Chapter 16 Test Review
Question 1_4 out of 4 points
A 22 year-old patient who has severe medical problems is placed under general anesthesia by an anesthetist for
a service not usually requiring anesthesia. What modifier would be appended to the service?
Selected Answer: b.
23
Correct Answer: b.
23
Response Rationale: In the CPT® codebook go to Appendix A – Modifiers. Review the modifiers to
Feedback: determine that modifier 23 is reported to indicate a procedure not usually requiring anesthesia
(either none or local) but due to unusual circumstances general anesthesia is necessary.
Question 2_4 out of 4 points
What modifier is used for medically-directed CRNA services?
Selected Answer: b.
QX
Correct Answer: b.
QX
Response Rationale: In the HCPCS Level II codebook look for where the modifiers are listed and refer to
Feedback: modifier QX. QX is the correct modifier for CRNA services when medically directed by a
physician.
Question 3_4 out of 4 points
What is the anesthesia code for a tubal ligation?
Selected Answer: b.
00851
Correct Answer: b.
00851
Response Rationale: In the CPT® Index, look for Anesthesia/Fallopian Tube/Ligation or Anesthesia/Tubal
Feedback: Ligation which directs you to 00851. Review the code in the numeric section to determine that
00851 describes the procedure.
Question 4_4 out of 4 points
Report the appropriate anesthesia code for an obstetric patient who had a planned general anesthesia for
cesarean hysterectomy.
, Selected Answer: c.
01963
Correct Answer: c.
01963
Response Rationale: Use the CPT® Index look for Anesthesia/Hysterectomy/Cesarean which directs you to
Feedback: 01963, 01969. Review the codes in the numeric section to determine that code 01963 is the
appropriate code. Note: Code 01969 is an add-on code and cannot be coded without a primary
procedure code.
Question 5_4 out of 4 points
What is the anesthesia code for a cast application to the wrist?
Selected Answer: b.
01860
Correct Answer: b.
01860
Response Rationale: In the CPT® Index for Anesthesia/Cast Application/Forearm, Wrist and Hand
Feedback: which directs you to 01860. Verify code selection in the numeric section.
Question 6_4 out of 4 points
The patient is receiving a cast change for a compound left trimalleolar fracture (ankle). What ICD-10-CM code
is reported?
Selected Answer: b.
S82.852D
Correct Answer: b.
S82.852D
Response Rationale: In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/ankle/trimalleolar
Feedback: (displaced) which directs you to code S82.85-. In the Tabular List it indicates the code requires a
6th character for the laterality and a 7th character for the episode of care. The 6th character 2 is
for the left ankle and the 7th character D is for subsequent care with routine healing. The
correct code is S82.852D. According to ICD-10-CM guideline, I.C.19.c., a fracture not indicated
whether displaced or not displaced should be coded to displaced. According to ICD-10-CM
guideline, I.C.19.a., an example of subsequent care is a cast change.
Question 7_4 out of 4 points
A 77 year-old patient was scheduled for a total hip replacement due to degenerative joint disease (DJD) and the
anesthesiologist documented the DJD as primary. The pre-anesthesia assessment indicates the patient had
surgery in 2015 for gastroesophageal reflux disease (GERD). What ICD-10-CM code(s) is/are reported?
Selected Answer: b.
M16.10
, Correct Answer: b.
M16.10
Response Rationale: The patient’s previous surgery (GERD) has no relevance to the anesthesia care
Feedback: provided for the hip surgery and is not reported with a diagnosis code. In the ICD-10-CM
Alphabetic Index look for Degeneration/joint disease which states to see Osteoarthritis. Look
for Osteoarthritis/hip or Osteoarthritis/primary/hip which directs you to M16.1-. In the Tabular
List confirm the subcategory code. M16.1- indicates that a 5th character is needed to indicate
laterality. We are not told which hip has the DJD so the coder would report M16.10.
Question 8_0 out of 4 points
Using your ICD-10-CM Alphabetic Index, what is the diagnosis code for a patient with a postoperative diagnosis
of uterus mass?
Selected Answer: a.
R19.09
Correct Answer: b.
N85.8
Response Rationale: In the Alphabetic Index look for Mass, you will see there is no subterm for uterus.
Feedback: There is a subterm for specified organ NEC which states to see Disease, by site. Look for
Disease/uterus/specified NEC which directs you to code N85.8. Confirm code in the Tabular list.
You will not select code D39.8, uncertain behavior from the Table of Neoplasms because to
report this code we need to see a pathology report to support the findings of a neoplasm of
uncertain behavior.
Question 9_4 out of 4 points
After a routine and uncomplicated appendix surgery the patient began bleeding post-operatively. What ICD-10-
CM code is reported?
Selected Answer: a.
K91.840
Correct Answer: a.
K91.840
Response Rationale: In the ICD-10-CM Alphabetic Index look for
Feedback: Complication/hemorrhage/postprocedural directs you to see Complication, postprocedural
hemorrhage. Look for Complication/postprocedural /hemorrhage (hematoma) (of)/digestive
system/following procedure on digestive system which directs you to code K91.840. Verify code
selection in the Tabular List.
Question 10_4 out of 4 points
A patient with diabetic peripheral circulatory disorder is having a lower leg amputation due to gangrene. What
ICD-10-CM code(s) is/are reported?
Selected Answer: a.
Question 1_4 out of 4 points
A 22 year-old patient who has severe medical problems is placed under general anesthesia by an anesthetist for
a service not usually requiring anesthesia. What modifier would be appended to the service?
Selected Answer: b.
23
Correct Answer: b.
23
Response Rationale: In the CPT® codebook go to Appendix A – Modifiers. Review the modifiers to
Feedback: determine that modifier 23 is reported to indicate a procedure not usually requiring anesthesia
(either none or local) but due to unusual circumstances general anesthesia is necessary.
Question 2_4 out of 4 points
What modifier is used for medically-directed CRNA services?
Selected Answer: b.
QX
Correct Answer: b.
QX
Response Rationale: In the HCPCS Level II codebook look for where the modifiers are listed and refer to
Feedback: modifier QX. QX is the correct modifier for CRNA services when medically directed by a
physician.
Question 3_4 out of 4 points
What is the anesthesia code for a tubal ligation?
Selected Answer: b.
00851
Correct Answer: b.
00851
Response Rationale: In the CPT® Index, look for Anesthesia/Fallopian Tube/Ligation or Anesthesia/Tubal
Feedback: Ligation which directs you to 00851. Review the code in the numeric section to determine that
00851 describes the procedure.
Question 4_4 out of 4 points
Report the appropriate anesthesia code for an obstetric patient who had a planned general anesthesia for
cesarean hysterectomy.
, Selected Answer: c.
01963
Correct Answer: c.
01963
Response Rationale: Use the CPT® Index look for Anesthesia/Hysterectomy/Cesarean which directs you to
Feedback: 01963, 01969. Review the codes in the numeric section to determine that code 01963 is the
appropriate code. Note: Code 01969 is an add-on code and cannot be coded without a primary
procedure code.
Question 5_4 out of 4 points
What is the anesthesia code for a cast application to the wrist?
Selected Answer: b.
01860
Correct Answer: b.
01860
Response Rationale: In the CPT® Index for Anesthesia/Cast Application/Forearm, Wrist and Hand
Feedback: which directs you to 01860. Verify code selection in the numeric section.
Question 6_4 out of 4 points
The patient is receiving a cast change for a compound left trimalleolar fracture (ankle). What ICD-10-CM code
is reported?
Selected Answer: b.
S82.852D
Correct Answer: b.
S82.852D
Response Rationale: In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/ankle/trimalleolar
Feedback: (displaced) which directs you to code S82.85-. In the Tabular List it indicates the code requires a
6th character for the laterality and a 7th character for the episode of care. The 6th character 2 is
for the left ankle and the 7th character D is for subsequent care with routine healing. The
correct code is S82.852D. According to ICD-10-CM guideline, I.C.19.c., a fracture not indicated
whether displaced or not displaced should be coded to displaced. According to ICD-10-CM
guideline, I.C.19.a., an example of subsequent care is a cast change.
Question 7_4 out of 4 points
A 77 year-old patient was scheduled for a total hip replacement due to degenerative joint disease (DJD) and the
anesthesiologist documented the DJD as primary. The pre-anesthesia assessment indicates the patient had
surgery in 2015 for gastroesophageal reflux disease (GERD). What ICD-10-CM code(s) is/are reported?
Selected Answer: b.
M16.10
, Correct Answer: b.
M16.10
Response Rationale: The patient’s previous surgery (GERD) has no relevance to the anesthesia care
Feedback: provided for the hip surgery and is not reported with a diagnosis code. In the ICD-10-CM
Alphabetic Index look for Degeneration/joint disease which states to see Osteoarthritis. Look
for Osteoarthritis/hip or Osteoarthritis/primary/hip which directs you to M16.1-. In the Tabular
List confirm the subcategory code. M16.1- indicates that a 5th character is needed to indicate
laterality. We are not told which hip has the DJD so the coder would report M16.10.
Question 8_0 out of 4 points
Using your ICD-10-CM Alphabetic Index, what is the diagnosis code for a patient with a postoperative diagnosis
of uterus mass?
Selected Answer: a.
R19.09
Correct Answer: b.
N85.8
Response Rationale: In the Alphabetic Index look for Mass, you will see there is no subterm for uterus.
Feedback: There is a subterm for specified organ NEC which states to see Disease, by site. Look for
Disease/uterus/specified NEC which directs you to code N85.8. Confirm code in the Tabular list.
You will not select code D39.8, uncertain behavior from the Table of Neoplasms because to
report this code we need to see a pathology report to support the findings of a neoplasm of
uncertain behavior.
Question 9_4 out of 4 points
After a routine and uncomplicated appendix surgery the patient began bleeding post-operatively. What ICD-10-
CM code is reported?
Selected Answer: a.
K91.840
Correct Answer: a.
K91.840
Response Rationale: In the ICD-10-CM Alphabetic Index look for
Feedback: Complication/hemorrhage/postprocedural directs you to see Complication, postprocedural
hemorrhage. Look for Complication/postprocedural /hemorrhage (hematoma) (of)/digestive
system/following procedure on digestive system which directs you to code K91.840. Verify code
selection in the Tabular List.
Question 10_4 out of 4 points
A patient with diabetic peripheral circulatory disorder is having a lower leg amputation due to gangrene. What
ICD-10-CM code(s) is/are reported?
Selected Answer: a.
