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Cytopathology is the study of:
a. Tissue
b. Cells
c. Blood
d. Organs
c. Unequal vision in the two eyes
What is the ICD-10-CM code for hay fever?
a. J30.1
b. J30.89
c. J30.81
d. J45.909
What is the ICD-10-CM code for eyestrain?
a. H53.10, H53.10
b. H57.8
c. H57.8, H57.8
d. H53.10
A 45 year-old-male patient has developed an ulcer on his upper back. He has had diabetes for several years and is on insulin. The provider determines that the ulcer is due to his diabetes. What ICD-10-CM codes are reported?
a. E11.622, Z79.4
b. E11.9, L98.429, Z79.4
c. E11.622, L98.429, Z79.4
d. E11.622, L98.429
b. Causes of injury or health condition.
A patient is prescribed anticonvulsant medication for her seizures. She returns to her doctor three days later with nausea and rash due to taking the anticonvulsant medication. The provider notes that this is a drug reaction to an anticonvulsant and changes the medication. What ICD-10-CM codes are reported?
a. L27.0, R11.2, T42.71XA
b. R21, R11.2, T42.71XA
c. R21, R11.0, T42.75XA
d. L27.0, R11.0, T42.75XA
Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?
a. There are separate codes for carbuncles and furuncles.
b. The differentiation between a carbuncle and a furuncle is specified by a 7th character extender.
c. Code L02.43 is a complete code.
d. Carbuncles and furuncles are reported with the same code.
Patient presents to the physician for removal of a squamous cell carcinoma of the right cheek. After the area is prepped and draped in a sterile fashion the surgeon measured the lesion, and documented the size of the lesion as 2.3 cm at its largest diameter. Additionally, the physician took margins of 2 mm on each side of the lesion. Single layer closure was performed. The patient tolerated the procedure well. What CPT® code(s) is/are reported?
a. 11643, 12013
b. 11642, 12013
c. 11643
d. 11442
Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician marked the area for excision. The margins and lesion measured a total of 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported?
a. 13121, 11401-51, D22.62
b. 11402, L72.3
c. 11401, D22.62
d. 12031, 11401-51, L72.3
Operative Report
Pre-Operative and Post-Operative Diagnosis: Squamous cell carcinoma, left leg
Open wound, right leg
Personal history of squamous cell carcinoma, right leg
INDICATIONS FOR SURGERY: The patient is an 81 year-old white man with biopsy-proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear.
Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well.
PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm². Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm².
What CPT® codes are reported?
a. 15100, 11603-51-LT, 15002-51-RT
b. 15100, 11403-51-LT, 15100-51-RT
c. 15100, 11603-51-LT
d. 15100, 15100-51-LT, 11603-51-LT, 15002-51-RT
A 49 year-old female presented with chronic deQuervain’s disease and has been unresponsive to physical therapy, bracing or cortisone injection. She has opted for more definitive treatment. After induction of anesthesia, the patient’s left arm was prepared and draped in the normal sterile fashion. Local anesthetic was injected using a combination 2% lidocaine and 0.25% Marcaine. A transverse incision was made over the central area of the first dorsal compartment. The subcutaneous tissues were gently spread to protect the neural and venous structures. The retractors were placed. The fascial sheath of the first dorsal compartment was then incised and opened carefully. The underlying thumb abductor and extensor tendons were identified. The tissues were dissected and the extensor retinaculum of the first extensor compartment was incised. The fibrotic tissue was incised and the tendons gently released. The tendons were freely moving. Subcutaneous tissues were closed with a 3-0 Vicryl and the skin with 3-0 Prolene subcuticular closure. Steri-strips, Xeroform and dry sterile dressings were applied. What CPT® code is reported?
a. 25001-LT
b. 25118-LT
c. 25085-LT
d. 25000-LT
This 45 year-old male presents to the operating room with a painful mass of the right upper arm. Upon deep dissection a large mass in the soft tissue of the patient’s shoulder was noted. The mass appeared to be benign in nature. With deep blunt dissection and electrocautery, the mass was removed and sent to pathology. What CPT® code is reported?
a. 23075-RT
b. 23066-RT
c. 23030-RT
d. 23076-RT
A 16 year-old female was hit by a car while crossing a two-lane highway. She was taken to the hospital by ambulance. She was found to have an open wound of the left lower thigh, just above the knee and a displaced fracture of the left femoral neck. She was taken to the operating room within four hours of her injury. She was given general endotracheal anesthesia and was prepped and draped in sterile fashion. Debridement including excision of devitalized skin and muscle was performed on the lateral thigh. The area was approximately 15 sq cm. After debridement and thorough copious irrigation, the wound was closed with layer sutures and a dressing was applied and then covered with adhesive plastic. The patient was then prepped and draped for the fracture and turned on her right side. We all rescrubbed. An 8 inch incision was made over the left hip and the head of the femur was exposed. Multiple fragments from the neck and the greater tuberosity were removed. The decision was made to replace the femoral head. The femur was removed from the acetabulum and the femoral head was removed. The femoral canal was reamed and a prosthesis was placed. It was then replaced in the acetabulum with a good fit, and the capsule was closed. The wound was closed. The patient was sent to recovery in good condition.
a. 27125-LT, 11010-59-LT
b. 27236-LT, 11043-59-LT
c. 27130-LT, 11010-59-LT
d. 27244-LT, 11043-59-LT
A 74 year-old male presented with ankle avascular necrosis of the talus with collapse of the body. After general anesthesia and sterile prep, the patient was placed prone. A lateral incision was made. The fibula was dissected and approximately 6 cm of the fibula was removed for the autograft. There were a lot of free fragments of bone around the subtalar joint and the talus itself. The bone fragments were removed and a large defect consistent with avascular necrosis of the body of the talus was noted. An egg-shaped burr was introduced and the articulating cartilage of the ankle joint was excised and debrided. The subtalar joint was approached and resection of the articulating surface of the subtalar joint was completed. Bone graft from the fibula was prepared on the back table. We made two large blocks to fill the defect in the talus and then additional small fragments of cortical cancellous bone to fill in smaller defects around the talus and ankle. Fixation was performed in the calcaneocuboid. The talar screw was inserted, followed by fixation of the talonavicular, tibiotalar and additional compression. The ankle screws were inserted proximally and the wound was irrigated and closed in layers. What CPT® codes are reported?
a. 28730, 20900-51
b. 28725, 20924-51
c. 28705, 20902-51
d. 28715, 20910-51
What is the largest single mass of lymphatic tissue?
a. Spleen
b. Peyer’s Patches
c. Tonsils
d. Thymus
An 18 month-old patient is seen in the ED unable to breathe due to a toy he swallowed which had lodged in his throat. Soon brain death will occur if an airway is not established immediately. The ED provider performs an emergency transtracheal tracheostomy. What CPT® and ICD-10-CM codes are reported?
a. 31601, 31603, T17.228A
b. 31601, J34.9, T17.298A
c. 31603, T17.220A
d. 31603, T17.290A
A 27 year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C.
What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?
a. 32850, 32855, 32851
b. 32850, 32856, 32851 x 2
c. 32850, 32856, 32853
d. 32850, 32855 x 2, 32850-50
A 45 year-old presents with acute pericarditis. The surgeon makes a small incision between two ribs and enters the thoracic cavity. An endoscope is introduced and the pericardial sac is examined by direct visualization. Using an instrument introduced through the endoscope, the surgeon creates an opening in the pericardial sac for drainage purposes. What CPT® code is reported?
a. 32659
b. 32662
c. 32658
d. 32661
Due to infections from hemodialysis, the physician replaces a dual chamber implantable defibrillator system with a multi-lead system with an epicardial lead and transvenous dual chamber lead defibrillator system. The original dual leads are extracted transvenously. The generator pocket is relocated. What CPT® codes are reported?
a. 33244, 33220-51, 33264-51, 33223-59
b. 33243, 33202-51, 33263-51, 33223-59
c. 33241, 32330-51, 33263-51, 33223-59
d. 33244, 33202-51, 33264-51, 33223-59
A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured.
a. 35761-78
b. 35241
c. 35761
d. 35820-78
A patient is seen in the ED for nausea and vomiting that has persisted for 4 days. The ED physician treats the patient for dehydration which is documented in the patient’s record as the final diagnosis. What ICD-10-CM code(s) is/are reported for this encounter?
a. R11.2, E86.0
b. E86.0
c. R11.14
d. R11.10, R11.0, E86.0
What CPT® and ICD-10-CM codes represent the creation of an opening into the stomach to insert a temporary feeding tube for nutritional support in an adult patient with proximal esophageal carcinoma due to alcohol dependence? A gastric tube was not created.
a. 43870, C15.8, F10.99
b. 43831, D49.0, F10.10
c. 43830, C15.3, F10.20
d. 43653, C15.9, F10.20
Margaret has a cholecystoenterostomy with a Roux-en-Y. Five hours later, she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and was demonstrating early signs of peritonitis. What is the correct coding for the subsequent services on this date of service? The same surgeon took her back to the OR as the one who performed the original operation.
What CPT® code is reported?
a. 49000-58
b. 49402-77
c. 49000-77
d. 49402-78
Patient comes in today to the provider’s office for routine monthly Foley catheter change. A two way Foley catheter is replaced in the usual sterile fashion. An abdominal urinary drainage bag and bedside bag are given to the patient. What is/are the correct code(s)?
a. 51702, A4338, A4357, A4358
b. 51100
c. 51102
d. 51701, A4338, A4357, A4358
The patient is a pleasant 51 year-old male with morbid obesity, weighing approximately 560 pounds and BMI being 85.1. He has uncontrolled diabetes and was evaluated due to testicular pain. He was found to have erythema, edema and possible areas of eschar on the scrotum. He was transferred to the hospital, evaluated and found to be stable with cellulitis and suspect early Fournier’s gangrene. What are the appropriate ICD-10-CM codes reported?
a. N49.2, E11.9, E66.01, Z68.45
b. N50.1, E11.9, N49.2, E66.01, Z68.45
c. N50.1, N49.2, E66.01, Z68.52
d. E66.01, E11.9, N50.1, E66.01, Z68.52
An ED physician treats a 30 year-old patient who was a victim of a rape. She has bruises and other trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure?
a. 59300, S31.41XA, T74.21XA
b. 57260, N89.8
c. 57200, S31.41XA, T74.21XA
d. 57289, N89.8
A patient has ovarian cancer of both ovaries. She has removal of her ovaries with peritoneal washings and assessment of the abdomen for any metastases, including inspection of omentum, diaphragm and multiple biopsies. Lymph nodes in the pelvic and peri-aortic areas were also biopsied. She has previously had a hysterectomy. What are the CPT® and ICD-10-CM codes reported for this service?
a. 58943, C56.1, C56.2
b. 58950, 49255, C79.61, C79.62
c. 58720, 38770, C56.1, C79.62
d. 58940, C56.1, C56.2
Mrs. Smith is visiting her mother and is 150 miles away from home. She is in the 26th week of pregnancy. In the late afternoon she suddenly feels a gush of fluids followed by strong uterine contractions. She is rushed to the hospital but the baby is born before they arrive. In the ED she and the baby are examined and the retained placenta is delivered. The baby is in the neonatal nursery doing okay. Mrs. Smith has a 2nd degree perineal laceration secondary to precipitous delivery which was repaired by the ED physician. She will return home for her postpartum care. What ICD-10-CM and CPT® codes are reported by the ED physician?
a. 59409, 59414-51, 59300-51, O62.3, O70.1, Z3A.26, Z37.0
b. 59414, 59300-51, O73.0, O70.1, Z3A.26, Z37.0
c. 59414, 59300-51, O62.3, O70.9, Z3A.26, Z37.0
d. 59409, O80, Z3A.26, Z37.0
b. Contractions occurring on opposite sides of the body.
How is Streptococcal A Meningitis reported in ICD-10-CM?
a. Only Streptococcal, group A, as the cause of diseases classified elsewhere is reported.
b. Only one code is reported for streptococcal meningitis.
c. Streptococcal, group A, as the cause of diseases classified elsewhere is reported first; Streptococcal meningitis is reported second.
d. Streptococcal meningitis is reported first; Streptococcal, group A, as the cause of diseases classified elsewhere is reported second.
A 47 year-old female presents to the OR for a partial corpectomy to three thoracic vertebrae. One surgeon performs the transthoracic approach while another surgeon performs the three vertebral nerve root decompressions necessary. How should each provider involved code their portion of the surgery?
a. 63087-52, 63088-52 x 2
b. 63087-80, 63088-80 x 2
c. 63085-62, 63086-62 x 2
d. 63085, 63086-82 x 2
A patient recently experienced muscle atrophy and noticed she did not have pain when she cut herself on a piece of glass. The provider decides to obtain a needle biopsy of the spinal cord under ultrasound guidance in the outpatient setting. The biopsy results come back as syringomyelia. What CPT® and ICD-10-CM codes are reported for the biopsy procedure?
a. 62269, G12.9
b. 62270, 76942-26, G95.0
c. 62270, G12.9
d. 62269, 76942-26, G95.0
A 70 year-old female has a drooping left eyelid obstructing her vision and has consented to having the blepharoptosis repaired. A skin marking pencil was used to outline the external proposed skin incision on the left upper eyelid. The lower edge of the incision was placed in the prominent eyelid crease. The skin was excised to the levator aponeurosis. An attenuated area of levator aponeurosis was dehisced from the lower strip. Three 6-0 silk sutures were then placed in mattress fashion, attaching this attenuated tissue superiorly to the intact tissue inferiorly. This provided moderate elevation of the eyelid. What CPT® code is reported?
a. 67911-E1
b. 67901-E1
c. 67903-E1
d. 67904-E1
A 53 year-old woman with scarring of the right cornea has significant corneal thinning with a high risk of perforation and underwent reconstruction of the ocular surface. The eye is incised and an operating microscope is used with sponges and forceps to debride necrotic corneal epithelium. Preserved human amniotic membrane is first removed from the storage medium and transplanted by trimming the membrane to fit the thinning area of the cornea then sutured. This process was repeated three times until the area of thinning is flush with surrounding normal thickness cornea. All of the knots are buried and a bandage contact lens is placed with topical antibiotic steroid ointment. What CPT® code is reported?
a. 65435
b. 65780
c. 65781
d. 65710
c. General, Regional and Monitored Anesthesia Care
c. When the anesthesiologist begins to prepare the patient for anesthesia
A 42 year-old patient was undergoing anesthesia in an ASC and began having complications prior to the administration of anesthesia. The surgeon immediately discontinued the planned surgery. If the insurance company requires a reported modifier, what modifier best describes the extenuating circumstances?
a. 53
b. 23
c. 73
d. 74
The patient is a 63 year-old gentleman diagnosed with rectal cancer, who had a resection of the cancer performed. He now presents to have a Port-A-Cath (a central venous access device) inserted for postoperative adjuvant therapy. An 18-gauge introducer needle was inserted into the left subclavian vein through which a soft tipped guide wire was inserted into the superior vena cava under fluoroscopy. A subcutaneous pouch in the anterior part of the chest was created for the port. The catheter was then tunneled and measured to length. The dilator and introducer sheath were passed over the wire into the superior vena cava under fluoroscopic guidance. The catheter was passed through the sheath and the port was applied with good venous return. What CPT® codes are reported?
a. 36571, 77001-26
b. 36560, 77002-26
c. 36561, 77001-26
d. 36563, 77003-26
A CT study of the lumbar spine (L2-L4) was performed with IV contrast in the hospital outpatient radiology department and the interpretation of the images is performed by the radiologist. What CPT® code(s) should be reported by the radiologist who is not an employee of the hospital?
a. 72132
b. 72132-26
c. 72132-26, 72132-TC
d. 72132-TC
A patient has a traumatic head injury and some cerebrospinal fluid (CSF) is removed to limit potential damage from swelling of the brain. The CSF is sent to pathology for examination and the results show unusual cytological counts, although no specific findings. The patient has had no previous symptoms known to his family members. What is the ICD-10-CM code for this examination of CSF?
a. A39.0
b. Z00.01
c. S06.1X0A
d. R83.6
A left breast biopsy is performed on a mass and the surgeon requests a frozen section examination of the specimen to determine whether more extensive resection is appropriate. The frozen section reveals no indications of malignancy. No other specimen is obtained but the remainder of the biopsy specimen is sent for further testing and examination, including decalcification. The results indicate breast fibrosclerosis only. What CPT® and ICD-10-CM codes are reported?
a. 88331, 88313, N63.20
b. 88305, 88331, 88311, N60.32
c. 88307, 88305, 88331, 88313, N60.32
d. 88307, 88331, R92.0
A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?
a. Established patient office visit
b. Preventive medicine visit
c. Office consultation
d. New patient office visit
A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?
a. The chronic tonsillitis is reported first; the acute tonsillitis is reported second.
b. The acute tonsillitis is reported first; the chronic tonsillitis is reported second.
c. Only the chronic tonsillitis is reported.
d. Only the acute tonsillitis is reported.
An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?
a. 99471-25, 94610, 36510
b. 99291
c. 99471
d. 99291-25, 31500, 36510, 94610
65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening.
CHIEF COMPLAINT: CHF
INTERVAL HISTORY: CHF symptoms worsened since yesterday.
Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I’m concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.
REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins.
PHYSICAL EXAMINATION:
GENERAL: Mild respiratory distress at rest
VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.
LUNGS: Worsening bibasilar crackles
CARDIOVASCULAR: RRR, no MRGs.
EXTREMITIES: Show worsening lower extremity edema.
LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.
IMPRESSION:
1. Severe exacerbation of CHF
2. Poorly controlled HTN
3. Worsening ARF due to cardio-renal syndrome
PLAN:
1. Increase BUMEX to 2 mg IV Q6.
2. Give 500 mg IV DIURIL times one.
3. Re-check usual labs in a.m.
What E/M Category is used for this visit?
a. Inpatient Consultation (99251-99255)
b. Established Patient Office/Outpatient Visit (99211-99215)
c. Subsequent Hospital Visit (99231-99233)
d. Initial Hospital Visit (99221-99223)
What ICD-10-CM code is reported when a flu vaccine is administered?
a. J11.1
b. Z28.3
c. Z28.04
d. Z23
A 5 year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child’s skin was scratched with two different allergens. The provider waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen. The provider included the test interpretation and report in the record.
a. 95004 x 2
b. 95027 x 2
c. 95024 x 2
d. 95018 x 2
A 32 year-old ETOH dependent female is in a partial hospitalization program and has been seeing an addictive disease specialist (psychotherapist) in a chemical dependency program. Her employer is aware of her problem. She was referred to the group through their Employee Assistance Program. As long as she is in compliance they will support her efforts. Recently, she has arrived late at the meetings. The provider met with the patient and discussed the importance of her treatment, compliance with the program and avoidance of situations in which she may use alcohol. She denies contact with her previous associates and assures the provider she has had no alcohol intake since beginning the substance abuse treatment program. They will continue to reinforce her progress and successful sobriety. Time of the session was 45 minutes. What CPT® and ICD-10-CM codes are reported?
a. 90832, F10.220
b. 90832, F10.20
c. 90834, F10.20
d. 90834, F10.220
When coding in operative report what action would NOT be recommended?
Coding from the header with out reading the body of the report
If an NCD doesn’t exist for a particular service/procedure performed on a Medicare patient who determines coverage?
Medicare administrative contractor (MAC)
MAC stands for what!?
Medicare administrative contractor
What is the definition of coding?
Translating documentation into numerical/alphabetical codes used to obtain reimbursement.
How many components should be included in an effective compliance plan?
7
Which of the following is NOT a function of the skin?
Acts as a gland by synthesizing vitamin A.
What is affected by myasthenia gravis?
Neuromuscular junction
The term “episiotomy” Best describes a procedure of what type?
An incision made into the perineum to enlarge the passage for the fetus during delivery
A patient is diagnosed with inflammation of the testes and epididymis. The medical term for this condition is:
Orchiepididymitis
A condition where the thyroid is overactive is called:
Thyrotoxicosis
What does ICD 10 CM stand for?
International classification of diseases – 10th revised – clinical modification
What is the sequencing order when coding a sequela (late effect)?
The residual condition is coded first, in the code(s) for the cause of the late effect are coded as secondary
What is the ICD 10 CM code for hives?
L50.9
20-year-old comes into the ED with symptoms of a severe headache, vomiting, stiff neck, and fever. The ED physician suspects that the meningitis is bacterial and performs a lumber puncture. The ED physician reviews the results in the patient is admitted in the hospital for meningitis. The ED physician suspects that the meningitis is bacterial. Which ICD 10 CM code is reported by the ED physician?
G03.9
45 year old female with malignant Mullerian duct cancer is receiving her first treatment of chemotherapy. What diagnosis codes are reported?
Z51.11, C57.7
The patient is a 12 month old with a history of muscle weakness. Unfortunately his etiology is unknown and to help delineate the diagnosis neurology has consulted us to obtain a right biceps muscle biopsy. What diagnosis code is reported?
M62.81
The provider orders the following serum blood tests as part of a pre-employment physical exam. The patient goes to the local hospital for the following tests: CBC automated and automated differential WBC count (85025), comprehensive metabolic panel (80053), and a thyroid stimulating hormone assay (84443), all part of the general health panel. A drug screen for multiple drug classes was also collected (80100). What diagnosis code is reported?
Z02.1
What ICD 10 CM code is reported for a patient who is a habitual abuser of cannabis?
F12.10
What codes, according to ICD 10 CM sequencing guidelines, describe a patient that has heart disease due to malignant hypertension with left heart failure?
I11.0, 150.1
A 45-year-old male patient has developed in ulcer on his upper back. He has had diabetes for many years and is on insulin. The physician determines that the ulcer is due to his diabetes. What ICD 10 CM code are reported?
E11.622, L98.429, Z79.4
What does the root word cool/o stand for?
Vagina
What does the abbreviation CKD stand for?
Chronic kidney disease
The patient is in for in initial replacement of a leaking dialysis catheter. What ICD 10 CM code is reported?
T82.43XA
What is/are the external cause code(s) for a passenger involved in a MVA that lost control on the highway and hit a guardrail?
Y92.411
A patient was admitted three weeks following a normal vaginal delivery with a postpartum breast abscess. What ICD 10 code should be reported?
O91.12
A 28-year-old male was rushed to the ED after being found unconscious. Information from family members indicated that the patient had left a suicide note and taking a large amount of LSD (a hallucinogenic). What ICD 10 CM codes are reported?
T40.8X2A, R40.20
A 63-year-old fractured her scaphoid bone in her right wrist three months ago in an accident. She now presents with a non-union of the scaphoid bone. What ICD 10 CM code is reported?
S62.001K
What three components are considered when relative value units are established?
Physician work, practice expense, malpractice insurance
What is the correct HCPCS Level II code for a removable metatarsal foot arch support which is pre-molded?
L3050
What is another term for hives?
Urticaria
The patient has a suspicious lesion of the left Jolle line. Clinical diagnosis of this lesion is unknown but due to the appearance malignancy is a realistic concern. The lesion was excised into the suspicious that measuring .8 cm and margins of .1 cm on each side. Hemostasis was achieved using light pressure. The wound was closed in layers using 5.0 Monocryl and 6.0 Prolene. Pathology revealed a benign nevus with clear margins. What CPT and ICD 10 CM codes are reported?
12051, 11441-51, D23.39
44-year-old male with biplanar deformity acquired limb length discrepancies in tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. The intraoperative mounting parameter deformity parameters and initial strut settings are inserted into the computer prior to Jim’s discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT code should reported?
20697
A young female patient was taken to the operative suite, and was placed under appropriate anesthesia. She has been suffering from pain and a potential rotator cuff tear of the right shoulder. The right arm was sterilely draped and prepped. Arthroscopic portals were created anteriorly- posteriorly. The joint line was carefully examined. The biceps insertion was noted to be normal. The middle and inferior glenohumeral ligaments were visualized in noted to be normal. The undersurface of the rotator cuff was clearly visualized and also noted to be normal. There was a large anterior spur formation. The blur was introduced through a lateral portal and the anterior lip of the acromion was resected. The undersurface of the clavicle was noted to be quite prominent and part of the impinging process. There was intense bursitis and a bursectomy was performed, allowing for acromial decompression and release. Spurs were removed from the distal clavicle. All instruments were removed skin incisions were closed and a dress was applied. The patient was placed in a sling and returned to the recovery room. What CPT code is reported?
23415-RT
What modifier must always be applied to medicare claims for test performed in a site with CLIA Waived certificate?
QW
What does “in vivo” mean?
in the living body
what is the code for gross and microscopic examination (surgical pathology) of the breast tissue from a simple mastectomy?
88307
A patient presents with worries she is at risk for cancer. She asks for tests to verify whether she has cancer. The test comes back normal. What type of service is this considered?
screening services
If the findings on examination of a pap smear are normal and described as “negative for intraepithelial lesion or malignancy” this is a example of what type of results reporting?
Bethesda
What ICD-10-CM code is reported for elevated blood sugar?
R73.09
What ICD-10-CM code is reported for an abnormal cervical pap smear?
R87.619
A lab test reveals an excessive level of alcohol in the blood. What ICD-10-CM code is reported?
R78.0
What do the services in the Reproductive Medicine Procedures section of the Pathology and Laboratory chapter of CPT report?
Services related to in vitro fertilization
What is usually found in the blood if a person has or used to have an infecting virus?
Antibody
A patient with AIDS presents for follow up care. The total T-cell count is ordered to evaluate any progression of the disease. What CPT code is reported?
86359- Code 86359 is for total T-cell count. If other studies were performed and they were not ordered they may not be billed, no matter how seemingly appropriate. In the CPT Index, look for T Cells/Count.
A patient with AIDS presents for follow up care. An NK (natural killer cell) total count is ordered. What CPT code is/are reported?
86357- Although there are a number of cells that attack viruses and other infectious organisms, NK cells are specifically identified by code 86357. In the CPT Index, see Natural Killer (NK) Cells.
A virus is identified by observing growth patterns on cultured media. What is this type of identification is called?
Presumptive- Presumptive identification identifies microorganisms like by viruses by observing growth patterns and other characteristics.
CPT stands for:
Current Procedure Terminology
Which term reflects the technologic advances made in medicine that are incorporated into the CPT manual?
special reports
How man sections is the CPT manual divided into?
6
Where is specific coding information about each section located?
Guidelines
In which CPT appendix would modifiers be found?
Appendix A
In which CPT appendix would additions, deletions, and revisions be found?
Appendix B
A list of the unlisted procedures for use in a specific section of the CPT manual is contained in:
Guidelines
Who requires a special report with the use of unlisted codes?
Third-party payers
Which of the following represents three of the six elements that a special report must contain?
nature, extent, need
Which punctuation mark between codes in the index of the CPT manual indicates a range of codes is available?
hypen
Which punctuation mark between codes in the index of the CPT manual indicates two codes are available?
comma
The words that follow a code number in the CPT manual are called:
procedure/ service descriptor
A code that has all the words that describe the code following it is called what type of code?
stand alone
According to surgery guidelines, is surgical destruction part of a surgical procedure?
yes
First division in the CPT
SECTION
Second division in the CPT
SUBSECTION
Third division in the CPT
SUBHEADING
Fourth division in the CPT
CATEGORY
What is the largest single mass of lymphatic tissue?
Spleen
Which main coronary artery bifurcates into two smaller ones?
Left
What is the term for the divider between the heart chamber walls?
Septum
__ is a term standing for enlargement of the heart
Cardiomegaly
cardio= heart megaly= enlargement
repair of coronary vessel is called:
Angioplasty
angio= vessel plasty= repair
Where is the hypertension table located in ICD-10-CM?
there is no hypertension table in ICD-10-CM
Which statement is true regarding codes for hypertension and heart disease in ICD-10-CM?
Hypertension and heart disease without a stated casual relationship must be coded separately.
What information is needed in order to accurately code hypertension retinopathy in ICD-10-CM?
The affected eye(s)
What is the default code for coronary artery atherosclerosis?
1125.10
How many layers of tissue does an artery have?
3
The conduction system contains pacemaker cells, nodes, the , and the _.
Purkinje fibers and Bundle of His
What part of the cardiovascular system is responsible for the one-way flow of blood through the chambers of the heart?
Heart valves
What information is required to accurately code PVD due to diabetes in ICD-10-CM?
Whether the patient has gangrene
Bile empties into the duodenum through what structure?
Common bile duct
Which of the following is not a function on the skin?
Acts as a gland by synthesizing vitamin A.
What ICD-10-CM code is reported for spontaneous pneumothorax?
J93.83
When a patient has a blood test for HIV that is inconclusive, what ICD-10-CM code is assigned?
R75
What does MRSA stand for?
Methicillin resistant Staphylococcus Aureus
When do you code acute respiratory failure as a secondary diagnosis?
When it occurs after admission
When the type of diabetes mellitus is not documented in the medical note, what is used as the default type?
Type 2
If a patient uses insulin, what type of diabetic does it mean the patient is?
The use of insulin doesn’t specify the patient is a certain type of diabetic
According to ICD-10-CM Guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported?
The malignancy is reported first, followed by the code for the anemia.
First episode of an acute myocardial infraction
I21.3
secondary neoplasm of the descending colon
C78.5
In which circumstances would an external cause code be reported?
causes of injury or health condition
adverse effect
rash developing when taking oenicillin
colp/o
vagina
CKD stand for:
Chronic Kidney Disease
Which statement is TRUE for reporting burn codes?
The highest degree of burn is reported as primary code
codes for diseases and disorders of the nails
chapter 12 Skin
What does the 7th character A indicate in Chapter 19?
initial encounter
What codes are reported voluntarily to payers to provide evidence-based performance-measure data?
CPT Category II codes
CPT Category III codes are reimbursable at what level of reimbursement?
Reimbursement, if any, is determined by the payer
HCPCS stands for:
Healthcare Common Procedures Coding System
How many days does it take for CMS to implement HCPCS Level II Temporary Codes that have been reported as added, changed, or deleted?
90
OPPS
C codes
Which statement is TRUE regarding the Instruction for use of the CPT codebook?
select the name of the procedure or service that accurately identifies the service performed.