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| Section | Weight | Objectives |
|---|---|---|
| Modifiers | 5-7% | |
| Medical Terminology & Anatomy | 8-10% | |
| Compliance & Regulations | 8-10% | - HIPAA, fraud & abuse - Reimbursement rules |
| CPT® Coding | 45-50% | - Surgery (10000–69999) - Radiology, Pathology/Laboratory, Medicine - Evaluation & Management (E/M) |
| Reimbursement & Revenue Cycle | 5-7% | |
| HCPCS Level II Coding | 5-7% | |
| ICD-10-CM Coding | 15-17% | - Code selection & sequencing - Diagnosis coding guidelines |
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NEW QUESTION # 328
A patient presents to the office with dysuria and lower abdominal pain. The physician suspects she has a UTI.
A non-automated urinalysis is done in the office and is negative. UTI is ruled out for the final diagnosis.
What CPT and ICD-10-CM codes are reported?
Answer: B
Explanation:
1. Procedure and CPTCode Selection:
The urinalysis performed was non-automated and without microscopy.
CPTCode 81002 is appropriate for a non-automated urinalysis without microscopy. This code accurately reflects the test performed in the office.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code R30.0 is used for dysuria, which was one of the patient's presenting symptoms.
ICD-10-CM Code R10.30 is used for lower abdominal pain, another presenting symptom.
Since the urinalysis ruled out a urinary tract infection, N39.0 (UTI) is not appropriate as a final diagnosis.
3. Rationale for Excluding Other Options:
Code 81000 (in options A and B) is for a urinalysis with microscopy, which was not performed here.
N39.0 is used when a UTI is confirmed, which is incorrect for this case since the urinalysis was negative, ruling out UTI.
4. AAPC and CPTCoding Guidelines:
AAPC guidelines recommend coding based on the symptoms when a specific diagnosis (such as UTI) is ruled out. Therefore, R30.0 and R10.30 are appropriate symptom codes for this encounter.
Thus, the correct answer is C. 81002, R30.0, R10.30.
NEW QUESTION # 329
(A 1-year-old patient was born with twosupernumerary digits, one extending from the right pinky and one extending from the left pinky. The digit from his left pinky is larger and includes themetacarpal bone with a jointand is amputated. The one on the right is anubbinand containsno bony structure. The hand surgeon removes the extra digit containingsoft tissueby a simple excision. What is the CPT coding for the procedures performed?)
Answer: B
Explanation:
Supernumerary digit removal coding depends on whether the extra digit hasbone/jointor is asoft-tissue tag
/nubbin. The left-hand extra digit includes ametacarpal bone with a joint, so it is treated as removal of an accessory digit with bony involvement, reported with26910(removal of extra digit, hand/foot;withbone and joint reconstruction elements implied by the code family context). Because it is theleftside, append-LT. The right-hand extra digit is described as anubbin with no bony structure, removed bysimple excision-this aligns with askin tag-likeremoval code,11200, for removal of benign skin tags/lesions by simple excision (as represented in the answer options) with-RTfor laterality. You should not bill both sides with a single "-50" here because the procedures arenot the sameon each side (bony digit vs soft-tissue nubbin). Therefore,26910- LT and 11200-RTis correct.
NEW QUESTION # 330
A pediatrician removes impacted cerumen using irrigation in the right ear and instrumentation in the left ear.
What CPT coding is reported?
Answer: A
Explanation:
69209 = Cerumen removal using irrigation
69210 = Cerumen removal using instrumentation
Different techniques on different ears require separate codes with laterality modifiers
NEW QUESTION # 331
According to the ICD-10-CM coding guidelines, when coding hypertension with heart conditions classified to I50.- or I51.4-I51.7, I51.89, I51.9, what category should be used?
Answer: A
Explanation:
When hypertension and heart disease are documented together, a cause-and-effect relationship is presumed unless stated otherwise.
Category I11 (Hypertensive heart disease) is used.
Additional codes from I50.- (heart failure) are assigned if applicable.
This follows ICD-10-CM Official Coding Guidelines.
NEW QUESTION # 332
View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See Nurses Notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Have been reviewed-tachycardic.
Eyes: Pupils equal, round and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardia. Heart sounds normal. Pulses normal.
E D. Course: Insulin IV drip per protocol, at 10 units/hr.
Zofran 8 mg 01:33 Jul 13 2008 IVP.
Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.
Total critical care time: 45 min.
Disposition: Admitted to Intensive Care Unit. Condition: stable.
Admit decision based on need for monitoring and IV hydration and medications.
CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.
What E/M code is reported for this encounter?
Answer: C
Explanation:
99291: This code is used for the first 30-74 minutes of critical care, evaluation, and management of the critically ill or critically injured patient.
99292: This code is used for each additional 30 minutes of critical care service beyond the first 74 minutes.
The documentation indicates that the patient received a total of 45 minutes of critical care, which involves continuous IV insulin for diabetic ketoacidosis, administration of antiemetics, and admission to the ICU. The critical care time documented justifies the use of 99291 for the first 30-74 minutes and 99292 for each additional 30 minutes.
CPT Professional Edition, AMA
NEW QUESTION # 333
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