AAPC CPC QUESTIONS AND ANSWERS SURE A+
✔✔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
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 - ✔✔C. G0120
✔✔What is PHI?
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
D. Evaluating the patient in the post-anesthesia recovery area - ✔✔C. Returning to the
operating room 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 -
✔✔D. External cause codes should never be sequenced as a first-listed or primary code
,✔✔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?
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?
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
✔✔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
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 - ✔✔C. G0120
✔✔What is PHI?
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
D. Evaluating the patient in the post-anesthesia recovery area - ✔✔C. Returning to the
operating room 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 -
✔✔D. External cause codes should never be sequenced as a first-listed or primary code
,✔✔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?
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?
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
