Medical Coding Training - CPC 2025
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11-year-old patient is seen in the OR for a secondary palatoplasty
for complete unilateral cleft palate. Shortly after general
anesthesia is administered, the patient begins to seize. The
surgeon quickly terminates the surgery in order to stabilize the
patient. What CPT® and ICD-10-CM codes are reported for the
surgeon?
A. 42220-53, Q35.9, R56.9
B. 42220-52, Q35.7, R56.9
A. 42220-53, Q35.9, R56.9
Rationale: In the CPT® Index, look for Palatoplasty. Code 42220
represents a secondary repair to a cleft palate. Modifier 53 is
appended because the procedure was terminated after
anesthesia due to extenuating circumstances.
The diagnosis of a complete unilateral cleft palate is indexed in
,ICD-10-CM under Cleft/palate referring you to code Q35.9. Code
R56.9 is reported because the patient began to seize after
administering the general anesthesia. This is indexed in the ICD-
10-CM under Seizure(s).
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12-year-old patient had an adenoidectomy in 2013 and a second
adenoidectomy this year. What CPT® code(s) is/are reported for
the second adenoidectomy performed this year?
D. 42836
Rationale: Sometimes adenoid tissue, even after it has been
removed, will grow back when a few cells are left in. For the
removal of the secondary adenoid tissue, we report the secondary
adenoidectomy represented by code 42836. Look in the CPT®
Index for Adenoids/Excision with a code range of 42830-42836. In
this case, the patient would have been over 12 years of age upon
presentation for the secondary adenoidectomy, further supporting
the criteria for 42836.
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20-year-old patient presented to the hospital with a history of
,bloody stools for three weeks duration. The patient was prepped
for a sigmoidoscopy. The sigmoidoscope was passed without
difficulty to about 40 cm. The entire mucosal lining was
erythematosus. There was no friability of the overlying mucosa
and no bleeding noted anywhere. No pseudo polyps were noted.
Biopsies were taken at about 30cm; these were thought to be
representative of the mucosa in general. The scope was retracted;
no other abnormalities were seen. What CPT® and ICD-10-CM
codes are reported?
A. 45331, K92.1
Rationale: CPT® code for a sigmoidoscopy with single or multiple
biopsies is reported 45331. This is indexed under
Sigmoidoscopy/Biopsy. Diagnostic sigmoidoscopy is always
bundled with a surgical sigmoidoscopy when both are performed
in the same operative session.
The ICD-10-CM code for bloody stools is found in the Index to
Diseases and Injuries under Blood/in/feces or Hematochezia or
Melena and coded K92.1. When a patient comes in with a GI
symptom (bloody stool, abdominal pain, etc.) and no definitive
diagnosis is documented for the symptom(s), the symptom(s) will
be reported.
, 28-year-old female that had symptoms of RLQ abdominal pain,
fever, and vomiting was diagnosed with acute appendicitis. The
surgeon makes an abdominal incision to remove the appendix.
The appendix was not ruptured. The incision is closed. What are
the correct CPT® and ICD-10-CM codes for this encounter?
A. 44950, K35.80
Rationale: In the CPT® Index, look for
Appendectomy/Appendix/Excision directing you to 44950, 44955,
44960. Code 44950 is correct. The appendectomy was performed
via open incision not by using a laparoscope.
According to the ICD-10-CM Official Coding Guidelines Section
I.B.5-6, if a definitive diagnosis is established, that is reported.
Any signs or symptoms that would be an integral part of that
definitive diagnosis/disease process would not be separately
reported. RLQ abdominal pain, fever and vomiting are signs and
symptoms of acute appendicitis, only diagnosis code K35.80 is
reported. In the Index to Diseases and Injuries, look for
Appendicitis/acute.
33-year-old male patient presents to the endoscopy suite to
determine if he has an ulcer. The physician performs a diagnostic
scope through the esophagus, stomach and into the duodenum
Update |100 Complete Exam Set Questions
And Verified Answers (solutions) | Get It
100% Accurate!!| Already Passed A+
11-year-old patient is seen in the OR for a secondary palatoplasty
for complete unilateral cleft palate. Shortly after general
anesthesia is administered, the patient begins to seize. The
surgeon quickly terminates the surgery in order to stabilize the
patient. What CPT® and ICD-10-CM codes are reported for the
surgeon?
A. 42220-53, Q35.9, R56.9
B. 42220-52, Q35.7, R56.9
A. 42220-53, Q35.9, R56.9
Rationale: In the CPT® Index, look for Palatoplasty. Code 42220
represents a secondary repair to a cleft palate. Modifier 53 is
appended because the procedure was terminated after
anesthesia due to extenuating circumstances.
The diagnosis of a complete unilateral cleft palate is indexed in
,ICD-10-CM under Cleft/palate referring you to code Q35.9. Code
R56.9 is reported because the patient began to seize after
administering the general anesthesia. This is indexed in the ICD-
10-CM under Seizure(s).
See an expert-written answer!
12-year-old patient had an adenoidectomy in 2013 and a second
adenoidectomy this year. What CPT® code(s) is/are reported for
the second adenoidectomy performed this year?
D. 42836
Rationale: Sometimes adenoid tissue, even after it has been
removed, will grow back when a few cells are left in. For the
removal of the secondary adenoid tissue, we report the secondary
adenoidectomy represented by code 42836. Look in the CPT®
Index for Adenoids/Excision with a code range of 42830-42836. In
this case, the patient would have been over 12 years of age upon
presentation for the secondary adenoidectomy, further supporting
the criteria for 42836.
See an expert-written answer!
20-year-old patient presented to the hospital with a history of
,bloody stools for three weeks duration. The patient was prepped
for a sigmoidoscopy. The sigmoidoscope was passed without
difficulty to about 40 cm. The entire mucosal lining was
erythematosus. There was no friability of the overlying mucosa
and no bleeding noted anywhere. No pseudo polyps were noted.
Biopsies were taken at about 30cm; these were thought to be
representative of the mucosa in general. The scope was retracted;
no other abnormalities were seen. What CPT® and ICD-10-CM
codes are reported?
A. 45331, K92.1
Rationale: CPT® code for a sigmoidoscopy with single or multiple
biopsies is reported 45331. This is indexed under
Sigmoidoscopy/Biopsy. Diagnostic sigmoidoscopy is always
bundled with a surgical sigmoidoscopy when both are performed
in the same operative session.
The ICD-10-CM code for bloody stools is found in the Index to
Diseases and Injuries under Blood/in/feces or Hematochezia or
Melena and coded K92.1. When a patient comes in with a GI
symptom (bloody stool, abdominal pain, etc.) and no definitive
diagnosis is documented for the symptom(s), the symptom(s) will
be reported.
, 28-year-old female that had symptoms of RLQ abdominal pain,
fever, and vomiting was diagnosed with acute appendicitis. The
surgeon makes an abdominal incision to remove the appendix.
The appendix was not ruptured. The incision is closed. What are
the correct CPT® and ICD-10-CM codes for this encounter?
A. 44950, K35.80
Rationale: In the CPT® Index, look for
Appendectomy/Appendix/Excision directing you to 44950, 44955,
44960. Code 44950 is correct. The appendectomy was performed
via open incision not by using a laparoscope.
According to the ICD-10-CM Official Coding Guidelines Section
I.B.5-6, if a definitive diagnosis is established, that is reported.
Any signs or symptoms that would be an integral part of that
definitive diagnosis/disease process would not be separately
reported. RLQ abdominal pain, fever and vomiting are signs and
symptoms of acute appendicitis, only diagnosis code K35.80 is
reported. In the Index to Diseases and Injuries, look for
Appendicitis/acute.
33-year-old male patient presents to the endoscopy suite to
determine if he has an ulcer. The physician performs a diagnostic
scope through the esophagus, stomach and into the duodenum
