Medical Coding II Coding Questions & Answers

The CPT category II code reported for a chronic obstructive pulmonary disease (COPD) patient's status as a current tobacco smoker is ___. - ANSWERS1034F The CPT category III code reported for a bilateral optical coherence tomography (OCT), middle ear, with interpretation and report is ___. - ANSWERS0486T A patient was supplied with an air pressure mattress. Report code ___ - ANSWERSE0186 Magnetic resonance imaging without contrast followed by with contrast, left breast. Report code ___ - ANSWERSC8905 LT A patient received an injection of hydrocortisone acetate, 15 mg, for contact dermatitis. Report code(s) ___ - ANSWERSJ1700 A patient received a gradient compression stocking, full length/chap style 30-40 mmHg. Report code ___ - ANSWERSA6537 A patient required catheterization for the collection of a specimen. Report code ___ - ANSWERSP9612 A patient received 2 mg IM injection of leuprolide acetate for treatment of prostate cancer. Report code(s) ___ - ANSWERSJ9218, J9218 A patient received behavioral health supportive treatment in the form of drug services, including methadone administration by a licensed physician. Report code ___ - ANSWERSH0020 An eight-year-old boy is fitted with a long-arm plaster cast. Service is performed in part by a resident under the direction of a teaching physician. Report code ___ - ANSWERSQ4007 GC The patient's family received 30 minutes of family training and counseling, which was provided for the purpose of child development. Report code(s) ___ - ANSWERST1027, T1027 A patient received a hand-held low-vision aid. Report code ___ - ANSWERSV2600 What code is reported for a level 3 emergency department service? - ANSWERS99283 An 89-year-old diabetic patient presented to the hospital emergency room for level 4 evaluation and management of a very painful lower left arm. An x-ray revealed left ulnar fracture. An appropriate medical history and examination was performed, and moderate level of medical decision making was documented. During the encounter, the physician reduced the fracture and applied a short-arm cast (for which a CPT Surgery section code was reported.) a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code and modifier are reported? (Enter None if no code is reported.) - ANSWERSa. Yes b. 99284-57 A 14-year-old patient presented to the primary care provider's office for treatment of a 3-centimeter laceration, which the physician sutured. The physician also administered a tetanus toxoid after confirming that the patient's tetanus immunization status was not up to date. Codes for suture repair of the laceration and administration of the tetanus toxoid were assigned from the CPT Surgery and Medicine sections, respectively. a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code is reported? (Enter None if no code is reported.) - ANSWERSa. no b. none Dr. Martinez performed a level 3 E/M service to treat an 18-year-old patient in the office for a urinary tract infection. The last time the patient was seen by Dr. Martinez was three months ago during a preventive medicine encounter. Urine culture revealed Escherichia coli bacteria. The patient was prescribed antibiotics and instructed to return for recheck in 10 days. a. The CPT E/M category is Office or Other Outpatient Services, and the subcategory is ___ Patient. b. The appropriate CPT code is ___. - ANSWERSa. Established b. 99213 Consultation: ASSESSMENT: Type 1 diabetes mellitus, controlled. Hypertension. PLAN: Glucotrol 5 milligrams daily, every morning. Procardia XL 30 milligrams daily. Relafen 1,000 milligrams daily. Continue home glucose monitoring. SMA-7 and glycosylated hemoglobin today. Return for routine follow-up in three months. a. What is the complexity of medical decision making? b. Which E/M code is assigned? - ANSWERSa. Moderate b. 99244 A 40-year-old patient was admitted to the hospital by the primary care provider (PCP) to control type II diabetes mellitus and to evaluate possible gangrene, left foot. The PCP ordered inpatient consultation services from an orthopedic surgeon, who provided level 4 E/M inpatient consultation services. The orthopedic surgeon told the patient and the PCP that immediate surgical debridement was necessary. Which Evaluation and Management code is assigned for the consultation service? - ANSWERS99254 57 The physician reviewed and revised the hospice agency care plan for an 84-year-old patient with Alzheimer's disease. For care plan oversight services requiring 25 minutes of the physician's time, CPT code __________ is reported. - ANSWERS99377 The physician provided 70 minutes of hospital inpatient discharge day management services to a 104-year-old patient who was transferred to an assisted living facility. Orders for pain management were provided to the facility. Which Evaluation and Management code(s) are assigned? - ANSWERS99239 A patient with a heart condition is scheduled to undergo a cesarean section. Due to the high-risk nature of the delivery, the attending physician requests standby service from a cardiac surgeon, and 30 minutes later the patient delivers a healthy newborn with no complications. Which Evaluation and Management code is reported by the cardiac surgeon? - ANSWERS99360 The physician had a 20-minute real-time interactive audio-video telemedicine encounter with an established patient to report results of blood tests, to provide instructions to the patient about lowering the Coumadin dosage, and to answer the patient's questions. A medically appropriate history was documented. Which Evaluation and Management code is reported? - ANSWERS99213 95 A new patient received treatment at a stand-alone urgent care center for flu symptoms with documentation of straightforward level of medical decision making. Which code is assigned? - ANSWERS99202 A six-year-old child undergoes an annual physical examination, and the child's last encounter was one year ago. Which code is reported? - ANSWERS99393 A patient with severe chest pain receives hospital observation services with documentation of a medically appropriate history and examination, moderate level of medical decision making, and discharge the same day. Which code is reported? - ANSWERS99235 A Medicare patient received office consultation services for the first time from a specialist who documented a medically appropriate history and examination during the 45-minute encounter. Which E/M code is reported? - ANSWERS99204 A patient diagnosed with sunburn and blister formation on the tops of the feet was seen in the emergency department with documentation of a medically appropriate history and examination and low level of medical decision making. Which code is reported? - ANSWERS99283 A physician performs a scheduled follow-up visit to a 65-year-old patient in a nursing facility who is recovering from pneumonia. A medically appropriate history and examination and straightforward level of medical decision making were documented. The patient has responded well to the treatment, and no complications are noted. Which code is reported? - ANSWERS99307 A new patient presents to the physician's office with complaints of severe earache, jaw pain, and facial swelling. The physician documented a medically appropriate history and examination. A total time of 50 minutes is documented for the encounter. Which code is reported? - ANSWERS99204 An established patient undergoes a four-month office check-up for medical management of high triglyceride levels, which lasted 20 minutes. A medically appropriate history and examination are documented. Which code is reported? - ANSWERS99213 A subsequent hospital visit was conducted for a 58-year-old patient admitted with an esophageal neoplasm who is spitting up blood. Metastasis is suspected, and the physician documented a medically appropriate examination and high level of medical decision making. Which is reported? - ANSWERS99233 A physician provided initial hospital care for the evaluation and management of a normal newborn infant who was admitted and discharged on March 5. Which code is reported? - ANSWERS99463 Office or Other Outpatient Services: A 4-year-old established patient received evaluation and management services in the physician's office, which included a low level of medical decision making. The patient is diagnosed with influenza ___. - ANSWERS99213 Office or Other Outpatient Services: A 16-year-old outpatient who is a new patient to the office complains of severe facial acne. A medically appropriate history and examination was documented. With a minimal number of diagnoses to consider and a minimal amount of data to review, the level of medical decision making is straightforward ___. - ANSWERS99202 Hospital Inpatient and Observation Care Services: A 50-year-old patient was admitted as a hospital inpatient on October 10 with a diagnosis of pneumonia due to Staphylococcus aureus, at which time level 2 E/M services were provided by the attending physician. On October 11 and October 12, the patient received level 2 E/M services. On October 13, the patient was discharged from the hospital in improved condition to follow up with the physician at home; the physician spent 30 minutes performing discharge day management functions. ___, ___, ___, ___ - ANSWERS99222, 99232, 99232, 99238 Hospital Inpatient and Observation Care Services: A patient is seen as a hospital inpatient on day two of the hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a medically appropriate history and examination. The possibility of pneumonia complicating the asthma must be considered. The patient's respiratory condition is still unstable. The level of medical decision making was moderate ___. - ANSWERS99232 Consultations: A 52-year-old patient was sent to a surgeon for an office consultation concerning hemorrhoids, and the health plan allows CPT consultation codes to be reported. A medically appropriate history and examination were performed. The consultant recommended treating with medication after straightforward level of medical decision making ___. - ANSWERS99242 Consultations: A 13-year-old was admitted as a hospital inpatient yesterday for a tympanotomy. Postsurgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested, and the health plan allows CPT consultation codes to be reported. This was done on the second hospital inpatient day and 24 hours after surgery. A medically appropriate history and examination was documented. The level of medical decision making was high complexity ___. - ANSWERS99255 Emergency Department Services: A patient in the emergency department has a temperature of 103°F and is in acute respiratory distress. Symptoms include severe shortness of breath, chest pain, and gasping. The physician is unable to obtain a history due to the patient's critical condition. The family was interviewed to obtain as much of a history as possible, and the physician performed a medically appropriate examination. The level of medical decision making is high ___. - ANSWERS99285 Emergency Department Services: With two-way communication, the physician provides direction of advanced life support to emergency medical technicians en route to the emergency department with an ambulance patient in apparent cardiac arrest ___. - ANSWERS99288 Emergency Department Services: A patient presents with the complaint of hematemesis. The patient also has a rapid pulse rate and low blood pressure. In the ED, critical care is provided by the ED attending to raise the patient's blood pressure and decrease blood loss. This is done for 70 minutes before the patient is transferred to the surgical suite for an endoscopic procedure to evaluate his esophagus. The ED physician also documents a medically appropriate examination and level of medical decision making is high. Due to the patient's serious medical condition, he is unable to provide any history; no family is present to provide information. ___, ___ - ANSWERS99285 57, 99291 Critical Care Services: A physician is called to the intensive care unit to provide care for a patient who received second- and third-degree burns over 50 percent of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day, the physician returns and provides an additional hour of critical care support to the patient. ___, ___, ___, ___, ___ - ANSWERS99291, 99292, 99292, 99292, 99292 Nursing Facility Services: A 72-year-old patient suffered a cerebral vascular accident. Today the patient is admitted to a skilled nursing facility (SNF) for rehab and medical care. The patient was just discharged from an acute care facility. The SNF medical director documents a medically appropriate history and examination. The physician orders a multidisciplinary rehabilitation care plan and continued treatment of the patient's other conditions, including hypertension and diabetes. The level of medical decision making is high ___. - ANSWERS99306 Nursing Facility Services: Subsequent follow-up care is provided for a comatose patient transferred to a long-term care center from the hospital two days ago. The resident shows no signs of consciousness on examination but appears to have developed a minor upper respiratory tract infection with a fever and rales heard on auscultation. The physician performs a medically appropriate history and examination. The physician is concerned that the respiratory infection could progress to pneumonia and orders the appropriate treatment. The level of medical decision making is low ___. - ANSWERS99308 Home or Residence Services: A 64-year-old established patient has diabetes and has been having problems adjusting prescribed insulin doses and has had an onset of dizziness and sensitivity to light. During the home visit, the physician documents a medically appropriate history and examination. The patient's condition is moderately severe, and level of medical decision making is low ___. - ANSWERS99348 Home or Residence Services: A 15-year-old new patient with cystic fibrosis is having problems with the dosage of Pulmozyme, which is a medication used to thin mucus that clogs the lungs. The patient is experiencing moderate throat pain and slight tightness of the chest. The physician makes a home visit, and a medically appropriate history and examination was documented. The level of medical decision making is moderate ___. - ANSWERS99344