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| Section | Weight | Objectives |
|---|---|---|
| ICD-10-CM Coding | 15-17% | - Code selection & sequencing - Diagnosis coding guidelines |
| Reimbursement & Revenue Cycle | 5-7% | |
| Compliance & Regulations | 8-10% | - Reimbursement rules - HIPAA, fraud & abuse |
| Medical Terminology & Anatomy | 8-10% | |
| Modifiers | 5-7% | |
| CPT® Coding | 45-50% | - Evaluation & Management (E/M) - Radiology, Pathology/Laboratory, Medicine - Surgery (10000–69999) |
| HCPCS Level II Coding | 5-7% |
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NEW QUESTION # 330
Patient with erectile dysfunction is presenting for same day surgery in removal and replacement of an inflatable penile prosthesis.
What CPTcode is reported for this service?
Answer: D
Explanation:
1. Procedure and CPTCode Selection:
The scenario describes the removal and replacement of an inflatable penile prosthesis due to erectile dysfunction.
CPTCode 54416 is specifically used for the removal and replacement of a multi-component inflatable penile prosthesis. This code accurately describes the procedure performed.
2. Rationale for Excluding Other Options:
Code 54401 represents the initial insertion of a multi-component inflatable penile prosthesis but does not cover removal and replacement, making it inappropriate for this scenario.
Code 54400 is for the insertion of a non-inflatable (malleable) penile prosthesis, which does not apply here as the prosthesis is inflatable.
Code 4417 does not exist in the CPTcoding system and is likely a typo or incorrect option.
3. AAPC and CPTCoding Guidelines:
According to AAPC and CPTguidelines, 54416 is the correct code when an inflatable prosthesis requires both removal and replacement, without the need for additional modifiers for this procedure.
Therefore, the correct answer based on CPTguidelines is D. 54416.
NEW QUESTION # 331
A patient who has colon adenocarcinoma undergoes a laparoscopic partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and remaining colon.
What procedure and diagnosis codes are reported?
Answer: B
Explanation:
The procedure involves a laparoscopic partial colectomy where the surgeon removes the proximal colon and terminal ileum, then reconnects the cut ends of the distal ileum and remaining colon.
Procedure Description:
Laparoscopic partial colectomy.
Removal of the proximal colon and terminal ileum.
Anastomosis of the distal ileum and remaining colon.
CPT Coding:
44204: Laparoscopy, surgical; colectomy, partial, with anastomosis.
ICD-10-CM Coding:
C18.2: Malignant neoplasm of ascending colon.
AMA's CPT Professional Edition (current year).
ICD-10-CM for corresponding diagnosis codes.
NEW QUESTION # 332
A flexible sigmoidoscopy is performed with ablation of two sigmoid colon polyps.
What CPT and ICD-10-CM codes are reported?
Answer: D
Explanation:
45346 = Sigmoidoscopy with ablation (reported once)
K63.5 = Polyp of colon
NEW QUESTION # 333
What is the HCPCS Level II code for a standard wheelchair?
Answer: A
Explanation:
K0001 = Standard wheelchair
Other K000 codes represent specialized wheelchairs
NEW QUESTION # 334 
Refer to the supplemental information when answering this question:
View MR 065174
What E/M code is reported for this encounter?
Answer: D
Explanation:
To determine the correct E/M code, we need to consider the three key components: history, examination, and medical decision making (MDM).
* History:
* The documentation indicates an expanded problem-focused history. This is supported by the detailed history of present illness, including the patient's description of symptoms, family history, and review of systems with pertinent positives and negatives.
* Examination:
* The examination is also expanded problem-focused. The physician focused on the relevant systems (head, neck, throat) and documented specific findings related to the chief complaint (thyromegaly).
* Medical Decision Making:
* The MDM is straightforward. The physician is evaluating a new problem (bilateral thyroid nodules) with a low level of risk. Although further workup is planned, this alone doesn't automatically increase the MDM complexity.
Based on these components, 99213 is the most appropriate code.
Why other options are incorrect:
* 99212: Requires a problem-focused history and examination, which is less comprehensive than what was documented.
* 99214 and 99215: Require a higher level of MDM (low or moderate complexity) and/or a more detailed examination. The documentation doesn't support this level of service.
References:
* CPT Codes 99211-99215: Office or other outpatient visit for the evaluation and management of an established patient
* 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 # 335
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