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NEW QUESTION # 180
(Full Case:Chief complaint:Syncope.HPI:68-year-old male arrives to ED inrespiratory distressafter sudden syncope/collapse while shopping; unresponsive; EMS: weak pulse, labored respirations, unresponsive.
History:CABG 5 years ago, no chest pain since.ROS:unobtainable (unconscious).Allergies:none.Meds:
Coumadin.PMH:HTN.Social:lives with wife.Exam/Vitals:BP 82/62, pulse 79, RR 12 shallow, O2 sat 90% on high flow O2; monitor shows right bundle branch block. Neuro: initially eyes closed, opens to questions, responds to some questions, later unresponsive. HEENT pupils sluggish equal; unable EOM/fundus. Neck supple, no JVD/bruits. Lungs mild rhonchi. Heart regular without murmurs. Abdomen benign. Extremities symmetric, no edema/cyanosis. Skin no rash. Neuro no focal deficits.Hospital course:IV x2; NS 1000 cc bolus with little response; dopamine drip 10 # 20 mcg/kg/min; O2 sat drops, respirations slow; becomes unresponsive; progresses tocardiac arrest; CPR; multiple adrenaline/atropine; defibrillation; ABG pH 7.1 etc; bicarbonate x2; no effect; pronounced dead 13:32.Critical care time:77 minutes continuous.Diagnosis:
Cardiorespiratory arrest.Question:What is the E/M coding reported for this encounter?)
Answer: A
Explanation:
The patient was critically ill withhemodynamic instability, respiratory failure progression, and cardiac arrest, requiring intensive interventions (multiple IVs, large bolus,vasopressor infusion, resuscitation with CPR
/defibrillation/medications, ABG management). The provider documents77 minutes of continuous critical care time. Critical care is reported with99291for thefirst 30-74 minuteson a date of service, and99292foreach additional 30 minutesbeyond that threshold. Because77 minutesexceeds 74 minutes, you report99291 + 99292 (one unit of 99292 covers the additional time beyond the initial critical care window). You donotadditionally report an ED E/M code (e.g., 99285) on the same date for the same provider when critical care encompasses the ED evaluation and management during that time period; the critical care service is the appropriate E/M reporting. The scenario supports that critical care criteria are met: high probability of life-threatening deterioration and active physician management. Therefore, the correct E/M coding is99291, 99292.
NEW QUESTION # 181
In medical terminology, suffixes indicate the procedure, condition, disorder, or disease.
Which term contains a suffix?
Answer: A
Explanation:
The suffix in medical terminology provides information about a condition, procedure, disorder, or disease.
The term "neuralgia" contains the suffix "-algia," which refers to pain, indicating a painful condition of the nerves. In contrast:
A: malaise has no identifiable suffix related to a specific medical condition or disease.
B: ambidextrous has no suffix indicating a disease, condition, or procedure.
D: hypotension includes the prefix "hypo-" (indicating low), but the core term "tension" refers to pressure without an additional suffix specific to condition.
Thus, "neuralgia" is the correct answer as it directly includes a suffix ("-algia") that denotes a pain-related condition in medical terms.
NEW QUESTION # 182
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT coding is reported for this case?
Answer: D
Explanation:
For the excision of an 11 cm lesion with a rotation flap repair, the appropriate CPT codes are 14001 for the adjacent tissue transfer or rearrangement (12 sq cm flap) and 11606-51 for the excision of a malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm. Modifier 51 indicates multiple procedures. The detailed operative report specifies the lesion size and the technique used, justifying these codes.
NEW QUESTION # 183
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.
What CPT coding is reported for this case?
Answer: B
Explanation:
The procedure involved the placement of an intra-aortic balloon pump (IABP) through the right common femoral artery for a patient with acute MI and severe left main arteriosclerotic coronary artery disease.
Procedure Description:
Placement of an intra-aortic balloon pump (IABP).
Right common femoral artery approach.
Confirmation of good waveform and securement of the catheter.
CPT Coding:
33975: Insertion of intra-aortic balloon assist device, percutaneous.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on cardiac procedures.
NEW QUESTION # 184
A patient who was training for a marathon collapsed due to heat exhaustion on a very hot day. The patient is driven by his wife to a non-facility urgent care center for him to be treated. On examination, the physician diagnoses heat exhaustion and dehydration. The physician began IV therapy of normal saline that consists of pre-packaged fluid and electrolytes. The hydration lasts for 1 and 30 minutes.
What CPT coding is reported?
Answer: D
Explanation:
1. Procedure and CPT Code Selection:
The patient received IV hydration therapy with normal saline, which lasted for 1 hour and 30 minutes.
CPT Code 96360 is used for initial IV hydration for the first hour. This code applies to the first 31-60 minutes of hydration therapy.
CPT Code 96361 is used for each additional hour of IV hydration. Since the hydration lasted 1 hour and 30 minutes, 96361 should be reported once to cover the additional 30 minutes after the initial hour.
2. Rationale for Excluding Other Options:
Code 96365 is for initial IV infusion for therapeutic, prophylactic, or diagnostic purposes, rather than hydration, and is not applicable in this case.
Code 96366 is used for additional therapeutic, prophylactic, or diagnostic infusions and does not apply to hydration services.
Option A (96360) would only cover the initial hour of hydration, missing the additional 30 minutes, which is appropriately coded with 96361.
3. AAPC and CPT Coding Guidelines:
According to AAPC and CPT guidelines, 96360 should be used for the first hour of IV hydration, and 96361 should be used for each additional hour or portion of an hour beyond the initial 60 minutes.
Therefore, the correct answer is D. 96360, 96361.
NEW QUESTION # 185
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