CPC PRactice Exam B UPDATED ACTUAL
Exam Questions and CORRECT
Answers
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 sub-glandular 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. The possibility
of injury to the implant was discussed with the patient. The 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 i - CORRECT ANSWER - 19081
Rationale :
To start narrowing your choices was the biopsy performed percutaneously or by an open
incision? The operative note documents that a "SenoRx needle" was used to obtain the biopsy,
which is percutaneous.
Code 19283 is reported only for the placement of the localization device. Stereotactic image was
used to perform the needle biopsy and placement of the clip.
Code 19081 is the only code reported for the operative note because its code description reports
both the biopsy and the placement of the clip under stereotactic imaging.
A 53-year-old male is in the dermatologist's office for the 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? - CORRECT ANSWER - 11310, 11104-59
Rationale :
The first procedure performed was the lesion on the lower lip removed by the shaving technique,
reported with code 11310.
The punch biopsy is performed on the lesion located on the nose, reported with code 11104.
Add-on code 11105 is only reported with codes 11104 or 11106, refer to the parenthetical
instructional note under add-on code 11105.
Modifier 59 indicates that the biopsy was totally separate performed on another lesion, otherwise
it is bundled with 11310.
A 76-year-old has dermatochalasis on bilateral upper eyelids. The condition does not interfere
with the function of the eyelids. The patient agrees to surgery. The patient is here for a bilateral
blepharoplasty. 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.
What CPT coding is reported? - CORRECT ANSWER - 15822-50
Rationale :
Patient is having a blepharoplasty done on the upper eyelids.
, The patient's condition is not interfering with function of the eyelids and there is no indication in
the scenario that excessive skin had to be excised.
Modifier 50 is appended to indicate the procedure was performed on both eyelids.
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 capsules and the posterior capsule was release - CORRECT
ANSWER - 29825-LT
Rationale :
To narrow down your choices decide if the procedure is an open procedure or performed with an
arthroscope?
The diagnostic arthroscopy (29805) is a separate procedure, and according to CPT Surgery
Guidelines : "The codes designated as "separate procedure" should not be reported in addition to
the code for the total procedure or service of which it is considered an integral component."
Meaning code 29806 already includes the diagnostic arthroscopy code, so you only report code
29806.
Code 29806 represents suturing of the capsule (capsulorrhaphy); however, this was not the
procedure performed. The procedure performed was lysis of adhesions for a frozen shoulder
(29825)
Exam Questions and CORRECT
Answers
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 sub-glandular 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. The possibility
of injury to the implant was discussed with the patient. The 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 i - CORRECT ANSWER - 19081
Rationale :
To start narrowing your choices was the biopsy performed percutaneously or by an open
incision? The operative note documents that a "SenoRx needle" was used to obtain the biopsy,
which is percutaneous.
Code 19283 is reported only for the placement of the localization device. Stereotactic image was
used to perform the needle biopsy and placement of the clip.
Code 19081 is the only code reported for the operative note because its code description reports
both the biopsy and the placement of the clip under stereotactic imaging.
A 53-year-old male is in the dermatologist's office for the 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? - CORRECT ANSWER - 11310, 11104-59
Rationale :
The first procedure performed was the lesion on the lower lip removed by the shaving technique,
reported with code 11310.
The punch biopsy is performed on the lesion located on the nose, reported with code 11104.
Add-on code 11105 is only reported with codes 11104 or 11106, refer to the parenthetical
instructional note under add-on code 11105.
Modifier 59 indicates that the biopsy was totally separate performed on another lesion, otherwise
it is bundled with 11310.
A 76-year-old has dermatochalasis on bilateral upper eyelids. The condition does not interfere
with the function of the eyelids. The patient agrees to surgery. The patient is here for a bilateral
blepharoplasty. 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.
What CPT coding is reported? - CORRECT ANSWER - 15822-50
Rationale :
Patient is having a blepharoplasty done on the upper eyelids.
, The patient's condition is not interfering with function of the eyelids and there is no indication in
the scenario that excessive skin had to be excised.
Modifier 50 is appended to indicate the procedure was performed on both eyelids.
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 capsules and the posterior capsule was release - CORRECT
ANSWER - 29825-LT
Rationale :
To narrow down your choices decide if the procedure is an open procedure or performed with an
arthroscope?
The diagnostic arthroscopy (29805) is a separate procedure, and according to CPT Surgery
Guidelines : "The codes designated as "separate procedure" should not be reported in addition to
the code for the total procedure or service of which it is considered an integral component."
Meaning code 29806 already includes the diagnostic arthroscopy code, so you only report code
29806.
Code 29806 represents suturing of the capsule (capsulorrhaphy); however, this was not the
procedure performed. The procedure performed was lysis of adhesions for a frozen shoulder
(29825)
