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The physician must establish the diagnosis—obesity or morbid obesity—and the
additional information can be pulled from ancillary documentation to establish the
correct code assignment for body mass index (BMI) (CMS 2020a, Section I.B.14, 17-
18).
A laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code?
0FB40ZZExcision of gallbladder, open approach
0FB44ZZExcision of gallbladder, percutaneous endoscopic approach
0FT40ZZResection of gallbladder, open approach
0FT44ZZResection of gallbladder, percutaneous endoscopic approach
a. 0FB40ZZ
b. 0FT40ZZ
c. 0FT44ZZ
d. 0FB44ZZ - answer-ANSWER: C
A cholecystectomy includes complete removal of the gallbladder; therefore, the correct
root operation is Resection. Since the procedure is specified as a laparoscopic
cholecystectomy, the approach is percutaneous endoscopic (Leon-Chisen 2020,
247248).
Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and
transurethral fulguration of bladder lesions over the dome and posterior wall (1.9 cm.)
was completed. A biopsy was taken of a lesion in the lateral wall. What modifier should
be added to the biopsy procedure code?
a. -50, Bilateral procedure
b. -51, Multiple procedures
c. -59, Distinct procedural service
d. -99, Multiple modifiers - answer-ANSWER: C
The surgery is done on two distinct areas within the bladder with two distinct
approaches. The biopsy is not of the area that was resected and warrants the use of -
59 (CPT Assistant Sept. 2001; CPT Professional Edition 2020, Appendix A).
A bronchoscopy with multiple biopsies of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure code billed
by the facility?
,a. -59, Distinct procedural service
b. -51, Multiple procedures
c. -76, Repeat procedure or service by same physician
d. No modifiers should be reported - answer-ANSWER: D
The procedure is reported with code 31625, the description of which indicates biopsy of
single or multiple sites. When reporting this code, it is not necessary to indicate multiple
procedures as the code itself does that (AMA CPT Professional Edition 2020, Appendix
A).
A patient is admitted with fever and urinary burning. Urosepsis is suspected. The
discharge diagnosis is Escherichia coli, urinary tract infection; sepsis ruled out. Which of
the following represents the diagnoses to report for this encounter and the appropriate
sequencing of the codes for those conditions?
a. Fever, urinary burning, urosepsis
b. Fever, urinary burning, sepsis
c. Escherichia coli sepsis
d. Urinary tract infection, Escherichia coli - answer-ANSWER: D
Symptoms are not coded when a related definitive diagnosis is present on discharge.
The patient has a discharge diagnosis of urinary tract infection, secondary to E. coli. A
secondary code of B96.20 is assigned to identify E. coli as the cause of the infection
(CMS 2020a, Section II.A., 108).
A patient was admitted to the emergency department for abdominal pain with diarrhea
and was diagnosed with infectious gastroenteritis. In addition to gastroenteritis, the final
diagnostic statement included angina and chronic obstructive pulmonary disease. List
the diagnoses that would be coded and their correct sequence.
a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease,
angina
b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina
c. Gastroenteritis, abdominal pain, angina
d. Diarrhea, chronic obstructive pulmonary disease, angina - answer-ANSWER: B The
abdominal pain and diarrhea are not coded as they are symptoms integral to the
diagnosis of infectious gastroenteritis. Review Coding Guideline IV.D for additional
information on coding of symptoms, signs, and ill-defined conditions (CMS 2020a,
Section IV.D., 113).
, A patient was admitted to the endoscopy unit for a screening colonoscopy. During the
colonoscopy, polyps of the colon were found and a polypectomy was performed. What
diagnostic codes should be used and how should they be sequenced?
Z12.11Encounter for screening for malignant neoplasm of colon
D12.6Benign neoplasm of colon, unspecified
Z86.010Personal history of colonic polyps
a. Z12.11, Z86.010
b. D12.6, Z12.11, Z86.010
c. Z12.11, D12.6
d. D12.6, Z12.11 - answer-ANSWER: C
The circumstances of the encounter are for a screening colonoscopy. Because of this
screening, colonoscopy is listed first, followed by a code for the polyps (CMS 2020a,
Section I.C.21.c.5, 97-98).
The patient is admitted for chest pain and is found to have an acute inferior myocardial
infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation
was controlled and the patient was stabilized, the patient underwent a CABG ×2 from
aorta to the right anterior descending and right obtuse, using the left greater saphenous
vein which was harvested via an open approach. Cardiopulmonary bypass was utilized.
The appropriate sequencing and ICD codes for the hospitalization would be:
I25.10Atherosclerotic heart disease of native coronary artery without angina
pectorisI21.19ST elevation (STEMI) myocardial infarction involving other coronary
artery of inferior wallI22.1Subsequent ST elevation (STEMI) myocardial infarction of
inferior wallI21.3ST elevation (STEMI) myocardial infarction, of unspecified
siteI22.9Subsequent ST elevation (STEMI) myocardial infarction of unspecified
siteI48.91Unspecified atrial fibrillationR07.9Chest pain, unspecified02100AWBypass
coronary artery, one artery from aorta with autologous arterial tissue, open
approach021109WBypass coronary
artery, two arteries from aorta with autologous venous tissue, open
approach06BQ0ZZExcision of left saphenous vein, open
approach5A1221ZPerformance of cardiac output, continuous
a. R07.9, I21.3, I48.91, I22.9, 02100AW, 5A1221Z
b. I21.19, I48.91, I22.9, 02100AW
c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z
d. I22.1, I48.91, I21.19, 021109W - answer-ANSWER: C
The patient's hospitalization includes a definitive diagnosis of myocardial infarction of
the inferior wall as well as the other diagnoses of coronary artery disease and atrial
fibrillation. The chest pain is not coded as it is a symptom of the MI. The patient