coding CPT/ICD questions with complete solutions

Contradictory documentation may be remedied proactively by using: Correct Answer: Communication tools Tools have been developed to facilitate communication to resolve differences between handwritten and dictated reports or other instances of disparate communication. Sometimes documentation in the health record or on the charge ticket needs to be corrected or verified. Many offices develop a form as a common communication tool for use between a coder and a physician. This form can be as simple or complex as the office sees fit (Kuehn 2014, 364). A bronchoscopy with biopsy of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure codes? Correct Answer: No modifiers should be reported. Because the lungs are paired organs, it may seem as though modifier -50 would be appropriate. However, a modifier would not be assigned because the bronchus is not a paired organ, and the bronchus is the location of the procedure, not the lungs. Similarly, it might seem as though modifier -LT would be assigned, but again, this would not be assigned as the bronchus is not a paired organ. In order to assign the correct modifier, it is important to note that paired organs include ears, eyes, nostrils, kidneys, lungs, ovaries, and such (CPT Assistant May 2003). According to the UHDDS, section III, the definition of other diagnoses is all conditions that: Correct Answer: Coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. The UHDDS item 11-b defines other diagnoses as "all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received or the length of stay" (HHS 2014, Section III, 100-101). What diagnoses and procedures should be reported for colonoscopy with cauterization of diverticular bleeding? Correct Answer: K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding 45382 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma, coagulator) The bleeding is included in the code for diverticulosis and therefore a second code is not warranted (CPT Assistant 4th Quarter 1990, 20-24). During an ambulatory surgery visit for excision of a malignant melanoma of the right forearm, the attending surgeon listed history o