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NEW QUESTION # 13
Which procedure uses a thin tube to examine the abdominal organs through a small incision in the belly?
- A. Laparoscopy
- B. Gastroscopy
- C. Endoscopy
- D. Laparotomy
Answer: A
Explanation:
A gastroscopy is a procedure that uses an endoscope to examine the stomach and some parts of the intestinal tract An endoscopy uses a thin tube through a natural opening in the body to examine the digestive tract. A laparotomy is a large incision in the belly to gain access into the abdominal cavity.
NEW QUESTION # 14
A provider documents that he spent 20 minutes with a patient. Based on this, an E/M can be chosen solely based on time.
- A. False
- B. True
Answer: B
Explanation:
The statement is true. According to AMA time documented is considered the minimum time the physician or other qualified health care professional spent on face-to-face and non-face-to-face services. This includes time spent reviewing the patient's medical record, consulting other healthcare professionals, or ordering prescriptions, tests, and/or other services.
NEW QUESTION # 15
The laboratory collected blood to test the patient's carbon dioxide, chloride, potassium, sodium, and glucose levels. Select the CPT codes that the laboratory will report.
- A. 80051, 80053
- B. 80051, 82947-59
- C. 80053-52
- D. 80051, 82947
Answer: D
Explanation:
It would not be appropriate to add modifier 52 to 80053 in answer A In answer C, 80051 and
80053 would not be reported together because CPT guidelines state that "when or more panel codes include the same tests, report the panel with the highest number of tests in common." Because the glucose test is not included in 80051, 82947 would be added to 80051, with no modifier 59, because the procedures are routinely billed together, thus eliminating answer D.
NEW QUESTION # 16
The relative value units of a procedure are based on how much effort is involved, expenses that the practice will incur, and the level of risk associated with it.
- A. False
- B. True
Answer: B
Explanation:
The statement is true. An insurance carrier will use these three measures to determine what the RVU of a procedure should be. Then, based on that, a medical coder can determine what the expected payment should be. Generally, the higher the RVU of a procedure is, the higher the payment will be.
NEW QUESTION # 17
A patient receives a positron emission technology (PET) scan at rest, where a metabolic evaluation study, including ventricular wall motion was performed using PET imaging. A computed tomography (CT) was performed at the same time. What CPT code(s) should the radiologist report?
- A. 0
- B. 78430, 76497-59
- C. 78429, 76497-59
- D. 1
Answer: D
Explanation:
PET scans are reported using CPT codes 78429-78434. The documentation specifies that a metabolic study was performed versus a perfusion study, thus eliminating answers B and D. A CT scan is included in the description of CPT 78429, thus making it unable to be separately reportable.
NEW QUESTION # 18
Anesthesiologist A begins providing services at 7:02 but is relieved at 8:47 by Anesthesiologist Z. If the recorded end time for anesthesia services is 11:32, which statement is be true?
- A. Anesthesiologist A would report 1.75 hours, and Anesthesiologist Z would report 2.75 hours of anesthesia time.
- B. Anesthesiologist A would report 4.5 hours of anesthesia time.
- C. Both anesthesiologists would separately report 4.5 hours of anesthesia time.
- D. Anesthesiologist Z would report 4.5 hours of anesthesia time.
Answer: D
Explanation:
When splitting/providing relief in the middle of a procedure, the anesthesiologist who provides services for the longest amount of time bills for the anesthesia services in their entirety. In this scenario, Anesthesiologist Z provided 60 minutes more than Anesthesiologist A and so would bill for the entire 4.5 hours. Even though Anesthesiologist A provided 1.75 hours, they would not submit any coding to the insurance carrier.
NEW QUESTION # 19
What is the difference between presumptive and definitive testing?
- A. Presumptive testing assumes a diagnosis; definitive testing confirms a diagnosis.
- B. Presumptive testing is based on exhibited signs and/or symptoms; definitive testing isbased on lab results.
- C. Presumptive testing confirms the presence of a drug class; definitive testing identifies thequantity or presence of a drug.
- D. Presumptive testing requires additional observation time; definitive testing requires ablood draw.
Answer: C
Explanation:
A presumptive test reports whether the patient is positive or negative for a specific drug. A definitive test would analyze which specific agent and/or how much of that agent is in the patients' system.
NEW QUESTION # 20
An orthopedic surgeon performs a meniscectomy for a right radial tear using an arthroscope. During the procedure, the surgeon removes a piece of the damaged meniscus from the lateral compartment of the knee and shaves the articular cartilage of the same compartment. A separate incision was made to remove a 6 mm loose body in the medial compartment. The surgery was completed without any complications. What procedure and diagnosis code(s) should be reported?
- A. 29882, 29877-51, 29874-51, S83.203A
- B. 29887, 29874-59,S83.281A
- C. 29881, 29874-59,S83.281A
- D. 29881, 29874-51, S83.203A
Answer: C
Explanation:
The procedures performed on this encounter were the meniscectomy (removal of damaged meniscus from the lateral compartment) with a chondroplasty (shaving of articular cartilage,
29881) and loose body removal by means of an arthroscopy (29874). Because the removal of loose bodies is considered inclusive to the primary procedure, modifier 59 is appended as opposed to modifier 51 to indicate that it was a distinct procedural service due to the separate incision.
Answers A and D can be eliminated based on the diagnosis chosen. S83.203A indicates the location of meniscus is unspecified: however, the surgeon removed the damaged meniscus from the lateral compartment, leading the biller to S83.281A.
NEW QUESTION # 21
A diaphragm resection and repair are done using a biologic mesh to reduce the formation of adhesions. Which procedure code should be reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
A diaphragm resection is reported with CPT codes 39560-39561. The use ofa biologic mesh makes the repair complex, whereas a simple repair would implement only internal sutures.
NEW QUESTION # 22
A low-risk obstetrical patient is told to come in for weekly ultrasounds in her first trimester. This is an example of what?
- A. Abuse
- B. Fraud
- C. Misuse
- D. Waste
Answer: D
Explanation:
In this case, the patient is not at risk, and most organs either are not developed and/or cannot be visualized in the first trimester. Thus, this would constitute as waste due to the provider overutilizing services that result in unnecessary cost. AAPC defines fraud as purposely billing "for services that were never given or to bill for a service that has a higher reimbursement than the service provided." Abuse is payment for services "that are billed by mistake by providers."
NEW QUESTION # 23
What would NOT be included in critical care services?
- A. Gastric intubation
- B. CPR
- C. Ventilator management
- D. Pulse oximetry
Answer: B
Explanation:
CPR is not a bundled service to critical care and should be reported separately with CPT code
92950.
NEW QUESTION # 24
A radiation oncologist reviews the port films, dose delivery, and treatment parameters of a 52-year-old female patient who has received external beam therapy three times in the current week He also spends 15 minutes examining the patient and collecting an intake of her response to the treatment program. Which CPT code(s) should the physician report?
- A. 0
- B. 99213-25, 77401x3units
- C. 77435, 99213-25
- D. 1
Answer: A
Explanation:
Treatment management of a patient undergoing radiation therapy is reimbursed by reporting CPT codes 77427-77470. Treatment management includes a review ofthe port films, dosimetry, dose delivery, treatment parameters, a physical examination, and related counseling. It would therefore not be appropriate to bill for a separate evaluation and management. CPT 77435 describes treatment management for a course of stereotactic body radiation therapy (SBRT), which the patient is not receiving. CPT 77401 describes the actual radiation and not the evaluation from the physician. CPT 77431 is reported when the entire course of therapy consists of one or nvo treatment sessions: however, a coder can infer from the documentation that the patient in this scenario has or will receive multiple sessions over the course of one or more weeks. Additionally, CPT guidelines advise that only three treatment sessions must occur to support the face-to-face encounter described in CPT 77427.
NEW QUESTION # 25
Code the following surgical note:
54-year-old male is experiencing left-sided weakness and visual disturbance. An MRI revealed a lesion in the brain. He presents today for a biopsy. General anesthesia is given, and the area is shaved and cleaned. The brain lab system is synced with prior MRI images to confirm the accurate placement of burr hole drilling. A cutting needle is inserted into the frontal lobe, and lesion location is confirmed with the brain lab system. A portion of the lesion is obtained without complication. All instruments removed, and the incision is sutured.
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
The coding crosswalk for a brain biopsy leads to three CPT codes. CPT code 61140 is a burr hole through which a lesion in the brain can be located and biopsied. CPT code 61750 is a biopsy using a CT or MRI scanning technique to locate the lesion in the brain. CPT code 61751 is the same as 61750, with the addition of the use of CT or MRI scanning during the procedure to confirm the location of lesion and/or accurate placement of surgical instruments. In this case, that occurred with the brain lab system. CPT code 61575 is a biopsy done on a different anatomic location and does not describe this procedure.
NEW QUESTION # 26
A male patient with cancerous cells in his right bronchus is given 150 mg of porfimer sodium via a single and slow intravenous injection and told to return to the office in 3 days.
Upon his return, the physician enters the right bronchus by means of a bronchoscope and activates LED for a total of 38 minutes to destroy the cancer cells. What should the physician report?
- A. 96573, J9600x2
- B. 96573, 96409, J9600x2
- C. 31641, 96570, 96571, 96409,J9600x2
- D. 31641, 96570, 96571, J9600x2
Answer: D
Explanation:
Photodynamic therapy applies a photosensitizing agent by either an external or endoscopic application. An external application is applied directly onto a patient's lesions, whereas an endoscopic application is an injection into the bloodstream, where it is absorbed by cells all over the body. Based on this differentiation, the documentation supports only an endoscopic application.
The code notes for CPT 96570 and 96571 indicate they are add-on codes to the bronchoscopy procedure, which is represented by CPT 31641. Any drug administration is inclusive to photodynamic therapy, making CPT 96409 not separately billable.
NEW QUESTION # 27
A 34-year-old established male patient presents for treatment to his lower back. He reports exacerbated symptoms due to lifting heavy materials at work. The osteopath performs a problem-focused history and exam followed by manipulative treatment to the lumbar and sacral region of the spine. What procedure(s) should the osteopath report?
- A. 0
- B. 99212-25, 98925
- C. 99212-25, 97140x2
- D. 1
Answer: B
Explanation:
Osteopathic manipulation services do not include evaluation and management services.
Although the patient's treatment has already been established, the osteopathic physician has enough supporting documentation to report a separate evaluation and management code.
Manipulation services rendered by an osteopathic physician are reported with CPT codes 98925-
98929. A chiropractor would report manipulative treatment to t'.vo body regions with CPT 98940, and a physical therapist would report CPT 97140.
NEW QUESTION # 28
The appendix is removed through an abdominal incision due to metastatic colon malignancy. How should this be reported?
- A. 44970, C78.5
- B. 44950, C78.5
- C. 44970, C18.9, C78.5
- D. 44950, C78.5, C18.9
Answer: D
Explanation:
An open appendectomy procedure is reported with CPT 44950. A metastatic colon malignancy is a cancer that began in the colon but has spread to other areas. In this scenario, that means that the primary malignancy is the colon, and the secondary malignancy is the appendix.
Additionally, ICD-IO-CM guidelines state that when "treatment is directed toward the metastatic site only, the metastatic site is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code." The malignancy codes do not specifically state
"appendix," but the ICD-IO-CM coding crosswalk in the neoplasm table assigns this diagnosis as C78.5 secondary malignant neoplasm of large intestine and rectum.
NEW QUESTION # 29
The CPT code 76805 requires that multiple elements of the exam be documented, such as the evaluation of the amniotic fluid, umbilical cord insertion site, and placental location. If the provider documents most elements, he/she can bill the CPT code 76805.
- A. True
- B. False
Answer: B
Explanation:
The statement is false. Per ICD-IO-CM, "Results must be documented in the report for each of the elements described in the code description." If the provider does not document a given element, they must include a reason for non-visualization for the CPT to be reported.
NEW QUESTION # 30
What is/are the code(s) for the repair of an incarcerated hernia in the inner groin requiring mesh placement on a 32-year-old female patient?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
Explanation:
There are several different types ofhernias that are categorized by their location. A hernia located in the inner groin is inguinal, and a hernia located on the outer groin is femoral. The repair of an incarcerated inguinal hernia on a 32 -year-old patient is coded to CPT 49507. Hernia mesh is used to reduce the risk of recurrence, and implantation of it is inclusive to an inguinal, umbilical, femoral, and laparoscopic hernia repair.
NEW QUESTION # 31
A 39-year-old female patient has developed a diaphragmatic hernia after an episode of domestic violence. The surgeon repairs the hernia through an incision into the abdomen. The patient is later discharged with no complications. How should this encounter be reported?
- A. 39540, K44.9, T74.11XA Y07.9
- B. 39541, K44.O, T74.11YA Y07.9
- C. 39540,K44.9, T 76.1 IXA
- D. 39541, K44.O, T76.1 IXA
Answer: A
Explanation:
Acute trauma results from a single incident, whereas chronic trauma is repeated, usually over the course of months or years. In this scenario, the documentation does not specify, so the coder should assume acute trauma. There is no mention of obstruction, so ICD-IO-CM code selection is K44.9, followed by the cause of the hernia. Vvhen an exam shows evidence of abuse, the abuse is no longer considered suspected but confirmed.
NEW QUESTION # 32
Which condition would describe a patient with a physical status modifier of P3?
- A. Multiple organ dysfunction
- B. Sepsis
- C. A recent myocardial infarction
- D. Poorly controlled diabetes
Answer: D
Explanation:
The physical status modifiers are used to identify different levels of complexity associated with the patient's condition. Additionally, they provide information surrounding the circumstances of the anesthesia service and are a useful tool to support medical necessity. Modifier P3 describes a patient with a severe systemic disease, such as uncontrolled diabetes and/or hypertension.
Multiple organ dysfunction is reported with modifier P5, which describes a patient who is not expected to survive without an operation. A recent myocardial infarction and sepsis both describe a severe systemic disease that is a threat to life and is reported with modifier P4.
NEW QUESTION # 33
Code the following physician's note:
A 14-year-old established patient is seen with mother to evaluate five 2 cm superficial lacerations to the left wrist. Patient admits to suicidal thoughts.
Lacerations were treated with Steri-Strips. Patient and mother counseled on suicide prevention and told to follow up with psych.
- A. 12004, S61.512A, T14.91XA
- B. 99214, S61.512A, T14.91XA
- C. 12004, S61.512A, R45.851
- D. 99213, S61.512A, R45.8S1
Answer: D
Explanation:
When the injury is treated with Steri-Strips or bandages, it should be reported with an E/M code and not a procedure code. Within the medical decision making, the number and complexity of problems addressed is low, the amount of data reviewed or analyzed is straightforward, and the risk of complications and/or morbidity or mortality of patient management from the injuries is low.
Therefore, the E/M is a 99213 because the medical decision-making is low. A suicide attempt would not be coded because the documentation is not specific as to whether the lacerations were an attempt at suicide.
NEW QUESTION # 34
Which of the four chambers in the heart receives deoxygenated blood from the body through the vena cava?
- A. Right atrium
- B. Right ventricle
- C. Left atrium
- D. Left ventricle
Answer: A
Explanation:
After receiving deoxygenated blood from the body through the vena cava, the right atrium pumps blood into the right ventricle. The right ventricle sends the blood to the lungs to be oxygenated. The left atrium receives blood from the lungs through the pulmonary veins and pumps it into the left ventricle via the mitral valve. The left ventricle then distributes oxygenated blood to tissues throughout the body.
NEW QUESTION # 35
A surgeon performs a craniectomy to excise a meningioma located above the tentorium cerebelli. During the procedure, an extradural hematoma is noted and removed via the same craniectomy site. How should the surgeon report the procedure?
- A. 0
- B. 61312-22
- C. 61519, 61314-51
- D. 61512, 61312-59
Answer: A
Explanation:
Surgical procedures on the nervous system are identified by where inside the skull they occur. A meningioma is being excised from above the tentorium cerebelli, otherwise known as supratentorial (CPT 61512). The removal of an extradural hematoma is inclusive to the primary craniectomy code because the finding is incidental and the same surgical site is used for its removal.
If the surgeon had to create a separate incision to access the extradural hematoma, that excision could be reported separately with modifier 59.
NEW QUESTION # 36
Code the following procedure note:
A 45-year-old female was referred for a urodynamics study due to complaints of bladder pain and weak urination. The provider places a rectal catheter simultaneously with a urethral catheter and begins to fill the bladder with water.
Using calibrated equipment, cytometry was done with a medium fill rate of 40 cc/ minute. A strong desire to void occurred at 84 cc. and the patient is instructed to void. The provider determines that the maximum urinary flow rate is 12 cc per second with a voiding time of 45 seconds and a voided volume of 102 cc. She voided with a sustained detrusor pressure. An abdominal pressure measurement was also taken, indicating no urinary leaking with abdominal straining. EMG patches were placed on the anal sphincter and found to be elevated with increased intra- abdominal pressure. All catheters and EMG patches were removed, and the procedure was completed without complications. A report will be forwarded to the referring provider, who will provide the interpretation of the results to the patient.
- A. 51728-TC, 51784-TC, 51797-TC
- B. 51726-TC, 51784-59-TC, 51797-59-TC, 51741-59-TC
- C. 51726-TC, 51784-51-TC, 51797-51-TC
- D. 51728-TC, 51784-TC, 51797-TC, 51741-TC
Answer: D
Explanation:
A urodynamics study is a diagnostic test to evaluate the function of the bladder. When performed using calibrated equipment, it becomes known as a complex cystometrogram (51726-
51729). In CPT code 51728, a complex cystometrogram is performed in conjunction with voiding pressure studies. In the provider's documentation, the bladder is filled with water, and voiding times and volume are recorded, thus fulfilling the requirements for this code. CPT code 51726 in answers A and B only describe a complex cystometrogram without the voiding pressure studies.
Electromyography (EMG) studies were performed without a needle to evaluate pelvic floor activity and are represented by 51784. An intraabdominal voiding pressure study (51797) can be inferred in that the provider had earlier inserted a rectal catheter and, after instructing the patient to cough, obtained an abdominal pressure measurement. A complex urinary flow study (51741) was performed in obtaining the maximum urinary flow rate through calibrated equipment. This procedure is missing in answers B and C. Modifier TC (indicating only a technical component) is amended on all the procedures because the provider is not interpreting the results to the patient.
Modifiers 51 and/or 59 is not amended on any procedure (A and B) because these are routinely billed together.
NEW QUESTION # 37
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