CCS Exam prep Questions and Answers Latest Update 2023 (Verified Answers) (95 Questions)

2. Body system = Q (Lower bones)

3. Root operation = R (Replacement)

4. Body Part = 0 (Lumbar vertebra)

5. Approach = 0 (Open)

6. Device = J (Synthetic substitute)

7. Qualifier = Z (No qualifier)

Image: Dr. Smith replaced the patient's L2 vertebra with a prosthetic vertebra during this open procedure. The ICD-10-PCS code to report is:(Check image at right)
0QR00JZ
0QR00KZ
0QR107Z
0QR03JZ

Sophie came in to see her regular physician to ask him to complete the paperwork so Medicare will pay for her wheelchair. The code for this is:

Z00.00 Encounter for general adult medical examination without abnormal findings

Z02.79 Encounter for issue of other medical certificate

Z04.2 Encounter for examination and observation following work accident

Z07.1 Encounter for disability determination [Encounter for issue of medical certificate of incapacity]

A) Z04.2

B) Z07.1

C) Z00.00

D) Z02.79

Z07.1-Encounter for disability determination [Encounter for issue of medical certificate of incapacity]

A physician orders a lipid panel on a 54-year-old male with hypercholesterolemia, hypertension, and a family history of heart disease. The lab employee in his office performs and reports the total cholesterol and HDL cholesterol only.

82465-Cholesterol, serum or whole blood total

83718-Lipoprotein direct measurement high density cholesterol, (HDL)

Patient undergoes enucleation of left eye, and muscles were reattached to an implant.

65105-LT enucleation of eye; with implant, muscles attached to implant.. A modifier of -LT should be added to this code to indicate it was the left eye.

In ICD-10-PCS, percutaneous radio frequency ablation of the left vocal cord

0C5V3ZZ– (Percutaneous radio-frequency ablation of the left vocal cord)

2. Body system = C (Mouth and Throat) (The vocal cords are in the throat .)

3. Root operation = 5 (Destruction) (Ablation = surgical destruction of a body part)

4. Body part = V (Vocal cord, left)

5. Approach = 3 (Percutaneous approach)

In ICD-10-PCS, percutaneous endoscopic clipping cerebral aneurysm

03VG4CZ-(Percutaneous endoscopic clipping cerebral aneurysm)

2. Body system = 3 (Upper arteries) Cerebral arteries are in the brain

3. Root operation = V (Restriction)

4. Body part = G (Intracranial artery)

5. Approach = 4 (Percutaneous endoscopic approach)

6. Device = C (Extraluminal device)

A patient is admitted with dermatitis due to prescription topical antibiotic cream used as directed by a physician, initial encounter.

L25.1-Dermatitis due to drugs in contact with skin

T49.0x5A-Topical antibiotic cream causing an adverse effect, initial encounter

A patient is admitted with acute ST inferolateral wall myocardial infarction. Several days later during the same episode of care, the patient sustained a subsequent non-ST subendocardial myocardial infarction.

I21.19-ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I22.2- Subsequent Non-ST elevation (NSTEMI) myocardial infarction

In ICD-10-PCS, EGD with removal FB from duodenum

0DC98ZZ-(EGD with removal FB from duodenum)

2. Body system = D (Gastrointestinal System) – An EGD (Esophogastroduodenoscopy)

3. Root operation = C (Extirpation) – Removal of the FB (foreign body)

4. Body part = 9 (Duodenum)

5. Approach = 8 (Via natural or artificial opening endoscopic approach)

In ICD-10-PCS, administration of a concentrated bone marrow aspirate, performed percutaneously in the muscle

XK02303- (Administration, concentrated bone marrow aspirate, percutaneously in muscle)

1. Section = X (The New Technology Section)

2. Body system = K (Muscles, Tendons, Bursae, and Ligaments)

3. Root operation = 0 (Introduction)

4. Body Part = 2 (Muscle)

5. Approach = 3 (Percutaneous)

6. Device/Substance/Technology = 0 (Concentrated bone marrow aspirate)

7. Qualifier = 3 (New Technology Group 3)

A D&C is performed for postpartum hemorrhage.

59160- Curettage, postpartum

Patient is admitted for a blepharoplasty of the left lower eyelid and a repair for a tarsal strip of the left upper lid.

67917-E1-repair of the tarsal strip (ectropion). (E1 is a modifier meaning left upper eyelid).

15820-E2-Blepharoplasty, lower eyelid.(E2 is a modifier meaning lower left eyelid).

Creatinine clearance

82575 creatinine clearance.

Dr. Gastron fulgurated a rectal polyp of the patient. The root operation term used for this ICD-10-PCS code is:

A) Extraction: pulling or stripping out or off all or a portion of a body part by the use of force

B) Destruction: physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

C) Extirpation: taking or cutting out solid matter from a body part

D) Removal: taking out or off a device from a body part

Destruction: physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

The patient was brought into the ED with an embolism in her right pulmonary vein. Dr. Rogers brought her into the procedure room to fragment the clot. This is reported from the ______ Body System character of the ICD-10-PCS code.

Upper veins

Lower arteries

Upper arteries

Heart and great vessels

Heart and great vessels

A patient is admitted with withdrawal delirium tremens with alcohol dependence.

F10.231-Withdrawal delirium tremens with alcohol dependence

A male patient is admitted with gastrointestinal hemorrhage resulting in acute blood-loss anemia. A bleeding scan fails to reveal the source of the bleeding.

K92.2-Gastrointestinal hemorrhage

D62-Acute blood-loss anemia

In ICD-10-PCS, laparoscopic appendectomy

0DTJ4ZZ- (Laparoscopic appendectomy)

2. Body system = D (Gastrointestinal system) (The appendix is part of the lower gastrointestinal system.)

3. Root operation = T (Resection) (The entire appendix was removed, so it is resection

4. Body part = J (Appendix)

5. Approach = 4 (Percutaneous endoscopic approach)) Laparoscopy is a percutaneous endoscopic procedure

Patient presents to the operating room for excision of a 4.5 cm malignant melanoma of the left forearm. A 6 cm x 6 cm (36 sq cm) rotation flap was created for closure.

14301- Adjacent tissue transfer or rearrangement any area defect 30.1 sq cm to 60.0 sq cm

Patient has been diagnosed with prostate cancer. Patient arrived in the operating room where a therapeutic orchiectomy is performed.

54520 – orchiectomy, simple

Young child presents with cleft lip and cleft palate. This is the first attempt of repair, which includes major revision of the cleft palate and unilateral cleft lip repair.

42215 – Palatoplasty for cleft palate, major revision

40700- Plastic repair of cleft lip/nasal deformity, primary partial or complete unilateral

Chlamydia culture

87110 – culture, chlamydia

A 10 sq cm epidermal auto-graft to the face from the back

15115-Epidermal autograph, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits. First 100 sq cm or less, or 1% of body area of infants and children.

A woman has a Pap smear that detected cervical high-risk human papillomavirus (HPV). The DNA test was positive.

R87.810- Cervical Pap smear, DNA positive

A patient developed a malunion of the left medial condyle humeral fracture. The original injury occurred 4 months ago.

S42.462P- Fracture, medial condyle humeral fracture, malunion, (P)=subsequent encounter

In the Medical Surgical Section of ICD-10-PCS, the second character position represents which of the following?

Identify the correct root operation term used in ICD-10-PCS for the following:

A transfusion of whole blood was administered to the patient.

An established patient returns to the physician’s office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient’s last three glucose tests. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient’s insulin. An expanded history was taken, and a physical examination was performed.

99213

99202

99232

99214

99213-office visit for an already-established patient being seen for a follow-up visit. An expanded problem-focused history and medical decision making of low complexity

In the Medical Surgical Section of ICD-10-PCS, the fourth character position represents which of the following?

Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician’s office 2 weeks ago, and the final pathology was positive for carcinoma. Patient is admitted for prostatectomy. The frozen section of the prostate and one lymph node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectomy became a radical perineal with bilateral pelvic lymphadenectomy.

55815

55815, 38562

38770

55845

55815- Prostatectomy with a radical perineal and bilateral pelvic lymphadenectomy (prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy). This code includes everything that was performed. No additional codes are needed

Patient presents to the operating room where a CABG x 3 is performed using the mammary artery and two sections of the saphenous vein.

33533– Coronary artery bypass using arterial graft(s) single

33518– 2 venous grafts (list separately in addition to code for primary procedure)

Laparoscopic retroperitoneal lymph node biopsy

38570- Laparoscopy with retroperitoneal lymph node biopsy

Laser destruction of extensive herpetic lesions of the vulva

56515– Destruction of lesions, vulva; extensive

Identify the correct approach term used in ICD-10-PCS for the following:

Laparoscopic cholecystectomy

percutaneous

open

percutaneous endoscopic

external

percutaneous endoscopic

In ICD-10-PCS, identify the approach for a needle biopsy.

percutaneous endoscopic

A patient is admitted for rectal bleeding. The laboratory results reveal chronic blood-loss anemia. The CT and the bleeding scan results of the abdomen revealed that the rectal bleeding is due to Crohn’s disease of the descending colon.

K50.111– Crohn’s disease of large intestine with rectal bleeding.

D50.0– Iron deficiency anemia, secondary to blood loss (Chronic)

A patient is admitted for observation for a head injury. The patient was struck while playing football. The patient also suffered a minor laceration to the forehead. Head injury was ruled out.

Z04.3 – Observation, head injury, ruled out

S01.81xA- Minor laceration, forehead, (A)= initial encounter

Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered X-rays of the ankle, which came back negative for a fracture. A problem-focused history/physical examination with straight forward decision making were performed, and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only.

99281

99282

99211

99201

99281 – physician completed a problem-focused history, problem-focused examination, and straightforward medical decision-making for an emergency department visit.

(Code 99201 should not be used since it is for an office or other outpatient visit for a new patient. Code 99211 should not be used since it is for an office or other outpatient visit for an established patient. Although code 99282 is for an emergency room visit, it should not be used because it requires 3 components: expanded problem-focused history, expanded problem-focused examination, and medical decision-making of low complexity).

Patient was involved in an accident and has been sent to the hospital. During transport, the patient develops breathing problems and, upon arrival at the hospital, an emergency transtracheal tracheostomy was performed. Following various X-rays, the patient was diagnosed with traumatic pneumothorax. A thoracentesis with insertion of tube was performed.

31610, 32555

31610, 32554

31603, 32554

31603, 31612

31603, 32554 (A code of 31603 is needed for the transtracheal tracheostomy procedure (tracheostomy, emergency procedure; transtracheal). An additional code of 32554 is needed for the thoracentesis procedure that was performed (thoracentesis, needle or catheter). Code 31610 should not be used since it is for tracheostomy, fenestration procedure with skin flaps. Code 32555 should not be used since it is for needle or catheter thoracentesis with aspiration of the pleural space with imaging guidance. Code 31612 should not be used since it is for percutaneous tracheal puncture with transtracheal aspiration and/or injection).

A patient is admitted for gestational diabetes, insulin-controlled, 28 weeks gestation.

O24.414 – Gestational diabetes, insulin-controlled

Z3A.28– 28-week gestation

In ICD-10-PCS, left knee arthroscopy with reposition of the anterior horn medial meniscus

0SSC4ZZ- Left knee arthroscopy with reposition of the anterior horn medial meniscus

2. Body system = S (Lower Joints)

3. Root operation = S (Reposition)

4. Body part = D (Knee Joint, Left)

5. Approach = 4 (Percutaneous endoscopic approach)

In ICD-10-PCS, removal FB left cornea

08C9XZZ – Removal FB left cornea

2. Body system = 8 (Eye) The cornea is a part of the eye

3. Root operation = C (Extirpation) removing a FB (foreign body)

4. Body part = 9 (Cornea, left)

5. Approach = X (External approach)

Identify the correct root operation term, used in ICD-10-PCS, for the following:

Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life-threatening injuries due to a multiple-car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient. Code only critical care.

99291, 99292

99285, 99288, 99291

99291, 99292, 99285

99282

99291, 99292

Code 99291 should be used for the first 74 minutes of critical care in the emergency department. An additional code 99292 should also be reported for the remaining 16 minutes of critical care given to the patient in the emergency department.Code 99282 and code 99285 should not be used since these are codes for emergency department visits, not specifically critical care.

Removal deep left vein thrombosis

(Excision: Cutting out or off, without replacement, a portion of a body part

Extirpation: Taking or cutting out solid matter from a body part

Removal: Taking out or off a device from a body part

Resection: Cutting out or off, without replacement, all of a body part)

Ureterolithotomy completed laparoscopically

(Since a ureterolithotomy was performed laparoscopically, it is important to capture CPT code 50945, which is ureterolithotomy that was completed by laparoscopy. Code 50600 should not be used since it is for ureterotomy with exploration or drainage. Code 52325 should not be used since it is for cystourethroscopy with fragmentation of ureteral calculus. Code 52352 should not be used since it is for cystourethroscopy with ureteroscopy and/or pyeloscopy with removal or manipulation of calculus).

Patient presents to the hospital with right ureteral calculus. Patient is taken to the operating room where a cystoscopy with ureteroscopy is performed to remove the calculus.

A code of 52352 should be used for the cystoscopy with ureteroscopy in order to remove the patient’s calculus (cystourethroscopy, with ureteroscopy; with removal or manipulation of calculus). This code includes all three procedures, so no additional codes are needed.

After being brought back to his hospital room following chemotherapy, the patient developed epistaxis. Packing material was placed. The ICD-10-PCS code reported is _____.

Packing for epistaxis

1. Section = 2 (The Placement Section)

2. Body system = Y (Anatomical Orifices)

3. Root operation = 4 (Packing)

4. Body Region = 1 (Nasal)

5. Approach = X (External)

6. Device = 5 (Packing material)

Patient undergoes X-ray of the foot with three views.

73630 Radiologic examination; complete, minimum of 3 views. No additional codes are needed as this code is good for up to three views.

Radial keratotomy

65771 Radial keratotomy procedure.

(Code 65767 should not be used since it is for epikeratoplasty. Code 65855 should not be used since it is for trabeculoplasty by laser surgery. Code 92071 should not be used since it is for fitting of contact lenses for treatment of ocular surface disease).

In ICD-10-PCS, patient admitted after experiencing seizure. CT of brain, high osmolar contrast taken with and without contrast

B02000Z – CT scan of brain, high osmolar contrast taken with and without contrast

1. Section = B (The Imaging Section)

2. Body system = 0 (Central Nervous System) (Brain is part of the CNS.)

3. Root operation = 2 (Computerized Tomography, CT Scan)

4. Body Part = 0 (Brain)

5. Contrast = 0 (High Osmolar)

6. Qualifier = 0 (Unenhanced and Enhanced)