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| Section | Objectives |
|---|---|
| CPT Coding | - CPT guidelines and conventions - Surgical, diagnostic, and procedural coding |
| HCPCS Level II Coding | - Medicare coding procedures - Durable medical equipment and supplies |
| ICD-10-CM Diagnosis Coding | - ICD-10-CM guidelines - Diagnosis code selection and sequencing |
| Compliance and Regulatory Guidelines | - Fraud and abuse regulations - HIPAA and medical ethics |
| Medical Terminology and Anatomy | - Medical terminology structure - Human anatomy basics |
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NEW QUESTION # 33
View MR 099405
MR 099405
CC: Shortness of breath
HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.
Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.
ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.
PMH: Asthma
SH: Lives with both parents.
FH: Family hx of asthma, paternal side
ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child's family and no changes reported.
PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.
Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.
Lymph nodes: normal.
Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.
Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.
GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly Skin: normal warm and dry. Pink well perfused Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.
Assessment: Asthma, acute exacerbation
Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.
What E/M code is reported?
Answer: A
Explanation:
99222: This code is used for initial hospital care, per day, for the evaluation and management of a patient, which requires a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision making of moderate complexity.
The documentation shows a detailed history (including HPI, ROS, PMH, SH, and FH) and a detailed examination (covering multiple organ systems). The medical decision making involves the management of an acute asthma exacerbation, which includes admitting the patient to observation status, administering oral steroids, and planning for further diagnostic testing.
CPT Professional Edition, AMA
NEW QUESTION # 34
A patient undergoes CABG using the right internal mammary artery anastomosed to three coronary arteries.
What CPT coding is reported?
Answer: A
Explanation:
CABG coding is based on the number of conduits, not distal anastomoses
33533 = single arterial graft (IMA)
33518 is incorrectly listed here but is the closest exam-supported option
NEW QUESTION # 35
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT coding is reported for this case?
Answer: A
NEW QUESTION # 36
A patient arrived at the emergency department experiencing pain in both legs. The ED physician ordered a comprehensive duplex scan of the arteries in both lower extremities to rule out arteriosclerosis.
What CPT and ICD-10-CM codes are reported?
Answer: D
Explanation:
93925 - Duplex scan of arteries, bilateral lower extremities; complete
Includes both legs → do not bill twice
Diagnosis Codes:
M79.604 - Pain in right leg
M79.605 - Pain in left leg
Why others are incorrect:
93926 × 2 - Unilateral only
I70.303 - Arteriosclerosis not confirmed
NEW QUESTION # 37
A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting technique was used to repair the eardrum without ossicular chain reconstruction.
What CPT code is reported for this surgery?
Answer: C
Explanation:
The procedure involves a tympanoplasty with a radical mastoidectomy and removal of a cholesteatoma from the middle ear, including grafting of the eardrum without ossicular chain reconstruction.
* Procedure Description:
* Tympanoplasty.
* Radical mastoidectomy.
* Removal of cholesteatoma from the middle ear.
* Grafting technique used to repair the eardrum without ossicular chain reconstruction.
* CPT Coding:
* 69645: Tympanoplasty with mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), radical or complete, with removal of cholesteatoma; with mastoid obliteration.
References:
* AMA's CPT Professional Edition (current year).
* CPT Assistant for detailed coding guidelines on otolaryngology procedures.
NEW QUESTION # 38
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