR 354859

What CPT® and ICD-10-CM coding is reported?

A cardiologist attempted to perform a percutaneous transluminal coronary angioplasty of a totally occluded blood vessel. The surgeon stopped the procedure because of an anatomical problem creating risk for the patient and preventing performance of the catheterization.

What modifier is appended to the procedure code?

An autopsy is ordered for a deceased patient of unknown cause. The pathologist performs gross and microscopic examination, including the brain and spinal cord.

What CPT® coding is reported?

A patient has five biopsies performed on the duodenum.

What CPT® coding is reported?

A patient is having X-ray imaging of his abdomen following a traumatic episode. A decubitus, supine, and erect views are performed on the abdomen.

What CPT® is reported?

A patient who was training for a marathon collapsed due to heat exhaustion on a very hot day. The patient is driven by his wife to a non-facility urgent care center for him to be treated. On

examination, the physician diagnoses heat exhaustion and dehydration. The physician began IV therapy of normal saline that consists of pre-packaged fluid and electrolytes. The hydration lasts

for 1 and 30 minutes.

What CPT® coding is reported?

(A provider states that all of their office visits should be reported asmoderate levelsbecause they treat patients with high-complexity problems. Would this be considered a compliance problem?)

Which is a TRUE statement for Place of Service (POS) codes for professional claims?

(A 32-year-old is in the outpatient clinic for anesophagoscopydue to increased difficulty swallowing with hiseosinophilic esophagitis. The flexible scope is inserted into the esophagus. Examination notes narrowing in the distal esophagus. Following an injection of Kenalog, atransendoscopic balloon dilationis performed in the area of stenosis, eventually reaching 18 mm. What CPT® coding is reported for this procedure?)

A 55-year-old patient with suspected liver cancer was seen by the physician to obtain a biopsy. The special biopsy needle was placed using ultrasonic guidance. The physician obtained a small tissue sample from the liver, which was then sent to pathology.

What CPT® codes are reported?

An established patient presents with fever and sore throat. Rapid strep test is positive.

What CPT® and ICD-10-CM codes are reported?

A 19-year-old is seen by his, primary care physician for an annual exam. His last exam with the primary care physician was four years ago. He has no complaints.

What CPT code is reported?

A witness of a traffic accident called 911. An ambulance with emergency basic life support arrived at the scene of the accident. The injured party was stabilized and taken to the hospital. What HCPCS Level II coding is reported for the ambulance's service?

View MR 003396

MR 003396

Operative Report

Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease

Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease

Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery

Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.

What CPT® coding is reported for this case?

(Regarding the CPT® Surgery Guidelines for a surgical code designated as a“Separate Procedure,”which statement isFALSE?)

(A patient presents for evaluation of suspicious skin lesions. During the encounter, the provider performs:

• Incisional biopsy of adeep inflammatory lesionon the upper arm

• Punch biopsy of aseparate lesionon the forearm

• Shave biopsy of asuperficial lesionon the shoulder

Each biopsy is performed on a separate lesion for diagnostic purposes, and all specimens are submitted to pathology. What CPT® coding is reported?)

A 74-year-old arrived at the ED experiencing bright red rectal bleeding when using the toilet. She does not have any abdominal pain, no nausea or vomiting. She has been undergoing dialysis for

years due to end-stage renal failure and has a diagnosis of myelodysplastic syndrome with a platelet count of just 3,000. Her hemoglobin level, which was 10 at her dialysis session the

previous day, dropped to 7. Abdominal films are negative. An urgent esophagogastroduodenoscopy (EGD) was performed, and no active bleeding was found in the esophagus or the stomach.

However, the scope was passed into the upper duodenum which did reveal some oozing, and was controlled with cautery. Next, the patient was then positioned on her left side for a

colonoscopy that extended from the colon to the ileum and into the lower duodenum, but no definitive sources of bleeding were found. Again, no outright bleeding sources were identified. A

CRNA performed the anesthesia and documented PS III.

What CPT® codes are reported for the CRNA?

(A three-year-old patient returns forstage 2treatment for double right outlet syndrome. The surgeon removes apulmonary artery bandand performstransposition repair of the great vesselsvia aortic pulmonary reconstruction. Central cannulae are inserted forECMO bypass, chemical cardioplegia is initiated, and a physician assistant monitors vitals and oxygenation until heart function resumes. What CPT® codes are reported for the surgery today?)

The CPT® code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.

What is the full description of CPT® code 69644?

A patient who has colon adenocarcinoma undergoes a laparoscopic partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and remaining colon.

What procedure and diagnosis codes are reported?

View MR 002395

MR 002395

Operative Report

Pre-operative Diagnosis: Acute rotator cuff tear

Post-operative Diagnosis: Acute rotator cuff tear, synovitis

Procedures:

1) Rotator cuff repair

2) Biceps Tenodesis

3) Claviculectomy

4) Coracoacromial ligament release

Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.

Findings: Complete tear of the right rotator cuff, synovitis, impingement.

Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the

supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.

What CPT® coding is reported for this case?

(A patient is in her otolaryngologist’s office to receive therapeutic treatment forasthmatic bronchitis with status asthmaticus. A subcutaneous injection ofomalizumab (150 mg)is given in her left upper arm. What is the CPT® and ICD-10-CM coding?)

Ten-year-old boy has a painful felon abscess of the deep tissues of the palmar surface of his right thumb. The provider makes an incision on one side of the nail and then across the fingertip parallel to the end of the nail. He identifies the area of abscess and drains it. A drainage tube is inserted.

What CPT® and ICD-10-CM is reported?

A 47-year-old male recently injured as a passenger in a car accident sustained multiple fractures. The patient now has physical restraints due to pulling out foley catheter, IV catheters and

attempted to pull out NG tube. Emergency department physician is asked to come see patient and injects 0.5 lidocaine into lumbar region of the spine. An indwelling catheter is placed into the

lumbar region for continuous infusion with fluoroscopy for pain management.

What CPT® is reported for the Emergency department physician?

A physician orders an obstetric panel that includes syphilis screening using the non-treponemal antibody approach, an automated CBC with manual differential WBC count, HBsAg, rubella antibody, a serum antibody screen, and ABO and Rh blood typing.

What CPT® coding is reported?

Which one of the following activities, when performed, is NOT considered when selecting an E/M service level based on time?