Medical Coding Practice and Career Preparation - Mod 1: Coding Practice Physician Practice Encounters Questions & Answers

A 13-month-old is brought to her pediatrician for her one-year checkup. During that exam, the physician discussed immunizations, developmental milestones, and age-related risks, such as climbing, falls, accidental poisoning, drowning, car seat usage, and early childhood education. A comprehensive examination was done per American Academy of Pediatrics guidelines. During her routine exam, the physician noted left otitis media and URI, and ordered antibiotics, to be rechecked in two weeks. Reporting of additional diagnoses included documentation of a medically appropriate history and examination and 20 minutes was spent with the 13-month-old. Which of the following is the correct ICD-10-CM and CPT code assignment for this visit? Z00.121, H66.92, J06.9, 99392 Z00.110, H66.92, J06.9, 99391 Z00.121, H66.92, J06.9, 99391, 99213-25 Z00.121 H66.92, J06.9, 99392, 99213-25 - ANSWERSZ00.121 H66.92, J06.9, 99392, 99213-25 An 85-year-old patient of Dr. Smith's was brought to the clinic from her home after her family failed to get her to respond to their phone calls. She was poorly nourished, dehydrated, and confused. Dr. Smith admitted her to the hospital to stabilize her and then spent 45 minutes to discharge her to a nursing facility the next day. Dr Smith is the admitting physician for the nursing facility. Assuming that all documentation guidelines for each level of service have been met, which of the following is the correct CPT code assignment for Dr. Smith's services? 99222, 99304 99214, 99222, 99239, 99304 99214, 99235, 99304 99222, 99239, 99304 - ANSWERS99222, 99239, 99304 Preoperative Diagnosis: Shortness of breath, abnormal chest x-ray showing left lower lobe mass Postoperative Diagnosis: Carcinoma of the left lower lobe (per pathology report) Description of Procedure: Following local anesthesia, the pleural core needle biopsy is performed by passing the needle over the left side of the ribs under fluoroscopic guidance and the pleural cavity is entered and used to enter the area of the concern. Tissue is obtained from the lung for pathological examination. Which of the following is the correct ICD-10-CM and CPT code assignment for this physician's services? C34.32, 32400 C34.32, 32408 C34.32, R06.02, 32408 C34.30, 32408, 77002 - ANSWERSC34.32, 32408 This 30-year-old female had a successful vaginal delivery after a previous cesarean delivery. The patient's previous cesarean section was four years ago. The attending physician also provided the antepartum and postpartum care. During the hospitalization, she had a postpartum bilateral tubal ligation performed. Which of the following is the correct CPT code assignment for this physician's services? 59618, 58611 59610, 58605 59610 59614 - ANSWERS59610, 58605 Dr. Bill admitted a patient to observation after seeing him in the Emergency Department with severe nausea, vomiting, and dizziness from dehydration. IVs were started, and the plan was to hydrate the patient and discharge him to home the next morning. The patient, however, had not improved enough the next day (day 2) and was kept an additional 24 hours. On day 3, the patient was discharged home. Assuming that all documentation guidelines for each level of service have been met, which of the following is the correct sequence of CPT codes for Dr. Bill's services? 99283, 99231, 99217 99283, 99219, 99217 99219, 99231, 99217 99219, 99224, 99217 - ANSWERS99219, 99224, 99217 A 10-month-old infant was found to have a heart murmur during the newborn hospital stay. A 2D echocardiogram and Doppler study demonstrated a ventricular septal defect. At the age of 3 months, congestive heart failure developed, which has been managed by digitalis administration and diuretics. During this encounter, a cardiac catheterization is performed to measure the magnitude of the defect and to assess pulmonary artery pressure and resistance. A right heart catheterization with selective biplane cineangiocardiograms to the femoral vein for pulmonary angiography and supravalvular aortography were performed in the cardiac catheterization suite of the hospital. Because of the age of the patient, conscious sedation was provided using an intravenous route by the physician. The procedure lasted 30 minutes. Which of the following ICD-10-CM and CPT codes are reported by the pediatric cardiologist reporting this service? - ANSWERSQ21.0, I50.9, 93593-26, 93567-26, 93568-26 Preoperative Diagnosis: Chronic bilateral recurrent suppurative otitis mediaPostoperative Diagnosis: SameOperation: Bilateral myringotomy; placement of permanent ventilating tubeAnesthesia: GeneralProcedure: A standard myringotomy incision was made, and a copious amount of serous fluid suctioned from the middle ear cleft. A Goode T-tube was placed without problems. The procedure was then repeated on the left side in the same manner. Which of the following ICD-10-CM and CPT codes are reported by the surgeon for this procedure performed in the hospital surgery center? H66.90, 69421 H66.90, 69421-50 H66.3X3, 69436 H66.3X3, 69436-50 - ANSWERSH66.3X3, 69436-50 This adult female presented to the emergency department with injury of the left ribcage. This injury resulted from striking the corner of a countertop during a fall. The emergency medicine physician performed an expanded problem focused history, a detailed examination, and medical decision making of moderate complexity. The emergency medicine physician confirmed a stable rib fracture on the left side. Which of the following ICD-10-CM and CPT codes are reported for the services rendered by the emergency medicine physician? Note: No External Cause codes are required by her health plan. S22.32XA S22.32XA, 21800, 99283-25 S22.32XA, 29200 S22.32XA, 99283 - ANSWERSS22.32XA, 99283 Preoperative Diagnosis: Desired sterility Postoperative Diagnosis: Same Procedure: Bilateral vasectomy The patient was premedicated, brought to the OR in the supine position, prepped with Betadine, and draped in sterile fashion. 2% Xylocaine was then injected on the left side. A 1.5 cm. nevus was removed from the skin of the left lower abdominal quadrant followed by simple closure. After picking up the vas with two fingers, the incision was made transversely about 3/4 cm long and deepened through the layer of the scrotum to reach the vas. An Allis clamp was used to pick up the vas, which was identified by the feel and look of the tube, and this was then cleaned off of the sheets and layers over the same. The artery to the vas was then coagulated. A 1cm segment of the vas was then isolated and divided between clamps. The cut end of the vas was then coagulated on both sides and 2-0 chronic transfixion stitch was taken - ANSWERSZ30.2, D22.5, 55250, 11402-51 This is a 59-year-old male who presents to the ED complaining of injury to the left fourth finger sustained when he fell at work. He denies any other injury, weakness, or numbness. X-ray reveals a dorsal dislocation of the proximal interphalangeal joint of the left fourth finger. There was a small avulsion fracture to the base of the middle phalanx, as well. No other fractures were seen. The patient was given a digital block with 1% Xylocaine. After adequate anesthesia, longitudinal traction was applied to the finger, and the finger was easily reduced. Post reduction x-ray view was obtained. There was still a small avulsion fracture to the base of the middle phalanx. Otherwise no fractures were seen. The patient had full range of motion now with flexion and extension. The fourth finger was placed in a finger splint. Impression: Left fourth proximal interphalangeal joint dislocation, reduced. Avulsion fracture to the - ANSWERS26775-F3 Dr. Morgan made a home visit to see his long-time patient who was dying of cancer. He pronounced the patient dead approximately 75 minutes after arriving. He stayed an additional 30 minutes comforting the family and discussing her disease process. He documented a comprehensive interval history and a detailed exam. Medical decision making was straightforward. Total time spent counseling the family was 85 minutes. Which of the following is the correct CPT code assignment for Dr. Morgan's services? 99350, 99358 99345-21 99350 99358 - ANSWERS99350, 99358 Dr. Smith stops Dr. Jones in the hallway at the hospital and asks for his opinion on a patient. The conversation lasts approximately 20 minutes. Which of the following is the correct E/M code assignment? 99441 No code 99251 99211 - ANSWERSNo code A patient who sings professionally has developed nodules on the vocal cords that require removal. The surgery is performed in the ambulatory surgery center owned by the hospital. An operating microscope is employed, since the nodules are quite small. A topical anesthetic is administered after the appropriate preparation and draping. Under direct laryngoscopy, the laryngeal tumors are isolated and dissected free using stripping forceps. The pathology report confirmed that the nodules were not malignant and described them as "singers' nodes." Which of the following is the correct ICD-10-CM and CPT code assignment for this physician's service? J38.2, 31540, 69990 D14.1, 31540, 69990 D14.1, 31541 J38.2, 31541 - ANSWERSJ38.2, 31541