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| Section | Objectives |
|---|---|
| Topic 1: ICD-10-CM Diagnosis Coding | - ICD-10-CM guidelines - Diagnosis code selection and sequencing |
| Topic 2: Medical Terminology and Anatomy | - Human anatomy basics - Medical terminology structure |
| Topic 3: HCPCS Level II Coding | - Medicare coding procedures - Durable medical equipment and supplies |
| Topic 4: Compliance and Regulatory Guidelines | - HIPAA and medical ethics - Fraud and abuse regulations |
| Topic 5: CPT Coding | - CPT guidelines and conventions - Surgical, diagnostic, and procedural coding |
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NEW QUESTION # 217
A 7-year-old boy is brought to the pediatric clinic by his mother. She reported that her son is complaining of discomfort in both ears and loss of hearing in the left ear for the past two days. The pediatrician diagnosis is impacted cerumen. Pediatrician with the mother's consent removes impacted cerumen using water irrigation In the right ear. For the left ear the cerumen impaction is removed using instrumentation.
What CPT coding is reported'
Answer: D
Explanation:
69209-RT - Removal of impacted cerumen using irrigation
69210-LT - Removal of impacted cerumen using instrumentation
Coding Rules Applied:
Different techniques โ different CPT codes
Different ears โ RT/LT modifiers, not modifier -50
Why Other Options Are Incorrect:
A - Modifiers reversed
B / D - Modifier -50 inappropriate when different CPT codes are used
NEW QUESTION # 218
According to the ICD-10-CM Guidelines, what code is reported as an additional code when the blood pressure of a patient with hypertension remains above goal in spite of the use of antihypertensive medications?
Answer: B
Explanation:
According to ICD-10-CM Guidelines, I11A.0 (Resistant hypertension) is used to indicate hypertension that remains uncontrolled despite the use of multiple antihypertensive medications. Resistant hypertension is coded to highlight the severity of the patient's condition and the difficulty in managing their blood pressure. This code is added as a secondary code to reflect the persistent elevation of blood pressure despite medication.
A . I10 (Essential hypertension) is a general code for primary hypertension but does not specify resistance to treatment.
B . A code from category I27 is related to pulmonary heart diseases, not directly related to hypertension management issues.
D . A code from category I16 (Hypertensive crisis) is used for hypertensive emergencies or urgencies, which are acute episodes, not persistent uncontrolled hypertension despite treatment.
Thus, the correct answer is C. I11A.0, Resistant hypertension.
NEW QUESTION # 219
A 44-year-old female patient came in for a planned laparoscopic total abdominal hysterectomy for endometriosis of the uterus. The surgeon attached the trocars, a scope is inserted examining the uterus, abdominal wall, bilateral ovaries, and fallopian tubes. The surgeon decided to convert the laparoscopic procedure to an open total hysterectomy because of the extensive amount of adhesions that need to be removed. A total hysterectomy was performed and due to removal of the extensive adhesions the surgery took longer than normal of 2 hours.
What CPTand diagnosis codes are reported?
Answer: B
Explanation:
1. Procedure and CPTCode Selection:
The patient initially underwent a laparoscopic total abdominal hysterectomy for endometriosis of the uterus.
However, due to extensive adhesions, the surgeon converted the procedure to an open total abdominal hysterectomy to complete the surgery.
CPTCode 58150 is appropriate for a total abdominal hysterectomy, including removal of the uterus and cervix, via an open approach. Since the procedure was converted to an open approach, 58150 is the correct code.
The -22 modifier is added to indicate increased procedural services due to the extensive adhesiolysis (removal of adhesions), which extended the surgery duration.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code N80.00 is used for endometriosis of the uterus, which is the primary condition that prompted the hysterectomy.
ICD-10-CM Code N73.6 is appropriate for female pelvic peritoneal adhesions, reflecting the extensive adhesions that necessitated the conversion to open surgery.
3. Rationale for Excluding Other Options:
Code 58571 (in options B and C) is for a laparoscopic approach, which is incorrect because the procedure was converted to an open approach.
The -78 modifier is incorrect in this context because the conversion to open surgery was part of the same operative session and not an unplanned return to the OR.
Diagnosis code N99.4 (in options B and D) pertains to postprocedural pelvic adhesions, which does not apply here as the adhesions were not due to a prior procedure.
4. AAPC and CPTCoding Guidelines:
AAPC guidelines specify using 58150 for an open total abdominal hysterectomy and adding the -22 modifier for increased complexity or time due to factors like extensive adhesiolysis.
Therefore, the correct answer based on CPTand ICD-10-CM guidelines is A. 58150-22, N80.00, N73.6.
NEW QUESTION # 220
A 3-day-old died in her sleep. The pediatrician determined this was the result of crib death syndrome. The parents give permission to refer the newborn for a necropsy. The pathologist receives the newborn with her brain and performs a gross and microscopic examination. The physician issues the findings and reports they are consistent with a normal female newborn.
What CPT code is reported?
Answer: C
Explanation:
* Procedure: Gross and microscopic examination of a newborn autopsy.
* CPT Code:
* 88028: This code is for the autopsy, gross and microscopic examination of a stillborn or newborn.
* Code Selection Justification: The procedure described matches the comprehensive postmortem examination of a newborn.
References:
* AMA CPT Professional Edition (current year)
* ICD-10-CM (current year)
* HCPCS Level II (current year)
NEW QUESTION # 221
Refer to the supplemental information when answering this question:
View MR 874276
What E/M code is reported?
Answer: A
Explanation:
To accurately code this emergency department visit, we need to assess the three key components: history, examination, and medical decision making (MDM).
History:
The documentation supports an expanded problem-focused history. This includes a chief complaint, a brief history of present illness (HPI), a review of systems (ROS) with pertinent positives and negatives, and a past medical history.
Examination:
The examination is also expanded problem-focused. The physician focused on the relevant systems (constitutional, HENT, respiratory) and documented specific findings related to the chief complaint (appears tired).
Medical Decision Making:
The MDM complexity is low. The physician is assessing a new problem (shortness of breath and weakness) with a low level of risk. No further testing or treatment is documented in this encounter.
Based on these components, 99283 is the most appropriate code.
Why other options are incorrect:
99282: Requires a problem-focused history and examination, which is less comprehensive than what was documented.
99284 and 99285: Require a higher level of MDM (moderate or high complexity) and/or a more detailed examination. The documentation doesn't support this level of service.
Reference:
CPT Codes 99281-99285: Emergency department visits
1995 and 1997 Documentation Guidelines for Evaluation and Management Services: These guidelines provide detailed criteria for selecting the appropriate E/M code based on history, examination, and MDM.
AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.
NEW QUESTION # 222
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