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NEW QUESTION # 190
A surgeon performs midface LeFort I reconstruction on a patient's facial bones to correct a congenital deformity. The reconstruction is performed in two pieces in moving the upper jawbone forward and repositioning the teeth of the maxilla of the mid face.
What CPT code is reported?
Answer: B
NEW QUESTION # 191
A patient is diagnosed with compression fractures of the C6, C7 and T1 vertebrae. The patient agrees to have vertebroplasty. Bone cement is injected in the vertebral space until each of the two whole vertebral body is filled. The procedure is performed bilaterally.
What CPTcoding is reported?
Answer: A
Explanation:
1. Procedure Type and CPTCode Selection:
The physician performed an injection into the wrist joint for degenerative osteoarthritis management using Synvisc (a viscosupplementation product).
Code 20606 is the correct CPTcode for an arthrocentesis, aspiration, and/or injection procedure in an intermediate joint, such as the wrist. This code specifically includes the use of ultrasound guidance, which is often standard in such injections.
Code 20551 (injection of a single tendon origin) and 20526 (injection into a carpal tunnel) are incorrect here as they do not apply to intra-articular injections for joint osteoarthritis management.
2. Diagnosis Code Selection (ICD-10-CM):
The diagnosis is degenerative osteoarthritis in the right wrist.
ICD-10-CM Code M19.231 is used for primary osteoarthritis of the right wrist. This code directly reflects the diagnosis of primary osteoarthritis affecting this specific joint.
M19.031 would represent primary osteoarthritis in the wrist but does not specify laterality; therefore, it is less accurate than M19.231, which denotes the right wrist.
3. Summary of Code Application:
The correct CPTand ICD-10-CM codes are 20606 for the injection procedure and M19.231 for primary osteoarthritis of the right wrist.
4. AAPC and CPTCoding Guidelines:
According to AAPC CPC guidelines, proper joint injection codes require specific identification of the joint location and guidance if used. Additionally, selecting the most specific ICD-10-CM code for laterality is essential for accuracy in musculoskeletal diagnoses.
Thus, based on CPTand ICD-10-CM coding guidelines, the verified answer is B. 20606, M19.231.
NEW QUESTION # 192
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: B
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 CPTcode 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 CPTguidelines 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 # 193
A patient is brought to the operating room with a right-sided peripheral vertigo. The provider makes a postauricular incision and uses an operating microscope to perform a mastoidectomy using a burr. He next destroys the semicircular canals, the utricle, and saccule completely removing the diseased labyrinth structures. The provider sutures the incision.
What CPT code and ICD-10-CM codes are reported?
Answer: D
Explanation:
Procedure Coding (CPT):
69910 - Labyrinthectomy, complete; transmastoid approach
Provider performed:
Mastoidectomy
Complete destruction/removal of semicircular canals, utricle, and saccule This is a complete labyrinthectomy, not partial
69990 - Microsurgical techniques, requiring use of operating microscope Separately reportable with otologic procedures Modifier -51 not required (add-on code) Diagnosis Coding (ICD-10-CM):
H81.391 - Peripheral vertigo, right ear
Correct laterality and condition
Why Other Options Are Incorrect:
69905 - Partial labyrinthectomy
R42 - Symptom code (dizziness), not used when definitive diagnosis exists
NEW QUESTION # 194
(A 42-year-old female is in the operative room to repair azone 2 flexor digitorum profundus (FDP) tendonlaceration involving her index finger with an associatedradial digital nerveinjury. The dorsal side of the FDP tendon was sutured. Next, themicroscopewas brought into place and the radial digital nerve was repaired using epineural sutures. What CPT codes are reported?)
Answer: A
Explanation:
Zone 2 flexor tendon repairs ("no man's land") are coded with thezone 2 flexor tendon repair
/advancementcode family. Because the case specifieszone 2 FDP tendon repairof the index finger, the correct tendon repair code is26356(zone 2 flexor tendon repair/advancement; primary, without free graft, each tendon). The associateddigital nerve repairis separately reported with64831(suture of digital nerve; one nerve). Since both procedures are performed in the same operative session, the secondary procedure commonly carriesmodifier -51for multiple procedures when required by payer/claim conventions (as reflected in the answer choices). The operative note specifically states use of anoperating microscopefor microsurgical nerve repair, which supports add-on code69990(microsurgical techniques requiring operating microscope), reportedonce per sessionandnotwith modifier 51. Therefore, the only fully correct option including tendon, nerve repair, and microscope reporting isA.
NEW QUESTION # 195
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