Medical Coding and Billing Final Exam
A 14-year-old male patient was brought into the emergency room by his parents after he
injured his left knee from sliding into third base during a high school baseball game. X-
rays revealed a sprained anterior cruciate ligament. - ANSWER-S83.512A, W21.89XA,
Y92.320, Y93.64, Y99.8
A 17-year-old male patient was taken to the emergency room because of third degree
burns to his chest wall and abdomen. He also has third degree burns to both upper
arms and forearms. The patient fell into a bonfire - ANSWER-T21.31XA, T21.32XA,
T22.312A, T22.332A, T22.311A, T22.331A, X03.0XXA
A 2-year-old boy was born with a cleft lip and nasal deformity. He was admitted to the
hospital and taken to the operating room. Dr. Mark Sloan performed a primary complete
plastic repair of the cleft lip and nasal deformity, unilateral. - ANSWER-40700
A 29-year-old patient is referred for placement of a tunneled central venous catheter
with subcutaneous port. To facilitate the advancement of the catheter and ensure
accurate placement fluoroscopy is used. - ANSWER-36561, 77001
A 32-year-old female patient was brought to the emergency department by her husband
for difficulty walking. They had been at a party at a friend's house where the wife had
taken Valium as prescribed by her physician and consumed three martinis. The patient
was examined and monitored for 12 hours and then discharged. The final diagnosis was
documented as: Overdose secondary to abuse of Valium and alcohol with resulting
ataxia. - ANSWER-T42.4X1A, T51.0X1A, R27.0, F10.10, F13.10, Y92.019
A 33-year-old female patient comes into the office today with complaints of chronic
coughing and wheezing. The physician sends her to the hospital for chest x-rays. The
final diagnosis for the office visit is coughing/wheezing, rule out mild persistent asthma.
- ANSWER-R05, R06.2
A 36-year-old male patient came into the orthopedic surgeons' office 3 days after being
in the emergency room. He had fallen off the ladder at home and hurt his ankle. This is
the patient's initial visit. The physician performs a detailed history, an expanded problem
focused exam; medical decision making is low complexity. The physician performs and
interprets a left ankle x-ray 2 views. The physician interprets the x-ray that the patient
has a closed bimalleolar fracture on the left ankle. He treated this closed fracture
bimalleolar fracture without manipulation by applying the initial cast while the patient is
in the office. - ANSWER-99202-25, 27808-LT, 73600-LT
A 38-year-old female patient was admitted to Harper Hospital on 2/19/xxxx with a
diagnosis of a herniated disk C6-7. She is being taken to the operating room for a C6-7
hemilaminectomy. Specifically, a laminotomy (hemilaminectomy) was performed with
decompression of nerve roots and excision of herniated intervertebral disk, one
,interspace, cervical. An arthrodesis was also performed, single level cervical below C2
segment. - ANSWER-63020, 22600
A 42-year-old female new patient went to see Dr. Shepherd for her migraine
headaches. Dr. Shepherd took a comprehensive history. The patient explained she is
now getting auras with her headaches and sometimes she even has passes out. She
informed the physician her sister suffers from migraines, as did her mother; however,
the mother passed away from a ruptured aneurysm. The patient is concerned about this
because she is nearing the age that her mother passed away. Dr. Shepherd performed
a detailed exam. When listening to the carotid bruits there was a high pitch thrill. The
abdominal aorta bruit was normal. The medical decision process was of high
complexity. The patient was currently having an intractable migraine with aura. She has
been taking her Topamax, took an Imitrix at 5 am, and a Fiorcet at 5 am with no relief.
The physician explained he was ordering an MRA of the brain and an ultrasound of the
carotids be t - ANSWER-99203-25, 96372x2, J1885x4, J3030
A 44-year-old male patient underwent a colon resection for adenocarcinoma one and
one-half years ago. Following the left colon surgery, he received systemic
chemotherapy. After six months of treatment, the patient's carcinoembryogenic antigen
(CEA) began to rise. CT imaging of the liver revealed three lesions along the anterior
and inferior surfaces of the right lobe of the liver. All three lesions were confirmed on
ultrasound examination and were felt to be superficial and accessible by laparoscopy.
The lesions measure 4 cm, 2.0 cm and 2.5 cm in diameter. The physician performed a
laparoscopy surgical ablation, cryosurgery technique using ultrasonic guidance
(supervision and interpretation). All three lesions were ablated by cryosurgery. -
ANSWER-47371, 76940-26
A 45-year-old male patient was admitted to the hospital for an excision of a parotid
tumor or gland or both. The patient was taken to the operating room and was put under
general anesthesia. Dr. Derek Shepherd opened the area and exposed the parotid
gland. Due to the size of the tumor (5.0 cm), the decision was made to remove the
entire gland. With careful dissection and preservation of the facial nerve, the parotid
gland was removed. Patient was taken to the recovery room in good condition. -
ANSWER-42420
A 46-year-old female patient was admitted to the hospital. She was taken to the
operating room to have a percutaneous transluminal angioplasty due to insufficient
hemodialysis based on segmental stenosis of the fistula/cephalic vein. The
percutaneous transluminal angioplasty involved navigating through the radial artery into
the cephalic vein to accomplish repair and a dialysis fistula angiography. - ANSWER-
36902
A 48-year-old female patient was admitted for hemodialysis for acute renal failure. The
patient also has stage I chronic renal failure and hypertension. - ANSWER-N17.9, I12.9,
N18.1
, A 51-year-old male patient comes in for his chemotherapy treatment. The
chemotherapy is injected into the pleural cavity with thoracentesis. - ANSWER-96440
A 55-year-male patient went to the ambulatory surgery center for his colonoscopy. The
physician anesthetized the patient with Versed, inserted the endoscope, and inspected
the descending colon. However, he could not finish the procedure because the patient
went into respiratory distress. The patient was stabilized and the procedure was
discontinued. What modifier would be applied to the colonoscopy code to indicate that
less than the code definition was performed? - ANSWER-74
A 67-year-old male patient went to his physician's office for a visit for his chronic,
systolic CHF and hypertension. After examination, the physician determined the
patient's condition is stable and will keep his current medication regimen the same. -
ANSWER-I11.0, I50.22
A 68-year-old male patient is seen in the Radiation Oncology Department at the hospital
for secondary prostate cancer. The primary site was the lower lobe of the lung. The
oncologist, who is an employee of the hospital, performs complex clinical treatment
planning, basic dosimetry calculation, and a complex isodose plan; treatment devices
include blocks, special shields and wedges. The patient had 5 days of radiation
treatments for 2 weeks, a total of 10 days of treatment. Report the physician service. -
ANSWER-77263, 77307, 77334, 77427x2
A 68-year-old male patient went to the ASC for a colonoscopy. The physician
administered the patient with Versed, inserted the endoscope, and inspected the
descending colon. The procedure could not be finished because the patient went into
respiratory distress. The patient was stabilized and the procedure was discontinued.
What modifier would be appended to the colonoscopy code to indicate that the
procedure was discontinued? - ANSWER-74
A 7-year-old child was seen in the emergency room for a dog bite on her left thigh. She
received an injection of rabies immunoglobulin since the dog was known to have rabies.
- ANSWER-S71.152A, Z20.3, W54.0XXA
A chief complaint is a concise statement describing the symptom, problem, condition,
diagnosis or other factor that is the reason for encounter. - ANSWER-true
A patient presents with abdominal pain. After a complete work-up the patient is found to
have an obstructive diaphragmatic hernia with gangrene - ANSWER-K44.1
A patient with stress incontinence requires repair for cystocele and incomplete vaginal
prolapse. The physician elects to perform a paravaginal defect repair. An abdominal
incision is made and entry into the space of Retzius gland. Six sutures are placed
through the anterior lateral edge of the vaginal wall and then through the fascia
condensation over the obturator internus muscle to the inferior aspect of the pubic bone
A 14-year-old male patient was brought into the emergency room by his parents after he
injured his left knee from sliding into third base during a high school baseball game. X-
rays revealed a sprained anterior cruciate ligament. - ANSWER-S83.512A, W21.89XA,
Y92.320, Y93.64, Y99.8
A 17-year-old male patient was taken to the emergency room because of third degree
burns to his chest wall and abdomen. He also has third degree burns to both upper
arms and forearms. The patient fell into a bonfire - ANSWER-T21.31XA, T21.32XA,
T22.312A, T22.332A, T22.311A, T22.331A, X03.0XXA
A 2-year-old boy was born with a cleft lip and nasal deformity. He was admitted to the
hospital and taken to the operating room. Dr. Mark Sloan performed a primary complete
plastic repair of the cleft lip and nasal deformity, unilateral. - ANSWER-40700
A 29-year-old patient is referred for placement of a tunneled central venous catheter
with subcutaneous port. To facilitate the advancement of the catheter and ensure
accurate placement fluoroscopy is used. - ANSWER-36561, 77001
A 32-year-old female patient was brought to the emergency department by her husband
for difficulty walking. They had been at a party at a friend's house where the wife had
taken Valium as prescribed by her physician and consumed three martinis. The patient
was examined and monitored for 12 hours and then discharged. The final diagnosis was
documented as: Overdose secondary to abuse of Valium and alcohol with resulting
ataxia. - ANSWER-T42.4X1A, T51.0X1A, R27.0, F10.10, F13.10, Y92.019
A 33-year-old female patient comes into the office today with complaints of chronic
coughing and wheezing. The physician sends her to the hospital for chest x-rays. The
final diagnosis for the office visit is coughing/wheezing, rule out mild persistent asthma.
- ANSWER-R05, R06.2
A 36-year-old male patient came into the orthopedic surgeons' office 3 days after being
in the emergency room. He had fallen off the ladder at home and hurt his ankle. This is
the patient's initial visit. The physician performs a detailed history, an expanded problem
focused exam; medical decision making is low complexity. The physician performs and
interprets a left ankle x-ray 2 views. The physician interprets the x-ray that the patient
has a closed bimalleolar fracture on the left ankle. He treated this closed fracture
bimalleolar fracture without manipulation by applying the initial cast while the patient is
in the office. - ANSWER-99202-25, 27808-LT, 73600-LT
A 38-year-old female patient was admitted to Harper Hospital on 2/19/xxxx with a
diagnosis of a herniated disk C6-7. She is being taken to the operating room for a C6-7
hemilaminectomy. Specifically, a laminotomy (hemilaminectomy) was performed with
decompression of nerve roots and excision of herniated intervertebral disk, one
,interspace, cervical. An arthrodesis was also performed, single level cervical below C2
segment. - ANSWER-63020, 22600
A 42-year-old female new patient went to see Dr. Shepherd for her migraine
headaches. Dr. Shepherd took a comprehensive history. The patient explained she is
now getting auras with her headaches and sometimes she even has passes out. She
informed the physician her sister suffers from migraines, as did her mother; however,
the mother passed away from a ruptured aneurysm. The patient is concerned about this
because she is nearing the age that her mother passed away. Dr. Shepherd performed
a detailed exam. When listening to the carotid bruits there was a high pitch thrill. The
abdominal aorta bruit was normal. The medical decision process was of high
complexity. The patient was currently having an intractable migraine with aura. She has
been taking her Topamax, took an Imitrix at 5 am, and a Fiorcet at 5 am with no relief.
The physician explained he was ordering an MRA of the brain and an ultrasound of the
carotids be t - ANSWER-99203-25, 96372x2, J1885x4, J3030
A 44-year-old male patient underwent a colon resection for adenocarcinoma one and
one-half years ago. Following the left colon surgery, he received systemic
chemotherapy. After six months of treatment, the patient's carcinoembryogenic antigen
(CEA) began to rise. CT imaging of the liver revealed three lesions along the anterior
and inferior surfaces of the right lobe of the liver. All three lesions were confirmed on
ultrasound examination and were felt to be superficial and accessible by laparoscopy.
The lesions measure 4 cm, 2.0 cm and 2.5 cm in diameter. The physician performed a
laparoscopy surgical ablation, cryosurgery technique using ultrasonic guidance
(supervision and interpretation). All three lesions were ablated by cryosurgery. -
ANSWER-47371, 76940-26
A 45-year-old male patient was admitted to the hospital for an excision of a parotid
tumor or gland or both. The patient was taken to the operating room and was put under
general anesthesia. Dr. Derek Shepherd opened the area and exposed the parotid
gland. Due to the size of the tumor (5.0 cm), the decision was made to remove the
entire gland. With careful dissection and preservation of the facial nerve, the parotid
gland was removed. Patient was taken to the recovery room in good condition. -
ANSWER-42420
A 46-year-old female patient was admitted to the hospital. She was taken to the
operating room to have a percutaneous transluminal angioplasty due to insufficient
hemodialysis based on segmental stenosis of the fistula/cephalic vein. The
percutaneous transluminal angioplasty involved navigating through the radial artery into
the cephalic vein to accomplish repair and a dialysis fistula angiography. - ANSWER-
36902
A 48-year-old female patient was admitted for hemodialysis for acute renal failure. The
patient also has stage I chronic renal failure and hypertension. - ANSWER-N17.9, I12.9,
N18.1
, A 51-year-old male patient comes in for his chemotherapy treatment. The
chemotherapy is injected into the pleural cavity with thoracentesis. - ANSWER-96440
A 55-year-male patient went to the ambulatory surgery center for his colonoscopy. The
physician anesthetized the patient with Versed, inserted the endoscope, and inspected
the descending colon. However, he could not finish the procedure because the patient
went into respiratory distress. The patient was stabilized and the procedure was
discontinued. What modifier would be applied to the colonoscopy code to indicate that
less than the code definition was performed? - ANSWER-74
A 67-year-old male patient went to his physician's office for a visit for his chronic,
systolic CHF and hypertension. After examination, the physician determined the
patient's condition is stable and will keep his current medication regimen the same. -
ANSWER-I11.0, I50.22
A 68-year-old male patient is seen in the Radiation Oncology Department at the hospital
for secondary prostate cancer. The primary site was the lower lobe of the lung. The
oncologist, who is an employee of the hospital, performs complex clinical treatment
planning, basic dosimetry calculation, and a complex isodose plan; treatment devices
include blocks, special shields and wedges. The patient had 5 days of radiation
treatments for 2 weeks, a total of 10 days of treatment. Report the physician service. -
ANSWER-77263, 77307, 77334, 77427x2
A 68-year-old male patient went to the ASC for a colonoscopy. The physician
administered the patient with Versed, inserted the endoscope, and inspected the
descending colon. The procedure could not be finished because the patient went into
respiratory distress. The patient was stabilized and the procedure was discontinued.
What modifier would be appended to the colonoscopy code to indicate that the
procedure was discontinued? - ANSWER-74
A 7-year-old child was seen in the emergency room for a dog bite on her left thigh. She
received an injection of rabies immunoglobulin since the dog was known to have rabies.
- ANSWER-S71.152A, Z20.3, W54.0XXA
A chief complaint is a concise statement describing the symptom, problem, condition,
diagnosis or other factor that is the reason for encounter. - ANSWER-true
A patient presents with abdominal pain. After a complete work-up the patient is found to
have an obstructive diaphragmatic hernia with gangrene - ANSWER-K44.1
A patient with stress incontinence requires repair for cystocele and incomplete vaginal
prolapse. The physician elects to perform a paravaginal defect repair. An abdominal
incision is made and entry into the space of Retzius gland. Six sutures are placed
through the anterior lateral edge of the vaginal wall and then through the fascia
condensation over the obturator internus muscle to the inferior aspect of the pubic bone
