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| Section | Weight | Objectives |
|---|---|---|
| CPTยฎ Coding | 45-50% | - Surgery (10000โ69999) - Evaluation & Management (E/M) - Radiology, Pathology/Laboratory, Medicine |
| ICD-10-CM Coding | 15-17% | - Diagnosis coding guidelines - Code selection & sequencing |
| Reimbursement & Revenue Cycle | 5-7% | |
| Modifiers | 5-7% | |
| Compliance & Regulations | 8-10% | - Reimbursement rules - HIPAA, fraud & abuse |
| Medical Terminology & Anatomy | 8-10% | |
| HCPCS Level II Coding | 5-7% |
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NEW QUESTION # 26
A patient is seen at the doctor's office for nausea, vomiting, and sharp right lower abdominal pain. CT scan of the abdomen is ordered. Labs come back indicating an increased WBC count with review of the abdominal CT scan. The physician determines the patient has chronic appendicitis. The physician schedules an appendectomy and takes the patient to the operating room. The appendix is severed from the intestines and removed via scope inserted through an umbilical incision. What CPT and diagnosis codes are reported?
Answer: B
Explanation:
1. Procedure and CPT Code Selection:
The patient underwent an appendectomy performed via laparoscopic approach. The procedure involved removal of the appendix using a scope inserted through an umbilical incision.
CPT Code 44970 is specific for a laparoscopic appendectomy, which is the correct code for this procedure.
Code 44950 would be used for an open appendectomy, but since this case was performed laparoscopically, 44970 is appropriate.
2. Diagnosis and ICD-10-CM Code Selection:
The diagnosis given by the physician is chronic appendicitis.
ICD-10-CM Code K36 is used to report chronic appendicitis, which is the definitive diagnosis in this case.
Additional codes for symptoms such as nausea (R11.2) and right lower quadrant pain (R10.31) are not necessary because the primary diagnosis of chronic appendicitis (K36) fully explains the symptoms, according to ICD-10-CM guidelines on coding symptoms when a definitive diagnosis is available.
3. AAPC and CPT Coding Guidelines:
AAPC guidelines indicate that when a definitive diagnosis is established, symptom codes should not be reported separately. The use of 44970 for laparoscopic appendectomy and K36 for chronic appendicitis is fully supported by these coding standards.
Therefore, the correct answer is C. 44970, K36.
NEW QUESTION # 27
What does the suffix -graph mean?
Answer: D
Explanation:
In medical terminology, the suffix -graph refers to an instrument used for recording data or the process of recording. This suffix is commonly tested on the CPC exam.
Examples include:
Electrocardiograph - instrument used to record heart activity
Angiograph - instrument used to record images of blood vessels
To distinguish from related suffixes:
-gram = the record or image itself
-graphy = the process of recording
Thus, option A is correct.
NEW QUESTION # 28
(Full Case:Patient:V. Bowen.Physician:C.S., MD.Reason for admission:Abdominal pain.HPI:admitted this morning; sudden onset RUQ pain began ~4:00 p.m. yesterday; started while eating; 8/10; chills/sweating
/nausea; no vomiting/diarrhea; last BM 2:00 p.m. yesterday; unable to pass stool or gas since; abdominal distention; poor sleep; prior similar episodes relieved by gas tablets but not this time; no discolored stool/urine.
PMH:HTN (losartan; missed dose).PSH:bunion surgery right foot.FH:HTN.SH:no smoking/alcohol.Meds:
losartan daily.Allergies:NKDA.ROS:nausea, no emesis; no flatus/stool since yesterday; no weight change; no SOB/chest pain; no jaundice; no urinary frequency/urgency.PE:alert/oriented x3; obvious abdominal discomfort. Vitals 139/100, pulse 100, RR 16, temp 36.4. HEENT normal; CV regular; lungs clear. Abdomen:
+BS, soft but very tender; worst RUQ;Murphy's sign; guarding and rebound (worse with palpation).
Extremities trace edema.Labs ordered/reviewed:CMP with abnormal LFT/bili; CBC WBC 9.9; etc.Final assessment:RUQ abdominal pain,rule out cholecystitis.Plan:NPO; morphine IV (controlled substance); IV NS
150 cc/hr; abdominal ultrasound and HIDA ordered; consider surgical consult based on results.Question:What CPT and ICD-10-CM codes are reported?)
Answer: B
Explanation:
This is aninitial hospital service(admitted this morning; "reason for admission"), so the correct E/M family isinitial hospital inpatient/observation carerather than subsequent hospital care (99232/99233). The encounter includes a detailed history, comprehensive exam elements focused on abdominal pathology, and meaningful initial management: NPO, IV fluids,IV morphine, ordering and reviewing lab panels, and ordering imaging (ultrasound and HIDA) with possible surgical consultation-supporting at leastmoderate MDM, consistent with99222in typical CPC exam mapping. Diagnosis coding: "rule out cholecystitis" is not a confirmed inpatient discharge diagnosis in the provided note; at this stage the physician's final assessment isRUQ abdominal pain, rule out cholecystitis. Therefore, you report thesign/symptomcodeR10.11 (right upper quadrant pain)rather thanK81.9(cholecystitis, unspecified), because cholecystitis is not established as definitive in the note. Option A correctly pairs an initial hospital E/M code with the symptom diagnosis supported by documentation.
NEW QUESTION # 29
A patient complains of tarry, black stool, and epigastric tightness. An esophagogastroduodenoscopy is recommended to evaluate the source of the bleeding. The endoscope is inserted orally. The esophagus appears normal on scope insertion. No evidence of bleeding in the stomach. The scope is then passed into the duodenum, where a polyp is found and removed with hot biopsy forceps. No evidence of bleeding post procedure.
What CPT code is reported?
Answer: A
Explanation:
An esophagogastroduodenoscopy (EGD) was performed with the removal of a polyp using hot biopsy forceps.
Procedure Description:
An EGD was performed.
A polyp was found in the duodenum and removed with hot biopsy forceps.
CPT Coding:
43250: Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
AMA's CPT Professional Edition (current year).
CPT Assistant for detailed coding guidelines on endoscopic procedures.
NEW QUESTION # 30
A patient is having X-ray imaging of his abdomen following a traumatic episode. A decubitus, supine, and erect views are performed on the abdomen.
What CPTis reported?
Answer: C
Explanation:
1. Procedure and CPTCode Selection:
The patient underwent X-ray imaging of the abdomen with multiple views: decubitus, supine, and erect. This is a comprehensive study that includes different positioning to evaluate the abdomen.
CPTCode 74022 is appropriate for an abdominal X-ray with a minimum of three views. This code accurately reflects the multiple views taken in this scenario.
2. Modifier 26:
Modifier 26 is applied to indicate the professional component of the service if the radiologist is only interpreting the images and not providing the technical component.
3. Rationale for Excluding Other Options:
Code 74018 (in option A) is for a single view of the abdomen, which does not apply here since multiple views were taken.
Code 74019 (in option C) covers two views of the abdomen, which is insufficient for this three-view study.
Code 74021 (in option D) represents an abdominal X-ray with more limited or focused views and does not align with the comprehensive three-view study described.
4. AAPC and CPTCoding Guidelines:
According to AAPC and CPTguidelines, 74022 is the correct code when an abdominal X-ray study involves at least three views, capturing various positions for a thorough examination.
Therefore, the correct answer is B. 74022-26.
NEW QUESTION # 31
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