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NEW QUESTION # 75
A 69-year-old patient with a medical history of diabetes is evaluated in the emergency room for a urinary tract infection. After performing a medically appropriate history and exam, the physician prescribes 100 mg of Macrobid every 12 hours and admits the patient to observation status to monitor for sepsis. After seeing an improvement in symptoms, the physician discharges the patient the following day. What CPT and ICD-IO-CM code(s) should be reported for the entirety of the patient's stay?
- A. 99284, 99238, Ell.69, N39.O
- B. 99234, N39.O, 397.89
- C. 99221, 99238, N39.O, Ell.9
- D. 99222, 99238, N39.O
Answer: C
Explanation:
When a patient is admitted into observation status from the emergency room, only the observation code is reported for that day. When observation extends past the initial date of service, the initial treatment would be reported with CPT codes 99221-99223. In this scenario, the appropriate level of service would be 99221, based on the moderate level of decision-making.
which can be ascertained by the number and complexity of problems addressed and the risk of complications and/or morbidity or mortality of patient management. Discharge from observation on a separate date is reported with CPT codes 99238-99239.
Because the diabetes is documented and is a coexisting chronic condition during the time of the encounter, it should follow the reason for admission. Due to a lack of specificity in the diabetes diagnosis, a causal relationship with a UTI is not presumed, and Ell.69 should not be coded.
NEW QUESTION # 76
A 39-year-old female patient has developed a diaphragmatic hernia after an episode of domestic violence. The surgeon repairs the hernia through an incision into the abdomen. The patient is later discharged with no complications. How should this encounter be reported?
- A. 39541, K44.O, T76.1 IXA
- B. 39540,K44.9, T 76.1 IXA
- C. 39541, K44.O, T74.11YA Y07.9
- D. 39540, K44.9, T74.11XA Y07.9
Answer: D
Explanation:
Acute trauma results from a single incident, whereas chronic trauma is repeated, usually over the course of months or years. In this scenario, the documentation does not specify, so the coder should assume acute trauma. There is no mention of obstruction, so ICD-IO-CM code selection is K44.9, followed by the cause of the hernia. Vvhen an exam shows evidence of abuse, the abuse is no longer considered suspected but confirmed.
NEW QUESTION # 77
A patient is having difficulties breast-feeding and receives a lactation consultation by a certified lactation consultant under the general supervision of a mid-level practitioner. How should this service be reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
Explanation:
CPT 98960 is used by nonphysician healthcare professionals who provide education to patients that enable them to self-manage established conditions. CPT 99078 could also be used to report lactation services, but these are specifically rendered in a group setting. CPT 98966 is used for healthcare management via the telephone, and CPT 99211 is not considered the most appropriate descriptor for services rendered in this instance.
NEW QUESTION # 78
A female patient presents to her obstetrical office 32 -weeks pregnant for a bi-weekly ultrasound. Code the following technician's report:
Fetal views obtained via transabdominal ultrasound as follows:
BPD: 32 mm
Femur Length: 63 mm
Head Circumference: 288 mm
Abdominal Circumference: 270 mm
BPP 8/8
NST from 11:15 to 12:17, showing 160 BPM and positive movement activity Doppler shows adequate systolic and diastolic flow velocities of the fetal umbilical artery.
- A. 76815-TC, 76819-TC, 76820-TC
- B. 76816, 76818, 76820
- C. 76816-TC, 76816-TC, 76820-TC
- D. 76815, 78819, 76820
Answer: B
Explanation:
CPT 76815 is a limited ultrasound, in which only the fetal heartbeat, position, placental location, and/or volume of amniotic fluid are evaluated. In this scenario, much more was done than a limited study. The ultrasound technician documented age-appropriate fetal measurements, which are supported by CPT 76816. A biophysical profile (BPP) was also done, which monitors the fetus's movements, tone, and breathing as well as evaluates the volume of amniotic fluid. Each of these elements counts as 2 units of grading to evaluate the general well-being ofthe fetus. The desired score of a BPP is 8/8. Because a fetal nonstress test (NST) was completed in conjunction with a BPP, report CPT 76818 instead of CPT 76819. Modifier TC is used to reflect that only a technical component of the procedure was completed. However, because the patient received these services in an obstetrical office that employs the physicians providing prenatal care and owns the ultrasound equipment the code should be submitted without modifiers TC or 26 to receive 100% reimbursement.
NEW QUESTION # 79
An orthopedic surgeon performs a meniscectomy for a right radial tear using an arthroscope. During the procedure, the surgeon removes a piece of the damaged meniscus from the lateral compartment of the knee and shaves the articular cartilage of the same compartment. A separate incision was made to remove a 6 mm loose body in the medial compartment. The surgery was completed without any complications. What procedure and diagnosis code(s) should be reported?
- A. 29881, 29874-51, S83.203A
- B. 29881, 29874-59,S83.281A
- C. 29882, 29877-51, 29874-51, S83.203A
- D. 29887, 29874-59,S83.281A
Answer: B
Explanation:
The procedures performed on this encounter were the meniscectomy (removal of damaged meniscus from the lateral compartment) with a chondroplasty (shaving of articular cartilage,
29881) and loose body removal by means of an arthroscopy (29874). Because the removal of loose bodies is considered inclusive to the primary procedure, modifier 59 is appended as opposed to modifier 51 to indicate that it was a distinct procedural service due to the separate incision.
Answers A and D can be eliminated based on the diagnosis chosen. S83.203A indicates the location of meniscus is unspecified: however, the surgeon removed the damaged meniscus from the lateral compartment, leading the biller to S83.281A.
NEW QUESTION # 80
The laboratory collected blood to test the patient's carbon dioxide, chloride, potassium, sodium, and glucose levels. Select the CPT codes that the laboratory will report.
- A. 80051, 82947
- B. 80051, 82947-59
- C. 80051, 80053
- D. 80053-52
Answer: A
Explanation:
It would not be appropriate to add modifier 52 to 80053 in answer A In answer C, 80051 and
80053 would not be reported together because CPT guidelines state that "when or more panel codes include the same tests, report the panel with the highest number of tests in common." Because the glucose test is not included in 80051, 82947 would be added to 80051, with no modifier 59, because the procedures are routinely billed together, thus eliminating answer D.
NEW QUESTION # 81
A patient with preexisting hypertension presents to the office at 23-weeks' gestation for prenatal care. Her blood pressure is slightly elevated, and a transabdominal ultrasound shows the fetus is small for dates. The provider advises rest and to follow up as normal. How would the provider code the visit if the patient has an insurance that accepts the global obstetrical package?
- A. 0502F, 76816, 010.012, Z3A. 23
- B. 99213-25, 76816, 010.012, Z3A. 23
- C. 0502F, 76815, 010.012, 036.5920, Z3A 23
- D. 99213-25, 76815, 010.012, 036.5920, Z3A. 23
Answer: A
Explanation:
The global obstetrical package includes routine prenatal care visits and blood pressure checks, so a placeholder code (0500F-0503F) is used to report that a visit occurred instead of an E/M code. CPT 76816 is reported when biometric measurements are taken ofthe fetus, whereas CPT 76815 is limited to one element of the fetus, such as the position or heartbeat. Per ICD-IO-CM, codes beginning with 035- and 036- are reported only "when the fetal condition is actually responsible for modifying the management of the mother."
NEW QUESTION # 82
A patient is scheduled for a total knee replacement. The assigned anesthesiologist performs a femoral nerve block using an ultrasound machine just prior to entering the operating room to aid in postoperative pain control. Once in the operating room, general anesthesia is administered to the patient. What CPT code(s) should the anesthesiologist report?
- A. 01400, 01991, 76942
- B. 01402
- C. 01400, 01991-59
- D. 01402,64447_59, 76942
Answer: D
Explanation:
CPT crosswalk for anesthesia administered during a total knee replacement is 01402.
Although CPT 01991 does describe a nerve block, it is considered monitored anesthesia care because the patient is awake. However, in this scenario, general anesthesia is being used for the primary procedure, and the femoral nerve block is administered for postoperative pain management. Therefore, the nerve block would be billed as CPT 64447 with modifier 59 to indicate that it is separately reportable from the primary procedure. If, on the other hand, the nerve block was being used as a component of the general anesthesia, CPT 64447 would be considered inclusive to the general anesthesia and not reported separately. Ultrasound guidance is not currently bundled with the administration of a nerve block and, when used, should be reported separately with CPT 76942.
NEW QUESTION # 83
A 74-year-old male patient recently had a bone marrow transplant due to aplastic anemi a. At his follow-up visit with the doctor, his blood is drawn and sent to the laboratory to determine if the engraftment was successful. The laboratory evaluates the immature reticulocyte fraction (IRF) using an automated cell counter and total reticulocyte by way of a manual count. What codes should the laboratory report?
- A. 85046, D61.9
- B. 85046, 85044, D61.9
- C. 85046, D61.9, Z79.89
- D. 85046, 85044, D61.9, Z94.81
Answer: A
Explanation:
When a hematologr procedure that could be billed alone is encompassed in another code, only the most complex of the tvo should be reported. Because CPT 85046 includes the reticulocyte count billing CPT 85044 as secondary despite using a different method would be considered an unbundling of services. Per ICD-IO-CM guidelines, an organ or tissue transplant status code is for use "only if there are no complications or malfunctions of the organ or tissue replaced." As the testing is to determine whether the engraftment was successful, a bone marrow transplant status code would not be appropriate until deemed by the provider.
NEW QUESTION # 84
A 22-year-old patient presents with a 5.5 cm gaping laceration on the right forearm and a
2 cm superficial laceration on the right wrist caused by a table saw. A local anesthetic is injected around both laceration sites. The physician irrigates the laceration on the wrist before closing the wound with a tissue adhesive and then performs an extensive cleaning and single-layer closure with sutures on the forearm. What should be coded for this encounter?
- A. 12032, S41.111A, S61.411A,W31.2kX.A
- B. 12032, 12001-59, S41.111A S61.411A W31.2XXA
- C. 12032, 97597, G0168, S41.111A, S61.411A W31.2XXA
- D. 12001, 12032-59, S61.411AS41.111A W31.2XXA
Answer: B
Explanation:
A "gaping" injury and/or "single-layer closure" is indicative of an intermediate repair and a
"superficial" injury and/or use of a "tissue adhesive" is indicative ofa simple repair. Because the repairs are not in the same classification, each repair is reported in a single code, sequenced from the most to the least severe (eliminating answers B and D), with modifier 59 appended to the less complicated procedure(s). Local anesthesia is included in these procedures, as is debridement unless the provider specifically indicates that it is extensive. In answer A, an HCPC's code for tissue adhesive would be reported only if the patient had Medicare.
NEW QUESTION # 85
A young man is triaged in the emergency room after sustaining multiple injuries in a car accident. The physician performs the following limited exams with image documentation: an abdominal and retroperitoneal ultrasound, a transthoracic echocardiography, and a chest ultrasound. He indicates in his report that all findings are normal. What charges should the provider submit to the insurance company?
- A. 93304-26, 76705-26, 76775-26, 76604-26
- B. 93304-TC, 76700-TC, 76770-TC, 76604-TC
- C. 93308, 76705-59, 76770-59, 76604-59
- D. 93308-26, 76705-26, 76775-26, 76604-26
Answer: D
Explanation:
CPT code 93304 describes an echocardiography used to evaluate a congenital defect. In this case, the provider is screening for any trauma-related injuries to the heart. Bearing in mind that the study is limited leads you to CPT 93308. Modifier 26 is used on all CPT codes because the procedures are being performed in a hospital setting. Therefore, only the professional component of the service should be billed. Modifier TC is reported by the entity providing the equipment, which in this case would be the hospital. Modifier 59 is not necessary because the procedures are routinely done in conjunction with each other.
NEW QUESTION # 86
A low-risk obstetrical patient is told to come in for weekly ultrasounds in her first trimester. This is an example of what?
- A. Abuse
- B. Misuse
- C. Waste
- D. Fraud
Answer: C
Explanation:
In this case, the patient is not at risk, and most organs either are not developed and/or cannot be visualized in the first trimester. Thus, this would constitute as waste due to the provider overutilizing services that result in unnecessary cost. AAPC defines fraud as purposely billing "for services that were never given or to bill for a service that has a higher reimbursement than the service provided." Abuse is payment for services "that are billed by mistake by providers."
NEW QUESTION # 87
Which term describes a migraine that is unmanageable with treatment?
- A. A migraine with aura
- B. Status migrainosus
- C. Classical migraine
- D. Intractable migraine
Answer: D
Explanation:
An intractable migraine is one that is continuous and obstinate to conventional treatment. If a migraine is preceded by symptoms ofvision disturbances and/or transient muscle weakness, those symptoms are collectively known as aura. A migraine with aura is also called a classical migraine. Status migrainosus describes a severe, debilitating migraine that lasts longer than 72 hours and usually results in hospitalization.
NEW QUESTION # 88
To rule out malignancy, a provider collects two biopsies from the right thyroid nodule using a large bore needle that is inserted through the skin. Which CPT code(s) should be reported?
- A. 10021, 10004-59
- B. 0
- C. 60100, 60100-59
- D. 10021, 10004
Answer: B
Explanation:
Although CPT codes 10021, 10004, and 60100 all represent percutaneous procedures, only CPT 60100 describes the use of a large bore needle to obtain a specimen. When multiple biopsies are taken from the same nodule, only report CPT 60100 once. Ifa separate nodule is biopsied, report 60100 a second time with modifier 59, indicating a procedure on a sperate anatomical site.
NEW QUESTION # 89
Dr. Black orders a hepatitis panel for a patient who has recently returned from traveling abroad and is now experiencing lower abdominal pain. The laboratory completed a hepatitis A antibody test, hepatitis B core antibody test, and a hepatitis C antibody test. Select the CPT and the ICD-IO-CM codes that the laboratory will report.
- A. 80074-52, RIO.30
- B. 80074, RIO.30
- C. 86709, 86705, 86803, RIO.30
- D. 86709, 86705, 86803, RIO.31, RIO.32
Answer: C
Explanation:
The hepatitis B surface antigen test was not performed, so the actual panel code in answer A was not completed, leaving each test to be reported separately. It would not be appropriate to add modifier 52 to 80074 in answer B. Because the provider did not specify which side the lower abdominal pain was on, it would be reported as unspecified with RIO.30, eliminating answer C.
NEW QUESTION # 90
During surgery to remove a malignant melanoma from the intestinal tract, one frozen section is sent for pathological consultation to confirm an adequate excision of the margins. A second specimen is also sent, which requires frozen sections on two tissue blocks. What CPT code(s) should the pathologist report?
- A. 88329, 88331, 88332, 88332
- B. 88331, 88331, 88332
- C. 88331, 88332
- D. 88331, 88332, 88332
Answer: B
Explanation:
CPT code 88331 is used to report only a single specimen. In this scenario, there are Evo separate specimens being sent to the pathologist. The first specimen, with one frozen section, is reported with CPT code 88331. The second specimen has tv.ro tissue blocks with frozen sections, thus represented by coding 88331 for the first tissue block, followed by 88332 for the additional tissue block CPT code 88329 is inclusive to 88331 and should not be reported separately.
NEW QUESTION # 91
A patient has a colonoscopy in which the provider removes three polyps from the transverse colon. The first polyp is removed by means of a hot snare technique, and the following two polyps are removed using hot biopsy forceps. What CPT code(s) should be reported for this encounter?
- A. 0
- B. 1
- C. 45385, 45384-59
- D. 45385, 45384-59, 45384-59
Answer: C
Explanation:
When coding colonoscopies, remember that the number of removal techniques is what has a bearing on code selection and not the number of lesions and/or polyps that are being removed. In this case, two techniques are being used: I) the snare technique (CPT 45385) and 2) the hot biopsy forceps technique (CPT 45384). Modifier 59 is appended onto the secondary code to indicate that separate polyps '.vere removed by two different techniques. CPT 45388 is reported when a provider uses any methods other than snare and hot biopsy forceps to remove a lesion and/or polyp.
NEW QUESTION # 92
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