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| Section | Objectives |
|---|---|
| HCPCS Level II Coding | - Medicare coding procedures - Durable medical equipment and supplies |
| Compliance and Regulatory Guidelines | - HIPAA and medical ethics - Fraud and abuse regulations |
| Medical Terminology and Anatomy | - Human anatomy basics - Medical terminology structure |
| CPT Coding | - CPT guidelines and conventions - Surgical, diagnostic, and procedural coding |
| ICD-10-CM Diagnosis Coding | - Diagnosis code selection and sequencing - ICD-10-CM guidelines |
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NEW QUESTION # 14
(A 3-year-old is seen by his primary care physician for anannual exam. His last exam with the primary care physician wastwo years ago. He has no complaints. What CPT code is reported?)
Answer: C
Explanation:
Preventive medicine codes are selected bypatient ageand whether the patient isnew or establishedto the provider. The child is3 years old, which falls into theearly childhoodpreventive age range. Because the child has been seen by this same primary care physician before (last exam two years ago), the patient isestablished, not new. For established patients, preventive codes are99391-99395, and for age1-4 yearsthe correct code is99392. However, among the answer choices, the closest matching established preventive code offered for this age group is99382, which is actually thenew patientpreventive code for age 1-4; the item's provided options appear to omit 99392. Given CPC exam rules, the correct code should be99392for an established 3- year-old. But since it is not offered and you must pick among A-D, the best keyed answer in this option set isD (99382)as presented. Exam tip: Always verifynew vs establishedfirst, then pick the age band.
NEW QUESTION # 15
A Medicare patient that is on dialysis for ESRD is seen by the nurse for a Hep B vaccination. This patient is given a dialysis patient dosage as part of a three-dose schedule. The nurse administers the Hep B vaccine in the right deltoid. The physician reviews the chart and signs off on the nurse's note.
What procedure and diagnosis codes are reported for the scheduled vaccine injection for this Medicare patient?
Answer: B
Explanation:
* Procedure: Hepatitis B vaccine administration for a Medicare patient on dialysis.
* CPT and HCPCS Codes:
* G0010: Administration of Hepatitis B vaccine.
* 90740: Hepatitis B vaccine, dialysis or immunosuppressed patient dosage, 3-dose schedule.
* ICD-10-CM Codes:
* Z23: Encounter for immunization.
* N18.6: End-stage renal disease.
* Z99.2: Dependence on renal dialysis.
* Code Selection Justification: G0010 is used for the administration of the vaccine for Medicare patients, and 90740 captures the specific vaccine for dialysis patients. The ICD-10 codes represent the encounter for vaccination and the patient's dialysis status.
References:
* AMA CPT Professional Edition (current year)
* ICD-10-CM (current year)
* HCPCS Level II (current year)
NEW QUESTION # 16
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.
What E/M coding is reported?
Answer: D
Explanation:
Emergency department visit with high severity
99285 = High complexity ED E/M
NEW QUESTION # 17
Day 1 - A provider admits the patient to observation care for type 2 diabetes mellitus with hyperglycemia. The provider orders a HbA1c, a urine (microalbumin), and kidney function lab tests.
Blood sugar is high and poorly controlled. The provider discusses the case with the patient's endocrinologist. The provider prescribes an IV insulin drip, along with SQ insulin and keeps the patient in observation overnight.
Day 2 - Patient is in observation care and the provider orders a blood glucose test. The patient's glucose levels have improved. The provider places an order for the dietitian to see the patient.
Provider
documents spending a total time of 25 minutes with the patient.
Day 3 - Patient has a blood glucose test. The patient's glucose level is back to normal. The provider documents spending 15 minutes with the patient. The provider discharges the patient.
What E/M coding is reported by the physician for the patient in observation care?
Answer: C
Explanation:
For a patient in observation care, selecting the correct E/M codes requires evaluating each day's service level and the provider's documentation.
Day 1: The patient was admitted for observation, and the physician prescribed IV and SQ insulin, noting diabetes with hyperglycemia requiring complex management. The CPT code 99235 is appropriate here because it represents an initial observation or inpatient care for patients with high-complexity medical decision-making (MDM), which aligns with the patient's unstable glucose and the management requirements.
Day 2: The patient's glucose levels improved, and the provider documented spending 25 minutes with the patient in continued observation care. Since this is an established patient with continued observation, 99231 applies here, indicating subsequent observation care with low MDM complexity.
Day 3: The provider documented spending 15 minutes with the patient, whose glucose levels normalized, and then discharged the patient from observation care. Code 99238 is used for a discharge from observation care and is selected based on discharge times under 30 minutes.
These codes were selected based on CPT guidelines for observation care and the provider's time-based documentation. This matches the medical decision complexity documented per the case and code descriptions available for observation care management.
NEW QUESTION # 18
A 43-year-old female with a history of joint pain and fatigue presents to the office with swollen salivary glands. Patient agrees to have a labial gland biopsy performed in office. Patient is numbed with a local anesthetic. Then an incision is made on the lower labial mucosa and tissue samples from the salivary gland are removed with tweezers. The incision is sutured. Pathology report findings are consistent with Sjogren's syndrome.
What CPTcode is reported?
Answer: C
Explanation:
1. Procedure and CPTCode Selection:
The scenario describes a labial gland biopsy of the salivary gland, performed in the office with a local anesthetic. The provider made an incision in the lower labial mucosa and took tissue samples from the salivary gland for biopsy.
Code 42400 is the correct CPTcode for a biopsy of a salivary gland. This code is specific to a biopsy without a more extensive excision or major surgery, aligning perfectly with the scenario of sampling salivary gland tissue.
2. Ruling Out Other Options:
Code 42408 is for the excision of a deep lobe of a parotid gland, which is a more extensive procedure than a simple biopsy and does not apply to this case.
Code 42405 is for the removal of an entire submandibular gland, which is a full excision and not applicable here.
Code 42450 is used for the removal of a sublingual gland, not for a biopsy of the labial salivary gland.
3. AAPC and CPTCoding Guidelines:
AAPC and CPTguidelines direct coders to use 42400 for minor biopsies of salivary gland tissue, particularly when only tissue samples are taken for diagnostic purposes, as described in this case.
Based on CPTcoding guidelines, the correct answer is C. 42400.
NEW QUESTION # 19
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