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NEW QUESTION # 49
A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins. The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.
What CPT coding is reported for the twin delivery?
- A. 59510, 59515
- B. 59510, 59514, 59515
- C. 0
- D. 59510 x 2
Answer: B
NEW QUESTION # 50
A patient underwent a cystourethroscopy with a pyeloscopy using lithotripsy to break up the ureteral calculus. An indwelling stent was also inserted during the same operative session on the same side. This service was performed in the outpatient hospital surgery center.
What CPT coding reported?
- A. 0
- B. 52353, 52332-51
- C. 52352, 52332-51
- D. 52325, 52332-51
Answer: A
NEW QUESTION # 51
A 3-day-old died in her sleep. The pediatrician determined this was the result of crib death syndrome. The parents give permission to refer the newborn for a necropsy. The pathologist receives the newborn with her brain and performs a gross and microscopic examination. The physician issues the findings and reports they are consistent with a normal female newborn.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
NEW QUESTION # 52
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.
What CPT coding is reported for this case?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
NEW QUESTION # 53
View MR 006399
MR 006399
Operative Report
Preoperative Diagnosis: Chronic otitis media in the right ear
Postoperative Diagnosis: Chronic otitis media in the right ear
Procedure: Eustachian tube inflation
Anesthesia: General
Blood Loss: Minimal
Findings: Serous mucoid fluid
Complications: None
Indications: The patient is a 2-year-old who presented to the office with chronic otitis media refractory to medical management. The treatment will be eustachian tube inflation to remove the fluid. Risks, benefits, and alternatives were reviewed with the family, which include general anesthetic, bleeding, infection, tympanic membrane perforation, routine tubes, and need for additional surgery. The family understood these risks and signed the appropriate consent form.
Procedure in Detail: After the patient was properly identified, he was brought into the operating room and placed supine. The patient was prepped and draped in the usual fashion. General anesthesia was administered via inhalation mask, and after adequate sedation was achieved, a medium-sized speculum was placed in the right ear and cerumen was removed atraumatically using instrument with operative microscope. The tube is dilated, an incision is made to the tympanum and thick mucoid fluid was suctioned. The patient was awakened after having tolerated the procedure well and taken to the recovery room in stable condition.
What CPT coding is reported for this case?
- A. 69421-RT
- B. 69420-RT
- C. 69436-RT
- D. 69433-RT
Answer: A
Explanation:
The procedure involves eustachian tube inflation to remove serous mucoid fluid in the right ear of a 2-year-old patient with chronic otitis media.
* Procedure Description:
* Eustachian tube inflation to remove fluid.
* General anesthesia.
* Incision to the tympanum and suctioning of thick mucoid fluid.
* CPT Coding:
* 69421-RT: Eustachian tube inflation, transnasal or transoral; with catheterization, including general anesthesia. The modifier -RT indicates the right ear.
References:
* AMA's CPT Professional Edition (current year).
* CPT Assistant for detailed coding guidelines on eustachian tube procedures.
NEW QUESTION # 54
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?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
Explanation:
The procedure described involves a LeFort I reconstruction, which is a type of orthognathic surgery performed to correct deformities of the midface. In this scenario, the surgeon performed the reconstruction in two pieces, moving the upper jawbone forward and repositioning the teeth of the maxilla. According to the CPT guidelines, CPT code 21146 describes a LeFort I (maxilla only) osteotomy, two-piece segment, including bone grafts (includes obtaining autografts). This code matches the description provided.
References:
* AMA's CPT Professional Edition (current year), Code 21146
NEW QUESTION # 55
A patient who has colon adenocarcinoma undergoes a laparoscopic partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and remaining colon.
What procedure and diagnosis codes are reported?
- A. 44140, C18.9
- B. 44205, C18.9
- C. 44204, C18.2
- D. 44160, C18.2
Answer: B
NEW QUESTION # 56
Patient has esotropia of the right eye and presents to operating suite for strabismus surgery. The physician resects the medial rectus horizontal and lateral rectus muscles of the eye and secures them with adjustable sutures. Extensive scar tissue is noted, due to a previous surgery involving an extraocular muscle. Extraocular muscle is isolated, and the muscle is freed from surrounding scar tissues.
What CPT codes are reported for this surgery?
- A. 67311, 67334
- B. 67312, 67335
- C. 67314, 67334
- D. 67316, 67335
Answer: B
NEW QUESTION # 57
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?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
NEW QUESTION # 58
Mr. Woolridge has had a suspicious lesion on his left shoulder for approximately eight weeks that is not healing. On the dermatologist's exam of left shoulder blade, there is excoriation and scabbing and the lesion not healing. Patient agrees and wishes to proceed with a punch biopsy of the lesion. A punch biopsy is taken of the lesion and sent to pathology. A simple repair is performed at the biopsy site.
What CPT and ICD-10-CM codes are reported?
- A. 11104,12001-51, L98.9
- B. 11102, 12001-51, D49.2
- C. 11102, L98.9
- D. 11104, D49.2
Answer: D
NEW QUESTION # 59
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?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
NEW QUESTION # 60
Patient is diagnosed with dacryocystitis, which is the inflammation of?
- A. Cornea
- B. Eardrum
- C. Lacrimal sac
- D. Fingernail
Answer: C
NEW QUESTION # 61
A patient had surgery a year ago to repair two flexor tendons in his forearm. He is in surgery for a secondary repair for the same two tendons.
Which CPT coding is reported?
- A. 25263 x 2
- B. 0
- C. 1
- D. 25272 x 2
Answer: A
NEW QUESTION # 62
Mr. Woolridge has had a suspicious lesion on his left shoulder for approximately eight weeks that is not healing. On the dermatologist's exam of left shoulder blade, there is excoriation and scabbing and the lesion not healing. Patient agrees and wishes to proceed with a punch biopsy of the lesion. A punch biopsy is taken of the lesion and sent to pathology. A simple repair is performed at the biopsy site.
What CPT and ICD-10-CM codes are reported?
- A. 11102, 12001-51, D49.2
- B. 11104, D49.2
- C. 11104,12001-51, L98.9
- D. 11102, L98.9
Answer: A
Explanation:
CPT code 11102 is for punch biopsy of skin, including simple closure. CPT code 12001-51 is for simple repair of superficial wounds, with modifier 51 indicating multiple procedures. ICD-10-CM code D49.2 is used for a neoplasm of unspecified behavior of the bone, soft tissue, and skin. This coding accurately reflects the punch biopsy and simple repair performed on the lesion.References: AMA's CPT Professional Edition (current year), ICD-10-CM (current year)
NEW QUESTION # 63
A diagnostic mammogram is performed on the left and right breasts. Computer-aided detection is also used to further analyze the image for possible lesions.
What CPT coding is reported for this radiology service?
- A. 0
- B. 77065-LT, 77065-RT
- C. 77067-50
- D. 77066-50
Answer: A
NEW QUESTION # 64
The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
Explanation:
* Colposcopy of the Cervix: This involves a visual examination of the cervix using a colposcope.
* Biopsy and Endocervical Curettage: The procedures performed include taking a biopsy and scraping the lining of the cervical canal.
* CPT Code 57454: This code represents a colposcopy of the cervix with biopsy and endocervical curettage.
References:
* AMA's CPT Professional Edition (current year)
NEW QUESTION # 65
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?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
NEW QUESTION # 66
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?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
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.
References:
* CPT Professional Edition, AMA
NEW QUESTION # 67
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis Procedure: Cholecystectomy Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT coding is reported for this case?
- A. 47600, 74300-26
- B. 47605, 74300-26
- C. 47563, 74300-26
- D. 47562, 74300-26
Answer: C
NEW QUESTION # 68
Patient has cervical spondylosis with myelopathy. The surgeon performed a bilateral posterior laminectomy with facetectomies at each level and foraminotomies performed between interspaces C5-C6 and C6-C7. Bilateral decompression of the nerve roots is achieved.
What CPT coding is reported?
- A. 63050-50
- B. 63040-50, 63043, 63043
- C. 63045, 63048
- D. 0
Answer: C
NEW QUESTION # 69
A 45-year-old has a dislocated patella in the left knee after a car accident. She taken to the hospital by EMS for surgical treatment. In the surgery suite, the patient is placed under general anesthesia. After being prepped and draped, the surgeon makes an incision above the knee joint in front of the patella. Dissection is carried through soft tissue and reaching the patella in attempt to reduce the dislocation. When the patella is exposed, it is severely damaged due to cartilage breakdown. The tendon is dissected and using a saw the entire patella is freed and removed. The tendon sheath is closed with sutures.
What procedure code is reported for this surgery?
- A. 27566-LT
- B. 27552-LT
- C. 27562-LT
- D. 27556-LT
Answer: A
NEW QUESTION # 70
A 65-year-old gentleman presents for refill of medications and follow-up for his chronic conditions. The patient indicates good medicine compliance. No new symptoms or complaints.
Appropriate history and exam are obtained. Labs that were ordered from previous visit were reviewed and discussed with patient. The following are the diagnoses and treatment:
Hypokalemia - stable. Refill Potassium 20 MEQ
Hypertension - blood pressure remaining stable. Patient states home readings have been in line with goals. Refill prescription Lisinopril.
Esophageal Reflux - Patient denies any new symptoms. Stable condition. Continue taking over the counter Prevacid oral capsules, 1 every day.
Patient is instructed to follow up in 3 months. Labs will be obtained prior to visit.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
NEW QUESTION # 71
The surgeon performs Roux-en-Y anastomosis of the extrahepatic biliary duct to the gastrointestinal tract on a 45-year-old patient.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
NEW QUESTION # 72
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