Chapter 13, Medical Coding, Exam
100% Correct!!
What is a root word for vagina? - ANSWER Colp/o
What ICD-10-CM code is reported for an incomplete uterine prolapse? - ANSWER N81.2
Response Feedback:Rationale: In the ICD-10-CM Alphabetic Index look for
Prolapse/uterus/incomplete directing you to code N81.2. Looking in the Tabular List confirms this
code selection.
Patient with genital warts has cryotherapy of an extensive number of lesions on her mons pubis,
labia and perineum. How is this procedure coded - ANSWER 56515
Response Feedback:Rationale: The mons pubis and labia are part of the vulva. In the CPT® Index look
for Destruction/Lesion/Vulva/Extensive and you are referred to 56515. The extensive code is
reported due to the extensive number of lesions. Verify the code in the numeric section.
Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled for amniocentesis to aspirate
some of the excessive fluid from the amniotic sac. The amniocentesis is performed under ultrasound
guidance. What is/are the code(s) for the procedure performed? - ANSWER 59001
Response Feedback:Rationale: In the CPT® Index look for Amniocentesis/Therapeutic/Amniotic Fluid
Reduction directing you to code 59001. Read the parentheses in the code descriptor; this code
includes the ultrasound guidance. The ultrasound guidance is not separately reported. 59000 is for
diagnostic amniocentesis.
A 40-year-old presents with vaginal bleeding for several weeks. The gynecologist orders an
ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this
encounter? - ANSWER N93.9
Response Feedback:Rationale: There is no indication that the vaginal bleeding is associated with her
menstrual cycle and there is no indication of menopause. Look in the ICD-10-CM Alphabetic Index for
Bleeding/vagina, vaginal (abnormal) directing you to N93.9.
What modifier is appropriate for a separately billable antenatal service during the global OB package
period? - ANSWER No modifier is needed
Response Feedback:Rationale: An antenatal service is performed before the baby is delivered.
According to the notes in the Maternity Care and Delivery subsection in the CPT® codebook
"Antepartum care includes the initial prenatal history and physical examinations; recording of weight,
, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks
gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery."
An ED physician treats a 30-year-old patient who was a victim of a rape. She has bruises and other
trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by
the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure? - ANSWER .
57200, S31.41XA, T74.21XA
Response Feedback:Rationale: Suturing of the vaginal wall is a colporrhaphy. In the CPT® Index, look
for Colporrhaphy/Nonobstetrical and you are referring to 57200. Verify in the numeric section.The
diagnosis is laceration of the vagina (S31.41XA) and rape (T74.21XA). In the ICD-10-CM Alphabetic
Index look for Laceration/vagina and Rape/adult/confirmed. You can also look in the ICD-10-CM
External Cause of Injuries Index for Rape. Both codes are seven characters. Placeholder X is used for
the 6th character and A is for the 7th character to indicate initial encounter.
What does the abbreviation IVF mean? - ANSWER In vitro fertilization
Response Feedback:Rationale: In the CPT® Index, look for IVF and you are directed to See Artificial
Insemination; In Vitro Fertilization. IVF stands for in vitro fertilization.
What procedure is performed to treat vaginal prolapse? - ANSWER Colpopexy
Response Feedback:Rationale: Vaginal prolapse occurs when the vaginal wall is stretched out and
there is no support in the pelvic structure and the pelvic organs fall downward protruding through
the vaginal canal. To correct this disorder, a suturing of the prolapsed vagina to its surrounding
structures is performed.All the choices have the prefix colpo- which means vagina. The suffix -pexy
means surgical fixation. The suffix -scopy means examination of. The suffix -ectomy means removal
of. The suffix -otomy is to make an incision or cut into. The correct answer is colpopexy.
Procedures involving which of the following structures found in the vulva are NOT coded in the
female reproductive system section of CPT® - ANSWER Skene's gland
Response Feedback:Rationale: Procedures on the Skene's glands are coded in the urinary system
If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a
breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the
E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded? -
ANSWER G0101
Response Feedback:Rationales: Medicare Part B requires that for pelvic examination (including
clinical breast examination), use HCPCS Level II code G0101 when ordered by a physician. This
information can be found on the CMS website at this link:
http://www.cms.gov/manuals/downloads/Pub06_PART_50.pdf, under the CHAPTER II - COVERAGE
100% Correct!!
What is a root word for vagina? - ANSWER Colp/o
What ICD-10-CM code is reported for an incomplete uterine prolapse? - ANSWER N81.2
Response Feedback:Rationale: In the ICD-10-CM Alphabetic Index look for
Prolapse/uterus/incomplete directing you to code N81.2. Looking in the Tabular List confirms this
code selection.
Patient with genital warts has cryotherapy of an extensive number of lesions on her mons pubis,
labia and perineum. How is this procedure coded - ANSWER 56515
Response Feedback:Rationale: The mons pubis and labia are part of the vulva. In the CPT® Index look
for Destruction/Lesion/Vulva/Extensive and you are referred to 56515. The extensive code is
reported due to the extensive number of lesions. Verify the code in the numeric section.
Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled for amniocentesis to aspirate
some of the excessive fluid from the amniotic sac. The amniocentesis is performed under ultrasound
guidance. What is/are the code(s) for the procedure performed? - ANSWER 59001
Response Feedback:Rationale: In the CPT® Index look for Amniocentesis/Therapeutic/Amniotic Fluid
Reduction directing you to code 59001. Read the parentheses in the code descriptor; this code
includes the ultrasound guidance. The ultrasound guidance is not separately reported. 59000 is for
diagnostic amniocentesis.
A 40-year-old presents with vaginal bleeding for several weeks. The gynecologist orders an
ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this
encounter? - ANSWER N93.9
Response Feedback:Rationale: There is no indication that the vaginal bleeding is associated with her
menstrual cycle and there is no indication of menopause. Look in the ICD-10-CM Alphabetic Index for
Bleeding/vagina, vaginal (abnormal) directing you to N93.9.
What modifier is appropriate for a separately billable antenatal service during the global OB package
period? - ANSWER No modifier is needed
Response Feedback:Rationale: An antenatal service is performed before the baby is delivered.
According to the notes in the Maternity Care and Delivery subsection in the CPT® codebook
"Antepartum care includes the initial prenatal history and physical examinations; recording of weight,
, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks
gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery."
An ED physician treats a 30-year-old patient who was a victim of a rape. She has bruises and other
trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by
the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure? - ANSWER .
57200, S31.41XA, T74.21XA
Response Feedback:Rationale: Suturing of the vaginal wall is a colporrhaphy. In the CPT® Index, look
for Colporrhaphy/Nonobstetrical and you are referring to 57200. Verify in the numeric section.The
diagnosis is laceration of the vagina (S31.41XA) and rape (T74.21XA). In the ICD-10-CM Alphabetic
Index look for Laceration/vagina and Rape/adult/confirmed. You can also look in the ICD-10-CM
External Cause of Injuries Index for Rape. Both codes are seven characters. Placeholder X is used for
the 6th character and A is for the 7th character to indicate initial encounter.
What does the abbreviation IVF mean? - ANSWER In vitro fertilization
Response Feedback:Rationale: In the CPT® Index, look for IVF and you are directed to See Artificial
Insemination; In Vitro Fertilization. IVF stands for in vitro fertilization.
What procedure is performed to treat vaginal prolapse? - ANSWER Colpopexy
Response Feedback:Rationale: Vaginal prolapse occurs when the vaginal wall is stretched out and
there is no support in the pelvic structure and the pelvic organs fall downward protruding through
the vaginal canal. To correct this disorder, a suturing of the prolapsed vagina to its surrounding
structures is performed.All the choices have the prefix colpo- which means vagina. The suffix -pexy
means surgical fixation. The suffix -scopy means examination of. The suffix -ectomy means removal
of. The suffix -otomy is to make an incision or cut into. The correct answer is colpopexy.
Procedures involving which of the following structures found in the vulva are NOT coded in the
female reproductive system section of CPT® - ANSWER Skene's gland
Response Feedback:Rationale: Procedures on the Skene's glands are coded in the urinary system
If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a
breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the
E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded? -
ANSWER G0101
Response Feedback:Rationales: Medicare Part B requires that for pelvic examination (including
clinical breast examination), use HCPCS Level II code G0101 when ordered by a physician. This
information can be found on the CMS website at this link:
http://www.cms.gov/manuals/downloads/Pub06_PART_50.pdf, under the CHAPTER II - COVERAGE
