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NEW QUESTION # 282 
Refer to the supplemental information when answering this question:
View MR 004813
What CPT and ICD-10-CM codes are reported?
Answer: D
Explanation:
CPT Code 43246: Esophagogastroduodenoscopy, with transoral insertion of intra-abdominal tube (e.g., gastrostomy or jejunostomy) This code describes the attempted PEG tube placement.
Modifier -52: Reduced services. This modifier is appended because the procedure was aborted and the PEG tube was not successfully placed.
ICD-10-CM Code K94.29: Other specified disorders of digestive system
This code captures the patient's chronic feeding requirement, which is the reason for the attempted PEG tube placement.
ICD-10-CM Code K44.9: Diaphragmatic hernia without obstruction or gangrene This code reports the small hiatal hernia that was found during the procedure.
References:
CPT Code 43246: Esophagogastroduodenoscopy, with transoral insertion of intra-abdominal tube (e.g., gastrostomy or jejunostomy) Modifier 52: Reduced services ICD-10-CM Code K94.29: Other specified disorders of digestive system ICD-10-CM Code K44.9: Diaphragmatic hernia without obstruction or gangrene AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.
NEW QUESTION # 283
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: A
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 # 284
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 CPT coding is reported?
Answer: C
Explanation:
52356 = Cystourethroscopy with ureteroscopy, lithotripsy and stent placement Combination code # do not report components separately
NEW QUESTION # 285
A 49-year-old patient arrives with hearing loss in his left ear. Impedance testing via tympanometry is performed.
What CPT code is reported?
Answer: A
NEW QUESTION # 286
(A physician performsexcisional debridementfor a patient with multiple wounds. A wound on thelower backmeasures12 cmand involves thefasciafor the debridement. A wound on theleft shouldermeasures8 cmand one on theleft lower legmeasures16 cminvolvessubcutaneous tissuefor the debridement. What CPT codes are reported?)
Answer: C
Explanation:
Debridement coding depends ondeepest tissue removedand thetotal surface areadebrided at each depth.
Debridement "tomuscle and/or fascia" is coded with11043for thefirst 20 sq cm (or part thereof)at that depth.
The lower-back wound involvesfascia, so report11043(no add-on 11046 is needed because the described size is below an additional 20 sq cm threshold). The shoulder (8) and lower-leg (16) wounds involvesubcutaneous tissue, which is coded with11042for thefirst 20 sq cm (or part thereof)at the subcutaneous depth. Their combined area is24 sq cm, so you report11042plus add-on11045for theadditional 4 sq cmbeyond the first 20.
Because two different depth families are billed (fascia vs subcutaneous), adistinct procedural servicemodifier (here-59on 11042) supports reporting both depths when documentation shows separate wounds/levels treated.
This matches optionD.
NEW QUESTION # 287
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