Compiled AAPC Certified Professional Coder (CPC®) Exam- Certification Exam *Q&A* (100% Correct) 2025/2026 |VERIFIED|

Compiled AAPC Certified Professional Coder (CPC®) Exam- Certification Exam *Q&A* (100% Correct) 2025/2026 |VERIFIED| A neonatologist performs intubation, ventilation management, and a complete echocardiogram on a 20 day-old infant with congenital heart disease. Which codes accurately describe the services provided? A. 99468-25, 93303-26 B. 99471-25, 31500, 94002, 93303-26 C. 99460-25, 31500, 94002, 93303-26 D. 99291-25, 93303-26 A woman had a previous biopsy showing positive malignant margins on the right side of her neck. A full excision of an 8 cm lesion was performed with a 0.5 cm margin and layered closure. The specimen was sent for histopathology. What CPT® codes apply? A. 11626 B. 11626, 12004-51 C. 11626, 12044-51 D. 11626, 13132-51, 13133 A 30-year-old woman undergoes debridement of a 15 sq cm ulcer on her right foot, extending to the bone. Minimal bone trimming was necessary. Cultures were collected, and the wound was dressed. What CPT® code is correct? A. 11043 B. 11012 C. D. 11042 11044 1 A 64-year-old woman with multiple sclerosis suffers a fall resulting in various lacerations: 6 cm on her face, 5 cm each on her arm and leg, and 3 cm on her hand and foot. The physician performed one-layer and layered closures for the respective injuries. Select the correct procedure codes. A. 99283-25, 12014, 12034-59, 12002-59, 11042-51 B. 99283-25, 12053, 12034-59, 12002-59 C. 99283-25, 12014, 12034-59, 11042-51 D. 99283-25, 12053, 12034-59 A 52-year-old woman has a 4 cm subcutaneous lipoma excised from her right flank. The surgeon used blunt dissection and electrocautery to remove the well-encapsulated lipoma. What CPT® and ICD-10-CM codes apply? A. 21932, D17.39 B. 21931, D17.1 C. 21935, D17.1 D. 21925, D17.9 A patient undergoes open reduction and internal fixation for a right scaphoid fracture. What is the appropriate CPT® code? A. 25628-RT B. 25630 C. 25628-50 D. 25620 An infant with genu valgum undergoes bilateral medial distal femur hemiepiphysiodesis. X-rays localized the growth plate, and Orthofix® plates were inserted. What procedure code applies? A. 27470-50 B. 27475-50 C. 27477-50 D. 27485-50 2 A 67-year-old man with metastatic colon cancer requires placement of an Infuse-A-Port. The procedure included tunneling and fluoroscopic guidance. What are the correct CPT® codes? A. 36556, 77001-26 B. 36560, 77002-26 C. 36561, 77001-26 D. 36555, 77001-26 A patient has a pleural effusion requiring a pigtail catheter placement for drainage under ultrasound guidance. What CPT® code applies? A. 32557 B. 32555 C. 32556 D. 32550 A 59-year-old male with recurrent carotid stenosis undergoes a redo carotid endarterectomy. What are the appropriate CPT® codes? A. 35301, 35741 B. 35301, 35390 C. 35301, 37609 D. 35390 A 42-year-old patient undergoes general anesthesia for a laparoscopic radical nephrectomy. What are the correct CPT® and ICD-10-CM codes? A. 00860-P1, C64.9, E11.9 B. 00840-P3, C65.9, E11.9 C. 00862-P2, C65.9, E11.9 D. 00868-P2, C79.02, E11.9 A healthy 32-year-old receives monitored anesthesia care for ORIF of a closed distal radius fracture. Which anesthesia code applies? 3 A. 01830-P1 B. 01830-QS-P1 C. 01860-QS-P1 D. 01860-QS-G9-P1 A 10-month-old undergoes anesthesia for removal of a laryngeal mass. What anesthesia code is correct? A. 00320 B. 00326 C. 00320, 99100 D. 00326, 99100 A patient has a catheter placed in the left common femoral artery, followed by angiograms of both the right external iliac and superficial femoral arteries. What codes are correct? A. 36217, 75736-26 B. 36247, 75716-26 C. 36217, 75756-26 D. 36247, 75710-26 A 56-year-old has a bilateral mammogram with computer-aided detection for screening due to a family history of breast cancer. What radiology code applies? A. 77065 x 2 B. 77065, 77066 C. 77067 D. 77066 A 63-year-old with bilateral ureteral obstruction undergoes stent placement and retrograde pyelogram interpretation. What codes should be reported? A. 52332, 74425 B. 52332-50, 74420-26 4 C. 52005, 74420 D. 52005-50, 74425-26 A pathological exam involves two specimens: arterial plaque from the left common femoral artery and cutaneous ulceration from the left leg. What pathology codes apply? A. 88304-26, 88302-26 B. 88305-26, 88304-26 C. 88307-26, 88305-26 D. 88309-26, 88307-26 - For a 52-year-old patient undergoing laparoscopic cholecystectomy, which codes represent the procedure and diagnosis of chronic cholecystitis? A. 47562, K81.0 B. 47562, K81.1 C. 47563, K80.20 D. 47600, K81.1 - A 70-year-old female with a symptomatic ventral hernia undergoes laparoscopic repair. Which is the correct procedural code? A. 49560, 49568 B. C. 49653 49652 D. 49652, 49568 - A 50-year-old male presents with acute appendicitis without rupture and undergoes a laparoscopic appendectomy. What is the appropriate CPT® code? A. B. 44950 C. 44960 D. 44979 44970 5 - What CPT® code is assigned for a laparoscopic nephrectomy performed for kidney donation? A. 50543 B. C. 50300 D. 50320 50547 - For a cystoscopy and placement of a sling due to urinary incontinence, which code(s) are reported? A. B. 57287 57288 C. 57288, 52000-51 D. 51992, 52000-51 - A 16-day-old male undergoes a repeat circumcision due to redundant foreskin with circumferential scarring. Select the appropriate CPT® code: A. 54150 B. 54160 C. D. 54164 54163 - For a 5-year-old female undergoing surgery to correct labial adhesions unresponsive to medical management, what is the correct CPT® code? A. 58660 B. 58740 C. 57061 D. 56441 - A 64-year-old female has a Medtronic pain pump and catheter removed due to infection. Which codes are appropriate? A. 62365, 62350-51, T85.898A, Z46.2 6 B. 62360, 62355-51, T85.79XA C. 62365, 62355-51, T85.79XA D. 36590, I97.42, T85.898A - A 73-year-old male has ventriculomegaly treated with ventriculoperitoneal shunt placement. Which CPT® code is reported? A. 62220 B. C. 62190 D. 62192 62223 - For decompression of the median nerve in the wrist (carpal tunnel release), what is the correct CPT® code? A. 64704 B. 64713 C. D. 64719 64721 - A 2-year-old male has chalazions excised from both the upper and lower eyelids of one eye under general anesthesia. What is the correct CPT® code? A. 67801 B. 67805 C. 67800 D. 67808 - An 80-year-old patient returns for pessary cleaning without complaints. Which CPT® and ICD-10-CM codes are reported? A. 99201, Z46.89 B. 99211, Z46.89 C. 99202, Z46.9 7 D. 99212, Z46.9 - A patient is admitted to the hospital for constipation with nausea and vomiting caused by medications. The physician documents a detailed history and moderate medical decision-making. Which E/M code is appropriate? A. 99285 B. 99284 C. D. 99222 99221 During a craniectomy the surgeon asked for a consult and sent a frozen section of a large piece of tumor and sent it to pathology. The pathologist received a rubbery pinkish tan tissue measuring in aggregate 3 x 0.8 x 0.8 cm. The entire specimen is submitted in one block and also a gross and microscopic examination was performed on the tissue. The frozen section and the pathology report are sent back to the surgeon indicating that the tumor was a medulloblastoma. What CPT® code(s) will the pathologist report? A. 80500 B. 88331-26, 88307-26 C. 80502 D. 88331-26, 88332-26, 88304-26 B. 88331-26, 88307-26 Physician orders a basic (80047) and comprehensive metabolic (80053) panels. Select the code(s) on how this is reported. A. 80053, 80047 B. 80053 C. 80047, 82040, 82247, 82310, 84075, 84155, 84460, 84450 D. 80053, 82330 D. 80053, 82330 A 4-year-old is getting over his cold and will be getting three immunizations in the pediatrician's office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next vaccination is 8 the live influenza (LAIV3) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and vaccines? A. 90713, 90658, 90716, 90460, 90461 x 2 B. 90713, 90660, 90716, 90460, 90461 x 1 C. 90713, 90660, 90716, 90471, 90472, 90474 D. 90713, 90658, 90716, 90471, 90472, 90473 C. 90713, 90660, 90716, 90471, 90472, 90474 A patient with chronic renal failure is in the hospital being evaluated by his nephrologist after just placing a catheter into the peritoneal cavity for dialysis. The physician is evaluating the dwell time and running f luid out of the cavity to make sure the volume of dialysate and the concentration of electrolytes and glucose are correctly prescribed for this patient. What code should be reported for this service? A. 90935 B. 90937 C. 90947 D. 90945 D. 90945 An established patient had a comprehensive exam in which she has been diagnosed with dry eye syndrome in both eyes. The ophthalmologist measures the cornea for placement of the soft contact lens for treatment of this syndrome. What codes are reported by the ophthalmologist? A. 92014-25, 92071-50 B. 99214-25, 92072-50 C. 92014-25, 92325-50 D. 92014-25, 92310-50 A. 92014-25, 92071-50 A patient who is a singer has been hoarse for a few months following an upper respiratory infection. She is in a voice laboratory to have a laryngeal function study performed by an otolaryngologist. She starts off with the acoustic testing first. Before she moves on to the aerodynamic testing she complains of throat pain and is rescheduled to come back to have the other test performed. What CPT® code is reported? A. 92520 B. 92700 C. 92520-52 9 D. 92614-52 C. 92520-52 What is the difference between entropion and ectropion? A. Entropion is the inward turning of the eyelid and ectropion is the outward turning of the eyelid. B. Entropion is facial droop and ectropion is a facial spasm. C. Entropion is the outward turning of the hands and ectropion is the inward turning of the hands. D. Entropion inward turning of the feet and ectropion is the outward turning of the feet due to muscle disorder. A. Entropion is the inward turning of the eyelid and ectropion is the outward turning of the eyelid. What is the full CPT® code description for 00846? A. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy B. Radical hysterectomy C. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified radical hysterectomy D. Radical hysterectomy not otherwise specified A. Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy Ventral, umbilical, spigelian and incisional are types of: A. Surgical approaches B. Hernias C. Organs found in the digestive system D. Cardiac catheterizations B. Hernias Fracturing the acetabulum involves what area? A. Skull B. Shoulder C. Pelvis D. Leg C. Pelvis 10 When a patient is having a tenotomy performed on the abductor hallucis muscle, where is this muscle located? A. Foot B. Upper Arm C. Upper Leg D. Hand A. Foot A 44-year-old had a history of adenocarcinoma of the cervix on a conization in March 20XX who has been followed with twice-yearly endocervical curettages and Pap smears that were all negative for two years, per the recommendation of a GYN oncologist. Her Pap smear results from the last visit noted atypical glandular cells. In light of this, she underwent a colposcopy and the biopsy of the normal appearing cervix on colposcopy was benign. The endocervical curettage was benign endocervical glands, and the endometrial sampling was benign endometrium. In light of the fact that she had had previous atypical glandular cells that led to diagnosis of adenocarcinoma and the concerns that this may have recurred, she had been recommended for a cone biopsy and fractional dilatation and curettage, which she is undergoing today. What ICD-10-CM code(s) should be reported? A. R87.619, C53.9 B. C55 C. R87.619, Z85.41 D. Z12.4, Z85.41 C. R87.619, Z85.41 Patient comes into see her primary care physician for a productive cough and shortness of breath. The physician takes a chest X-ray which indicates the patient has double pneumonia. Select the ICD-10-CM code(s) for this visit. A. J18.9, R05, R06.2 B. R05, R06.2, J18.9 C. J18.9 D. J15.9 C. J18.9 What is the correct way to code a patient having bradycardia due to Demerol that was correctly prescribed and properly administered? A. T40.2X1A, R00.1 11 B. T40.2X3A, R00.1 C. R00.1, T40.2X5A D. R00.1, T40.2X2A C. R00.1, T40.2X5A Which statement is TRUE when reporting pregnancy codes (O00-O9A): A. These codes can be used on the maternal and baby records. B. These codes have sequencing priority over codes from other chapters. C. Code Z33.1 should always be reported with these codes. D. The seventh character assigned to these codes only indicate a complication during the pregnancy. B. These codes have sequencing priority over codes from other chapters. A 66-year-old Medicare patient, who has a history of ulcerative colitis, presents for a colorectal cancer screening. The screening is performed via barium enema. What HCPCS Level II code is reported for this procedure? A. G0104 B. G0105 C. G0120 D. G0121 What is PHI? C. G0120 A. Physician-health care interchange B. Private health insurance C. Protected health information D. Provider identified incident-to C. Protected health information What is NOT included in CPT® surgical package? A. Typical postoperative follow-up care B. One related Evaluation and Management service on the same date of the procedure C. Returning to the operating room the next day for a complication resulting from the initial procedure 12 C. Returning to the operating room D. Evaluating the patient in the post-anesthesia recovery area the next day for a complication resulting from the initial procedure Which statement is TRUE about reporting codes for diabetes mellitus? A. If the type of diabetes mellitus is not documented in the medical record the default type is E11.- Type 2 diabetes mellitus. B. When a patient uses insulin, Type 1 is always reported. C. The age of the patient is a sole determining factor to report Type 1. D. When assigning codes for diabetes and its associated condition(s), the code(s) from category E08-E13 are not reported as a primary code. A. If the type of diabetes mellitus is not documented in the medical record the default type is E11.- Type 2 diabetes mellitus. Which statement is TRUE for reporting external cause codes of morbidity (V00-Y99)? A. All external cause codes do not require a seventh character. B. Only report one external cause code to fully explain each cause. C. Report code Y92.9 if the place of occurrence is not stated. D. External cause codes should never be sequenced as a first-listed or primary code cause codes should never be sequenced as a first-listed or primary code D. External PRE OP DIAGNOSIS: Left Breast Abnormal MMG or Palpable Mass; Other Disorders of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obt A. 19081 A 53-year-old male is in the dermatologist's office for removal of 2 lesions located on his lower lip and nose. Lesions were identified and marked. The lower lip lesion of 4 mm in size was shaved to the level of the superficial dermis. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. What are the CPT® codes for these procedures? 13 A. 40490, 11104-59 B. 11310, 11104-59 C. 17000, 17003 D. 11440, 11105-59 B. 11310, 11104-59 A 76-year-old has dermatochalasis on bilateral upper eyelids. A blepharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT® code(s) is/are? A. 15822, 15823-51 B. 15823-50 C. 15822-50 D. 15820-LT, 15820-RT C. 15822-50 A 42-year-old male has a frozen left shoulder. An arthroscope was inserted in the posterior portal in the glenohumeral joint. The articular cartilage was normal except for some minimal grade III-IV changes, about 5% of the humerus just adjacent to the rotator cuff insertion of the supraspinatus. The biceps was inflamed, not torn at all. The superior labrum was not torn at all, the labrum was completely intact. The rotator cuff was completely intact. An anterior portal was established high in the rotator interval. The rotator interval was very thick and contracted. Adhesions were destroyed with electrocautery and the Bovie. The superior glenohumeral ligament, the middle glenohumeral ligament and the tendinous portion of the subscapularis were released. The arthroscope was placed anteriorly, adhesions were destroyed and the shaver was used to debride some of the posterior capsule and the posterior capsule was released D. 29825-LT After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped away from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT® codes for this visit? 14 A. C. 22630, 22632 x 2, 22842, 20938, 20930 PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application of an external fixation system, left wrist fracture FINDINGS: The patient is a 46 year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixation system was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of B. 25605- LT, 20690-51 A 79-year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where an insertion of a DDD pacemaker will be performed. After the anesthesiologist provided moderate sedation, the cardiologist performed a left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed and the second needle was withdrawn. An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire and the wire and dilator were A. 33208 Patient has lung cancer in his upper right and middle lobes. Patient is in the operating suite to have a video-assisted thorascopy surgery (VATS). A 10-mm-zero-degree thoracoscope is inserted in the right pleural cavity through a port site placed in the ninth and seventh intercostal spaces. Lung was deflated. The tumor is in the right pleural. Both lobes were removed thorascopically. Port site closed. A chest tube was placed to suction and patient was sent to recovery in stable condition. Which CPT® code is reported for this procedure? A. 32482 B. 32484 C. 32670 D. 32671 C. 32670 15 The patient is a 58-year-old white male, one month status post pneumonectomy. He had a post pneumonectomy empyema treated with a tunneled cuffed pleural catheter which has been draining the cavity for one month with clear drainage. He has had no evidence of a block or pleural fistula. Therefore a planned return to surgery results in the removal of the catheter. The correct CPT® code is: A. 32440-78 B. 32035-58 C. 32036-79 D. 32552-58 D. 32552-58 This 67-year-old man presented with a history of progressive shortness of breath. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general area. Both of these holes were closed with a single pericardial patch. What CPT® and ICD-10-CM codes are reported? A. 33675, Q21.0 B. 33647, Q21.1, R06.02 C. 33645, Q21.2, R06.02 D. 33641, Q21.1 D. 33641, Q21.1 An 82-year-old female had a CAT scan which revealed evidence of a proximal small bowel obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made, excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the small bowel. The omentum and bowel were stuck up to the anterior abdominal wall. Time consuming, tedious and spending an extra hour to lysis the adhesions to free up the entire length of the gastrointestinal tract from the ligament to Treitz to the ileocolic anastomosis. The correct CPT® code is: A. 44005 B. 44180-22 C. 44005-22 D. 44180-59 C. 44005-22 55 year-old patient was admitted with massive gastric dilation. The endoscope was inserted with a catheter placement. The endoscope is passed through the cricopharyngeal muscle area without difficulty. Esophagus is normal, some chronic reflux changes at the esophagogastric junction noted. 16 Stomach significant distention with what appears to be multiple encapsulated tablets in the stomach at least 20 to 30 of these are noted. Some of these are partially dissolved. Endoscope could not be engaged due to high grade narrowing in the pyloric channel, the duodenum was not examined. It seems to be a high grade outlet obstruction with a superimposed volvulus. A repeat examination is not planned at this t ime. What code should be used for this procedure? A. 43246-52 B. 43241-52 C. 43235 D. 43191 B. 43241-52 The patient is a 78-year-old white female with morbid obesity that presented with small bowel obstruction. She had surgery approximately one week ago and underwent exploration, which required a small bowel resection of the terminal ileum and anastomosis leaving her with a large inferior ventral hernia. Two days ago she started having drainage from her wound which has become more serious. She is now being taken back to the operating room. Reopening the original incision with a scalpel, the intestine was examined and the anastomosis was reopened , excised at both ends, and further excision of intestine. The fresh ends were created to perform another end- to-end anastomosis. The correct procedure code is: A. 44120-78 B. 44126-79 C. 44120-76 D. 44202-58 A. 44120-78 PREOPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula POST OPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula PROCEDURE: Hartmann procedure, which is a sigmoid resection with Hartmann pouch and colostomy. DESCRIPTION OF THE PROCEDURE: Patient was prepped and draped in the supine position under general anesthesia. Prior to surgery patient was given 4.5 grams of Zosyn and Rocephin IV piggyback. A lower midline incision was made, abdomen was entered. Upon entry into the abdomen, there was an inflammatory mass in the pelvis and there was a large abscessed cavity, but no feces. The abscess cavity was drained and irrigated out. The left colon was immobilized, taken down the lateral perineal attachments. The sigmoid colon was mobilized. There was an inflammatory mass right at the area of the sigmoid colon consistent with a divertiliculitis or perforation with infection. Proximal to this in the distal left B. 44143 A 5-year-old male with a history of prematurity was found to have a chordee due to congenital hypospadias. He presents for surgical management for a plastic repair in straightening the abnormal 17 curvature. Under general anesthesia, bands were placed around the base of the penis and incisions were made degloving the penis circumferentially. The foreskin was divided in Byers flaps and the penile skin was reapproximated at the 12 o'clock position. Two Byers flaps were reapproximated, recreating a mucosal collar which was then criss- crossed and trimmed in the midline in order to accommodate median raphe reconstruction. This was reconstructed with use of a horizontal mattress suture. The shaft skin was then approximated to the mucosal collar with sutures correcting the defect. Which CPT® code should be used? A. 54304 B. 54340 C. 54400 D. 54440 A. 54304 A 22-year-old is 14 weeks pregnant and wants to terminate the pregnancy. She has consented for a D&E. She was brought to the operating room where MAC anesthesia was given. She was then placed in the dorsal lithotomy position and a weighted speculum was placed into her posterior vaginal vault. Cervix was identified and dilated. A 6.5-cm suction catheter hooked up to a suction evacuator was placed and products of conception were evacuated. A medium size curette was then used to curette her endometrium. There was noted to be a small amount of remaining products of conception in her left cornua. Once again the suction evacuator was placed and the remaining products of conception were evacuated. At this point she had a good endometrial curetting with no further products of conception noted. Which CPT® code should be used? A. 59840 B. 59841 C. 59812 D. 59851 B. 59841 A 37-year-old female has menorrhagia and wants permanent sterilization. The patient was placed in Allen stirrups in the operating room. Under anesthesia the cervix was dilated and the hysteroscope was advanced to the endometrium into the uterine cavity. No polyps or fibroids were seen. The Novasure was used for endometrial ablation. A knife was then used to make an incision in the right lower quadrant and left lower quadrant with 5-mm trocars inserted under direct visualization with no injury to any abdominal contents. Laparoscopic findings revealed the uterus, ovaries and fallopian tubes to be normal. The appendix was normal as were the upper quadrants. Because of the patient's history of breast cancer and desire for no further children, it was decided to take out both the tubes and ovaries. This had been discussed with the patient prior to surgery. What are the codes for these procedures? A. 58660, 58353-51 18 B. 5866 B. 58661, 58563-51 MRI reveals patient has cervical stenosis. It was determined he should undergo bilateral cervical laminectomy at C3 through C6 and fusion. The edges of the laminectomy were then cleaned up with a Kerrison and foraminotomies were done at C4, C5, and,C6. The stenosis is central; a facetectomy is performed by using a burr. Nerve root canals were freed by additional resection of the facet, and compression of the spinal cord was relieved by removal of a tissue overgrowth around the foramen. Which CPT® code(s) is (are) used for this procedure? A. 63045-50, 63048-50 B. 63020-50, 63035-50, 63035-50 C. 63015-50 D. 63045, 63048 x 2 D. 63045, 63048 x 2 An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacomulsicfication unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex allowing the insertion of the intraocular lens. What CPT® code is reported? A. 66985 B. 66984 C. 66982 D. 66983 C. 66982 An infant who has chronic otitis media in the right and left ears was placed under general anesthesia and a radial incision was made in the posterior quadrant of the left and right tympanic membranes. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears. What CPT® and ICD-10-CM codes are reported? A. 69436-50, H65.33 B. 69436-50, H66.43 C. 69433-50, H65.113 D. 69421-50, H65.33 A. 69436-50, H65.33 A 50-year-old patient is coming to see her primary care physician for hypertension. The patient also discusses with her physician that the OBGYN office had just told her that her Pap smear came back with 19 an abnormal reading and is worried because her aunt had passed away with cervical cancer. The physician documents she spent 40 minutes face-to-face time with the patient, and 25 minutes of that t ime is giving counseling on the awareness, other screening procedures and treatment if it turns out to be cervical cancer. What E/M code(s) is (are) reported for this visit? A. 99215 B. 99213, 99358 C. 99214, 99354 D. 99213 A. 99215 A patient was admitted yesterday to the hospital for possible gallstones. The following day the physician who admitted the patient performed a detailed history, a detailed exam and a medical decision making of low complexity. The physician tells her the test results have come back positive for gallstones and is recommending having a cholecystectomy. What code is reported for this evaluation and management service for the following day? A. 99253 B. 99221 C. 99233 D. 99234 C. 99233 A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select the appropriate code(s) for this visit. A. 99284, 99219 B. 99219 C. 99284 D. 99235 B. 99219 A 6-month-old patient is administered general anesthesia to repair a cleft palate. What anesthesia code(s) is (are) reported for this procedure? A. 00170, 99100 B. 00172 20 C. 00172, 99100 D. 00176 C. 00172, 99100 A 50-year-old female had a left subcutaneous mastectomy for cancer. She now returns for reconstruction which is done with a single TRAM flap. Right mastopexy is done for asymmetry. Select the anesthesia code for this procedure. A. 00404 B. 00402 C. 00406 D. 00400 B. 00402 A patient is having knee replacement surgery. The surgeon requests that in addition to the general anesthesia for the procedure that the anesthesiologist also insert a continuous lumbar epidural infusion for postoperative pain management. The anesthesiologist performs postoperative management for two postoperative days. A. 01400-AA, 62326, 01996 x 2 B. 01402-AA, 62327, 01966 x 2 C. 01402-AA, 62326, 01996 x 2 D. 01404-AA, 62327 C. 01402-AA, 62326, 01996 x 2 A 35-year-old male sees his primary care physician complaining of fever with chills, cough and congestion. The physician performs a chest X-ray taking lateral and AP views in his office. The physician interprets the X-ray views and the patient is diagnosed with walking pneumonia. Which CPT® code is reported for the chest X-rays performed in the office and interpreted by the physician? A. 71046-26 B. 71047-26 C. 71046 D. 71045-26-TC C. 71046 This gentleman has localized prostate cancer and has chosen to have complete transrectal ultrasonography performed for dosimetry purposes. Following calculation of the planned transrectal 21 ultrasound, guidance was provided for percutaneous placement of 1-125 seeds. Select the appropriate codes for this procedure. A. 55920, 76965-26 B. 55876, 76942-26 C. 55860, 76873-26 D. 55875, 76965-26 D. 55875, 76965-26 A 76-year-old female had a ground level fall when she tripped over her dog earlier this evening in her apartment. The Emergency Department took X-rays of the left wrist in oblique and lateral views which revealed a displaced distal radius fracture, type I open left wrist. What radiological service and ICD-10 CM codes are reported? A. 73100-26, S52.502B, W18.31XA, Y92.039 B. 73110-26, S52.602A, W18.31XA, Y92.039 C. 73115-26, S52.502A, W18.31XA, Y92.039 D. 73100-26, S52.602B, W18.31XA, Y92.039 A. 73100-26, S52.502B, W18.31XA, Y92.039 An 18-year-old female with a history of depression comes into the ER in a coma. The ER physician orders a drug screen on antidepressants, phenothiazines, and benzodiazepines. The lab performs a screening for single drug class using an immunoassay in a random access chemistry analyzer. Presence of antidepressants is found and a drug confirmation is performed to identify the particular antidepressant. What correct CPT® codes are reported? A. 80307, 80338 B. 80305, 80338 C. 80306 x 3, 80332 D. 80307 x 3, 80333 A. 80307, 80338 A patient uses Topiramate to control his seizures. He comes in every two months to have a therapeutic drug testing performed to assess serum plasma levels of this medication. What lab code(s) is (are) reported for this testing? A. 80305 B. 80375 C. 80201 22 D. 80306, 80375 C. 80201 Patient that is a borderline diabetic has been sent to the laboratory to have an oral glucose tolerance test. Patient drank the glucose and five blood specimens were taken every 30 to 60 minutes up to three hours to determine how quickly the glucose is cleared from the blood. What code(s) is (are) reported for this test? A. 82947 x 5 B. 82946 C. 80422 D. 82951, 82952 x 2 D. 82951, 82952 x 2 A patient with severe asthma exacerbation has been admitted. The admitting physician orders a blood gas for oxygen saturation only. The admitting physician performs the arterial puncture drawing blood for a blood gas reading on oxygen saturation only. The physician draws it again in an hour to measure how much oxygen the blood is carrying. Select the codes for reporting this service. A. 82805, 82805-51 B. 82810, 82810-91 C. 82803, 82803-51 D. 82805, 82805-90 B. 82810, 82810-91 A new patient is having a cardiovascular stress test done in his cardiologist's office. Before the test is started the physician documents a comprehensive history and exam and moderate complexity medical decision making. The physician will be supervising and interpreting the stress on the patient's heart during the test. What procedure codes are reported for this encounter? A. 93015-26, 99204-25 B. 93016, 93018, 99204-25 C. 93015, 99204-25 D. 93018-26, 99204-25 C. 93015, 99204-25 A cancer patient is coming in to have a chemotherapy infusion. The physician notes the patient is dehydrated and will first administer a hydration infusion. The infusion time was 1 hour and 30 minutes. Select the code(s) that is (are) reported for this encounter? 23 A. 96360 B. 96360, 96361 C. 96365, 96366 D. 96422 A. 96360 A patient that has multiple sclerosis has been seeing a therapist for four visits. Today's visit the therapist will be performing a comprehensive reevaluation to determine the extent of progress. There was a revised plan assessing the changes in the patient's functional status. Initial profile was updated to reflect changes that affect future goals along with a revised plan of care. A total care of 30 minutes were spent in this re-evaluation. What CPT® and ICD-10-CM codes should be reported? A. 97168, Z51.89, G35 B. 97164, Z56.89, G35 C. 97167, G35 D. 97163, Z56.9, G35 A. 97168, Z51.89, G35 What is the term used for inflammation of the bone and bone marrow? A. Chondromatosis B. Osteochondritis C. Costochondritis D. Osteomyelitis D. Osteomyelitis The root word trich/o means: A. Hair B. Sebum C. Eyelid D. Trachea A. Hair Complete this series: Frontal lobe, Parietal lobe, Temporal lobe, ____________. A. Medulla lobe B. Occipital lobe 24 C. Middle lobe D. Inferior lobe B. Occipital lobe A patient is having pyeloplasty performed to treat an uretero-pelvic junction obstruction. What is being performed? A. Surgical repair of the bladder B. Removal of the kidney C. Cutting into the ureter D. Surgical reconstruction of the renal pelvis D. Surgical reconstruction of the renal pelvis A 27-year-old was frying chicken when an explosion of the oil had occurred and she sustained second degree burns on her face (5%), third degree burns on both hands (5%). There was a total of 10 percent of the body surface that was burned. Select which ICD-10-CM codes are reported. A. T20.20XA, T23.301A, T23.302A, T31.10, X10.2XXA, Y93.G3 B. T23.301A, T23.302A, T20.20XA, T31.11, X10.2XXA, Y93.G3 C. T23.301A, T23.302A, T20.20XA, T31.10, X10.2XXA, Y93.G3 D. T23.601A, T23.602A, T20.60XA, T31.10, X10.2XXA, Y93.G3 T31.10, X10.2XXA, Y93.G3 C. T23.301A, T23.302A, T20.20XA, A patient that has cirrhosis of the liver just had an endoscopy performed showing hemorrhagic esophageal varices. The ICD-10-CM codes are reported: A. I85.01, K74.69 B. I85.11, K74.60 C. K74.60, I85.11 D. I85.00, K74.69 C. K74.60, I85.11 A 55-year-old-patient had a fracture of his left knee cap six months ago. The fracture has healed but he still has staggering gait in which he will be going to physical therapy. What ICD-10-CM codes are reported? A. S82.002A, R26.81 B. R26.0, S82.002A 25 C. S82.092S, R26.0 D. R26.0, S82.002S D. R26.0, S82.002S Which statement is TRUE about Z codes: A. Z codes are never reported as a primary code. B. Z codes are only reported with injury codes. C. Z codes may be used either as a primary code or a secondary code. D. Z codes are always reported as a secondary code. code or a secondary code. C. Z codes may be used either as a primary Patient with corneal degeneration is having a cornea transplant. The donor cornea had been previously prepared by punching a central corneal button with a guillotine punch. This had been stored in Optisol GS. It was gently rinsed with BSS Plus solution and was then transferred to the patient's eye on a Paton spatula and sutured with 12 interrupted 10-0 nylon sutures. Select the HCPCS Level II code for the corneal tissue. A. V2790 B. V2785 C. V2628 D. V2799 B. V2785 The patient presents to the office for an injection. Joint prepped using sterile technique. Muscle group location: gluteus maximus. Sterilely injected with 40 mg of Kenalog-10, 2 cc Marcaine and 2 cc lidocaine 2%. Sterile bandage applied. Choose the HCPCS Level II code for this treatment. A. J3301 x 4 B. J3301 C. J3300 x 40 D. J3300 A. J3301 x 4 Which of the following is an example of electronic data? A. A digital X-ray B. An explanation of benefits 26 C. An advance beneficiary notice D. A written prescription A. A digital X-ray Which health plan does NOT fall under HIPAA? A. Medicaid B. Medicare C. Workers' compensation D. Private plans C. Workers' compensation Guidelines from which of the following code sets are included as part of the code set requirements under HIPAA? A. CPT® Category III codes B. ICD-10-CM C. HCPCS Level II D. ADA Dental Codes B. ICD-10-CM Which statement is an example in which a diabetes-related problem exists and the code for diabetes is NEVER sequenced first? A. If the patient has an underdose of insulin due to an insulin pump malfunction. B. If the patient is being treated for secondary diabetes. C. If the patient is being treated for Type 2 diabetes and uses insulin. D. If the patient is diabetic with an associated condition. insulin due to an insulin pump malfunction. A. If the patient has an underdose of Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon. No tumor was identified after the final stage of the microscopically controlled surgery. What procedure codes are reported? A. 17313, 17314, 17314 27 B. 17313, 17315 C. 17260, 17313, 17314 D. 17313,17314, 17315 D. 17313,17314, 17315 A 45-year-old male is in outpatient surgery to excise a basal cell carcinoma of the right nose and have reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect. Which CPT® code(s) is (are) reported? A. 14060 B. 11642, 14060 C. 11642, 15115 D. 15574 A. 14060 A 24-year-old patient had an abscess by her vulva which burst. She has developed a soft tissue infection caused by gas gangrene. The area was debrided of necrotic infected tissue. All of the pus was removed and irrigation was performed with a liter of saline until clear and clean. The infected area was completely drained and the wound was packed gently with sterile saline moistened gauze and pads were placed on top of this. The correct CPT® code is: A. 56405 B. 10061 C. 11004 D. 11042 C. 11004 A 76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o'clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues. The specimen wa D. 19125, D24.2 28 The patient is a 66-year-old female who presents with Dupuytren's disease in the right palm and ring f inger. This results in a contracture of the ring digit MP joint. She is having a subtotal palmar fasciectomy for Dupuytren's disease right ring digit and palm. An extensile Brunner incision was then made beginning in the proximal palm and extending to the ring finger PIP crease. This exposed a large pretendinous cord arising from the palmar fascia extending distally over the flexor tendons of the ring finger. The fascial attachments to the flexor tendon sheath were released. At the level of the metacarpophalangeal crease, one band arose from the central pretendinous cord-one coursing toward the middle finger. The digital nerve was identified, and this diseased fascia was also excised. What procedure code(s) is (are) used? A. 26123-RT, 26125-F7 B. 26121-RT C. 26035-RT D. 26040-RT A. 26123-RT, 26125-F7 This is a 32-year-old female who presents today with sacroilitis. On the physical exam there was pain on palpation of the left and right sacroiliac joint and fluoroscopic guidance was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left and right sacroiliac joint with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up will be as needed. The correct CPT® code(s) is (are): A. 20611 B. 27096-50, 77012 C. 27096-50 D. 27096, 27096-51, 77012 C. 27096-50 PREOPERATIVE DIAGNOSIS: Medial meniscus tear, right knee POSTOPERATIVE DIAGNOSIS: Medial meniscus tear, extensive synovitis with an impingement medial synovial plica, right knee TITLE OF PROCEDURE: Diagnostic operative arthroscopy, partial medial meniscectomy and synovectomy, right knee The patent was brought to the operating room, placed in the supine position after which he underwent general anesthesia. The right knee was then prepped and draped in the usual sterile fashion. The arthroscope was introduced through an anterolateral portal, interim portal created anteromedially. The suprapatellar pouch was inspected. The findings on the patella and the femoral groove were as noted above. An intra-articular shaver was introduced to debride the loose fibrillated articular cartilage from the medial patellar facet. The hypertrophic synovial scarring between the patella and the femoral groove was debrided. The hypertrophic C. 29881-RT, M23.221, M65.861, M94.261, M22.41 29 A 61-year-old gentleman with a history of a fall while intoxicated suffered a blow to the forehead and imaging revealed a posteriorly displaced odontoid fracture. The patient was taken into the Operating Room, and placed supine on the operating room table. Under mild sedation, the patient was placed in Gardner-Wells tongs and gentle axial traction under fluoroscopy was performed to gently try to reduce the fracture. It did reduce partially without any change in the neurologic examination. More manipulation would be necessary and it was decided to intubate and use fiberoptic technique. The anterior neck was prepped and draped and an incision was made in a skin crease overlying the C4-C5 area. Using hand-held retractors, the ventral aspect of the spine was identified and the C2-C3 disk space was identified using lateral fluoroscopy. Using some pressure upon the ventral aspect of the C2 body, we were able to achieve a s D. 22318 The patient is a 51-year-old gentleman who has end-stage renal disease. He was in the OR yesterday for a revision of his AV graft. The next day the patient had complications of the graft failing. The patient was back to the operating room where an open thrombectomy was performed on both sides getting good back bleeding, good inflow. Select the appropriate code for performing the procedure in a post-operative period: A. 36831-76 B. 36831 C. 36831-78 D. 36831-58 C. 36831-78 The patient is a 77-year-old white female who has been having right temporal pain and headaches with some visual changes and has a sed rate of 51. She is scheduled for a temporal artery biopsy to rule out temporal arteritis. A Doppler probe was used to isolate the temporal artery and using a marking pen the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade scalpel the skin was opened in the preauricular area and dissected down to the subcutaneous tissue where the temporal artery was identified in its bed. It was a medium size artery and we dissected it out for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the artery was removed from its bed and sent to Pathology as specimen. What CPT® code is reported? A. 37609 B. 37605 C. 36625 D. 37799 A. 37609 A 50-year-old female has recurrent lymphoma in the axilla. Ultrasound was used to localize the lymph node in question for needle guidance. An 11 blade scalpel was used to perform a small dermatotomy. An 30 18 x 10 cm Biopence needle was advanced through the dermatotomy to the periphery of the lymph node. A total of 4 biopsy specimens were obtained. Two specimens were placed an RPMI and 2 were placed in formalin and sent to laboratory. The correct CPT® code(s) is (are): A. 10005 B. 38500, 77002-26 C. 38505, 76942-26 D. 38525, 76942-26 C. 38505, 76942-26 Patient is going into the OR for an appendectomy with a ruptured appendicitis. Right lower quadrant transverse incision was made upon entry to the abdomen. In the right lower quadrant there was a large amount of pus consistent with a right lower quadrant abscess. Intraoperative cultures anaerobic and aerobic were taken and sent to microbiology for evaluation. Irrigation of the pus was performed until clear. The base of the appendix right at the margin of the cecum was perforated. The mesoappendix was taken down and tied using 0-Vicryl ties and the appendix fell off completely since it was already ruptured with tissue paper thin membrane at the base. There was no appendiceal stump to close or to tie, just an opening into the cecum; therefore, the appendiceal opening area into the cecum was tied twice using f igure of 8 Vicryl sutures. Omentum flap was tacked over this area and anchored in place using interrupted 3-0 Vi B. 44960, 49905, K35.33 A 15 year-old female is to have a tonsillectomy performed for chronic tonsillitis and hypertrophied tonsils. A McIver mouth gag was put in place and the tongue was depressed. The nasopharynx was digitalized. No significant adenoid tissue was felt. The tonsils were then removed bilaterally by dissection. The uvula was a huge size because of edema, a part of this was removed and the raw surface oversewn with 3-0 chromic catgut. Which CPT® code(s) is (are) reported? A. 42821 B. 42825, 42104-51 C. 42826, 42106-51 D. 42842 C. 42826, 42106-51 A 34-year-old male developed a ventral hernia when lifting a 60 pound bag. The patient is in surgery for a ventral herniorrhaphy. The abdomen was entered through a short midline incision revealing the fascial defect. The hernia sac and contents were able to easily be reduced and a large plug of mesh was placed into the fascial defect. The edge of the mesh plug was sutured to the fascia. What procedure code(s) is (are) reported? A. 49560 31 B. 49561, 49568 C. 49652 D. 49560, 49568 D. 49560, 49568 A 25-year-old female in the OR for ectopic pregnancy. Once the trocars were place a pneumoperitoneum was created and the laparoscope introduced. The left fallopian tube was dilated and was bleeding. The left ovary was normal. The uterus was of normal size, shape and contour. The right ovary and tube were normal. Due to the patient's body habitus the adnexa could not be visualized to start the surgery. At this point the laparoscopic approach was terminated. The pneumoperitoneum was deflated, and trocar sites were sutured closed. The trocars and laparoscopic instruments had been removed. Open surgery was performed incising a previous transverse scar from a cesarean section. The gestation site was bleeding and all products of conception and clots were removed. The left tube was grasped, clamped and removed in its entirety and passed off to pathology. What code(s) is (are) reported for this procedure? A. 59150, 59120 B. D. 59120 A 23-year-old who is pregnant at 39-weeks and 3 days is presenting for a low transverse cesarean section. An abdominal incision is made and was extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the lower uterine segment incised in a transverse fashion with the scalpel. The bladder blade was removed and the infant's head delivered atraumatically. The nose and mouth were suctioned with the bulb suction trap and the cord doubly clamped and cut. The placenta was then removed manually. What CPT® and ICD-10-CM codes are reported for this procedure? A. 59610, O34.211, Z37.0, Z3A.39 B. 59510, O64.1XX0, Z37.0, Z3A.39 C. 59514, O82, Z37.0, Z3A.39 D. 59515, O82, Z37.0, Z3A.39 C. 59514, O82, Z37.0, Z3A.39 A 55-year-old female has a symptomatic rectocele. She had been admitted and taken to the main OR. An incision is made in the vagina into the perineal body (central tendon of the perineum). Dissection was carried underneath posterior vaginal epithelium all the way over to the rectocele. Fascial tissue was brought together with sutures creating a bridge and the rectocele had been reduced with good support between the vagina and rectum. What procedure code should be reported? A. 45560 B. 57284 32 C. 57250 D. 57240 C. 57250 A craniectomy is being performed on a patient who has Chiari malformation. Once the posterior inferior scalp was removed a C-1 and a partial C-2 laminectomy was then performed. The right cerebellar tonsil was dissected free of the dorsal medulla and a gush of cerebrospinal fluid gave good decompression of the posterior fossa content. Which CPT® code is reported? A. 61322 B. 61345 C. 61343 D. 61458 C. 61343 Under fluoroscopic guidance an injection of a combination of steroid and analgesic agent is performed on T2-T3, T4-T5, T6-T7 and T8-T9 on the left side into the paravertebral facet joints. The procedure was performed for pain due to thoracic root lesions. What are the procedure codes? A. 64479, 64480x3, 77003 B. 64490, 64491, 64492x2, 77003 C. 64520x4, 77003 D. 64490, 64491, 64492 D. 64490, 64491, 64492 An entropion repair is performed on the left lower eyelid in which undermining was performed with scissors of the inferior lid and inferior temporal region. Deep sutures were used to separate the eyelid margin outwardly along with stripping the lateral tarsus to provide firm approximation of the lower lid to the globe. The correct CPT® code is: A. 67914-E4 B. 67924-E2 C. 67921-E2 D. 67917-E1 B. 67924-E2 The patient is here to follow up on her atrial fibrillation. Her primary care physician is not in the office. She will be seen by the partner physician that is also in the same group practice. No new problems. A problem focused history is performed. An expanded problem focused physical exam is documented with 33 the following, Blood pressure is 110/64. Pulse is regular at 72. Temp is 98.6F Chest is clear. Cardiac normal sinus rhythm. Medical making decision is straightforward. Diagnosis: Atrial fibrillation, currently stable. What E/M code is reported for this service? A. 99201 B. 99202 C. 99212 D. 99213 C. 99212 Documentation of a new patient in a doctor's office setting supports a detailed history in which there are four elements for an extended history of present illness (HPI), three elements for an extended review of systems (ROS) and a pertinent Past, Family, Social History (PFSH). There is a detailed examination of six body areas and organ systems. The medical making decision making is of high complexity. Which E/M service supports this documentation? A. 99205 B. 99204 C. 99203 D. 99202 C. 99203 A 2 year-old is brought to the ER by EMS for near drowning. EMS had gotten a pulse. The ER physician performs endotracheal intubation, blood gas, and a central venous catheter placement. The ER physician documents a total time of 30 minutes on this critical infant in which the physician already subtracted the t ime for the other billable services. Select the E/M service and procedures to report for the ER physician? A. 99291-25, 36555, 31500 B. 99291-25, 36556, 31500, 82803 C. 99285-25, 36556, 31500, 82803 D. 99475-25, 36556 A. 99291-25, 36555, 31500 A 2-year-old is coming in with his mom to see the pediatrician for fever, sore throat, and pulling of the ears. The physician performs an expanded problem focused history. An expanded problem focused exam. A strep culture was taken for the pharyngitis and came back positive for strep throat. A diagnosis was also made of the infant having acute otitis media with effusion in both ears. The medical decision making was of moderate complexity with the giving of a prescription. What CPT® and ICD-10-CM codes are reported? 34 A. 99212, J02.9, H66.93 B. 99213, J02.0 H65.93 C. 99212, J02.0 H65.193 D. 99213, J02.0 H65.193 D. 99213, J02.0 H65.193 A very large lipoma is removed from the chest measuring 8 sq cm and the defect is 12.2 cm requiring a layered closure with extensive undermining. MAC is performed by a medically directed Certified Registered Nurse Anesthetist (CRNA). Code the anesthesia service. A. 00400-QX-QS B. 00400-QS C. 00300-QS D. 00300-QX-QS A. 00400-QX-QS PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse marginal, saphenous vein graft to the diagonal. The patient is placed on heart and lung bypass during the procedure. Anesthesia time: 6:00 PM to 12:00 AM Surgical time: 6:15 PM to 11:30 PM What is the correct anesthesia code and anesthesia time? A. 00567, 6 hours B. 00566, 6 hours C. 00567, 5 hours and 30 minutes D. 00566, 5 hours and 30 minutes A. 00567, 6 hours A CT density study is performed on a post-menopausal female to screen for osteoporosis. Today's visit the bone density study will be performed on the spine. Which CPT® code is reported? A. 77075 B. 77080 C. 77078 D. 72081 C. 77078 35 The patient is 15-weeks pregnant with twins coming back to her obstetrician to have a transabdominal ultrasound performed to reassess anatomic abnormalities of both fetuses that were previously demonstrated in the last ultrasound. What ultrasound code(s) is (are) reported? A. 76815 B. 76816, 76816-59 C. 76801, 76802 D. 76805, 76810 B. 76816, 76816-59 67-year-old female fractured a port-a-cath surgically placed a year ago. Under sonographic guidance a needle was passed into the right common femoral vein. The loop snare was positioned in the right atrium where a portion of the fractured catheter was situated. The catheter crossed the atrioventricular valve with the remaining aspect of the catheter in the ventricle. A pigtail catheter was then utilized to loop the catheter and pull the catheter tip into the inferior vena cava. The catheter was then snared and pulled through the right groin removed in its entirety. What CPT® and ICD-10-CM codes are reported? A. 37200, T81.509D B. 37197, T82.514A C. 37193, T80.219A D. 37217, T88.8XXA B. 37197, T82.514A A 53-year-old woman with ascites consented to a procedure to withdraw fluid from the abdominal cavity. Ultrasonic guidance was used for guiding the needle placement for the aspiration. What CPT® codes should be used? A. 49083 B. 49180, 76942-26 C. 49082, 77002-26 D. 49180, 76998-26 A. 49083 Cells were taken from amniotic fluid for analyzation of the chromosomes for possible Down's syndrome. The geneticist performs the analysis with two G-banded karyotypes analyzing 30 cells. Select the lab code(s) for reporting this service. A. 88248 B. 88267, 88280, 88285 36 C. 88273, 88280, 88291 D. 88262, 88285 B. 88267, 88280, 88285 Sperm is being prepared through a washing method to get it ready for the insemination of five oocytes for fertilization by directly injecting the sperm into each oocyte. Choose the CPT® codes to report this service. A. 89257, 89280 B. 89260, 89280 C. 89261, 89280 D. 89260, 89268 B. 89260, 89280 A pathologist performs a comprehensive consultation and report after reviewing a patient's records and specimens from another facility. The correct CPT® code to report this service is: A. 88325 B. 99244 C. 88323 D. 88329 A. 88325 Patient with hemiparesis on the dominant side due to having a CVA lives at home alone and has a therapist at his home site to evaluate meal preparation for self-care. The therapist observes the patient's functional level of performing kitchen management activities within safe limits. The therapist then teaches meal preparation using one handed techniques along with adaptive equipment to handle different kitchen appliances. The total time spent on this visit was 45 minutes. Report the CPT® and ICD 10-CM codes for this encounter. A. 97530 x 3, I67.89, G81.91 B. 97535 x 3, G81.90, I69.959 C. 97530 x 3, I69.959, I67.89 D. 97535 x 3, I69.959 D. 97535 x 3, I69.959 A 10-year-old patient had a recent placement of a cochlear implant. She and her family see an audiologist to check the pressure and determine the strength of the magnet. The transmitter, 37 microphone and cable are connected to the external speech processor and maximum loudness levels are determined under programming computer control. Which CPT® code should be used? A. 92601 B. 92603 C. 92604 D. 92562 B. 92603 A cardiologist pediatrician sends a four week-old baby to an outpatient facility to have an echocardiogram. The baby has been having rapid breathing. He is sedated and a probe is placed on the chest wall and images are taken through the chest wall. A report is generated and sent to the pediatrician. The interpretation of the report by the pediatrician reveals the baby has an atrial septal defect. Choose the CPT® code the cardiologist pediatrician should report. A. 93303 B. 93315-26 C. 93303-26 D. 93315