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質問 # 62
A provider places a catheter on the right side of the heart chamber via an incision made on the lower left side of the patient's chest while performing a transcatheter mitral valve replacement. How should this encounter be coded?
- A. 0484T
- B. 0483T, 93451
- C. 0484T, 93451-59
- D. 0
正解：A
解説：
0484T describes a transcatheter mitral valve replacement via a thoracic approach. CPT code
33430 describes a mitral valve replacement in which cardiopulmonary bypass is initiated. CPT code
0483T describes a transcatheter mitral valve replacement with a percutaneous approach: however, the documentation identifies a transthoracic incision. Catheterization is bundled into the procedure and is not separately identifiable unless the provider documents extenuating circumstances (i.e. no prior study available, inadequate visualization, etc.).
質問 # 63
If past family and social history is not documented for the evaluation and management of a new patient, what is the highest level of service that can be coded?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
解説：
Effective January I, 2023, new evaluation and management (E/ M) guidelines were implemented for inpatient, outpatient, home health, and preventative medicine services. These new guidelines remove the Patients' history and examination as elements in selecting the level of code.
Instead, E/M services are leveled based on the medical decision-making process. Therefore, in this scenario, the highest level of service that can be billed for a new patient with no documented past medical, family, and social history is 99205, CPT codes 99213 and 99214 are reported for established patients.
質問 # 64
When it comes to documentation, which of the following is NOT an example of a moderate level of service?
- A. A nurse practitioner reviews CBC, CMP, and tumor markers
- B. A physician changes the frequency of chemotherapy
- C. Anew patient presents with lymphoma while undergoing treatment for melanoma
- D. A physician reviews the most recent X-Ray
正解：D
解説：
If a physician were to only review the most recent X-ray, the physician is only meeting one of the nvo categories in the amount and/or complexity of data reviewed and analyzed. Meeting only one ofthe categories contributes to a low level of medical decision-making. On the other hand, altering a drug management program, reviewing several unique tests, and/or addressing an exacerbation of a chronic illness, all contribute to a moderate level of medical decision-making.
質問 # 65
A provider documents that he spent 20 minutes with a patient. Based on this, an E/M can be chosen solely based on time.
- A. False
- B. True
正解：B
解説：
The statement is true. According to AMA time documented is considered the minimum time the physician or other qualified health care professional spent on face-to-face and non-face-to-face services. This includes time spent reviewing the patient's medical record, consulting other healthcare professionals, or ordering prescriptions, tests, and/or other services.
質問 # 66
An extracapsular cataract extraction procedure was performed on a patient with a clouded and discolored lens. The physician uses iris hooks in the right pupil to ensure safe and controlled access to the cataract and blue staining dye to visualize the capsulorhexis. Using suction, the existing lens capsule is removed, and an intraocular lens is inserted. What should the physician report?
- A. 66982-RT, H27.8
- B. 66984-RT, H26.8
- C. 66984-RT, H18.891
- D. 66982-RT, Q12.8
正解：A
解説：
When deciding between a routine extracapsular cataract removal and a complex extracapsular cataract removal, bear in mind the code descriptor for a complex procedure involves
"devices or techniques not generally used in a routine cataract surgery (e.g., iris expansion device)." Because iris hooks were used, the procedure is complex (CPT 66982). When it comes to the diagnosis, do not get confused with the anatomy of the eye. Although the cornea works with the lens to help refract light, they are anatomically separate, thus eliminating answer B as an acceptable choice. A congenital condition is one that is genetic and/or present from birth. The documentation does not specifiy the origin, nor does it indicate when the lens abnormality began. Symptoms of a cataract include clouded and discolored lenses but should not be reported unless the physician clearly identifies this as the diagnosis. Coding crosswalk for diseases of the lens leads a coder to H27.8 (other specified disorders of lens).
質問 # 67
A 15-year-old male patient is seen in the emergency department due to a dislocated left elbow, caused by a fall from his skateboard. The physician performs a comprehensive physical evaluation to check for other injuries before manually realigning the dislocation and placing a splint from the shoulder to wrist. The patient is informed to follow up in 4 weeks. Which CPT and ICD-IO-CM codes should the emergency department report?
- A. 99283, 24600-LT, VOO.131A
- B. 24600-LT, S53.105A. VOO.131A
- C. 99282-57, 24600-LT, S53.105A VOO.131A
- D. 24600-LT, 29105, S53.195AVOO.131A
正解：C
解説：
An E/M is always billed when a patient is seen in the emergency department because it is unscheduled and urgent. In this case, the documentation encompasses a straightforward level of decision-making (one acute, uncomplicated injury, minimal or no data reviewed, superficial dressings that result in minimal risk or morbidity of the patient), which lead the coder to 99282.
Modifier 57 is appended to indicate that the decision for surgery was made just prior to the procedure and is not bundled. CPT coding crosswalk confirms that a closed treatment of a dislocated elbow is CPT code 24600. Application ofa splint is represented by CPT code 29105 but is not applicable when performed with a surgery to correct the dislocation. ICD-IO-CM crosswalk for dislocation of left elbow is S53.105A.
質問 # 68
Code the excision of a large goiter extending into the chest cavity using a transthoracic approach.
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
解説：
A goiter is an abnormal enlargement of the thyroid gland. The removal of that gland is a thyroidectomy, represented by CPT codes 60240-60271. CPT 60270 is selected based on the approach used. CPT codes 21602 and 32900 are obtained by using the coding crosswalk for resection ofthe chest wall and describe the removal of a tumor and one or more ribs. CPT 32140 is a thoracotomy, which involves pulling apart the ribs to reach and remove a lung cyst.
質問 # 69
What would be considered a sequela to an injury?
- A. Foreign body removal from a laceration
- B. Chronic pain persisting after an injury has healed
- C. Removal of an external fixation device
- D. Prescription drug management
正解：B
解説：
Per ICD-IO-CM, a sequela describes "complications or conditions that arise as a direct result of a condition." In this case, the chronic pain would be a condition that resulted from a prior injury.
Removal of a foreign body is active treatment of a laceration. Removal of a fixation device and prescription drug management are both considered routine and subsequent care.
質問 # 70
Diagnostic endoscopy is always inclusive to a surgical endoscopy.
- A. False
- B. True
正解：B
解説：
The statement is true. When multiple endoscopic procedures are performed in the same session, only the most extensive service should be reported. In this case, it would be the surgical endoscopy because it has a higher revenue value.
質問 # 71
Code the following surgical note:
Patient is seen for an epidural injection into the following three levels: L3-L4, L4-L5 and L5-S1.
A 22 -gauge spinal needle is inserted into the zygapophyseal joint using fluoroscopic guidance. After confirming the needles placement at L3-L4 on the left side, 0.5 cc of a local anesthetic is injected into the joint. The whole process is repeated on the left side at the other two levels. The procedure was completed without any complications.
- A. 0
- B. 64493-LT, 64494-59-LT, 64495-59u
- C. 64493-LT, 64494-LT, 64495-LT
- D. 0216T-LT, 0217T-LT, 0218T-LT
正解：C
解説：
64493 is used for the initial injection of an anesthetic, followed by 64494 and 64495 as add-on codes for the other Two levels. Because there are two sides of a facet joint, modifier LT would be amended to show the carrier that the procedure occurred on the left side of the spine.
In answer B, CPT codes 0216T-0218T exclude fluoroscopic guidance and refer the biller to codes
64490-64495. In general, modifier 59 would not be used on add-on codes, so answer C can be eliminated. Answer D describes an injection in the interlaminar epidural or subarachnoid space and is not the correct procedure code for this circumstance.
質問 # 72
Which is NOT a type of injection through which contrast is administered?
- A. Intra-articular
- B. Intrathecal
- C. Intravascular
- D. Intramuscular
正解：D
解説：
Per CPT guidelines, administration of contrast materials is given through the following routes: intravascular, intra-articular, and intrathecal. Alternate routes also include orally and/or rectally; however, the "contrast administration alone does not qualify as a study 'with contrast'"
質問 # 73
Code the following procedure note:
A selective catheter is placed into the thoracic aorta, where it is then manipulated into the left coronary artery and followed through into the right common carotid artery. Contrast injections are made, and digital imaging is performed. Upon completion, the catheter is removed, pressure is applied at the puncture site, and the patient is discharged.
- A. 36200, 36215, 36216-59
- B. 0
- C. 1
- D. 36215, 36216-59
正解：D
解説：
The left coronary artery and the right common carotid artery would each be considered their own vascular family. Therefore, when the starting point of selective catheterization is the aorta, the left coronary artery would be considered first order (36215) in the vascular family and the right common carotid artery would be considered the second order (36216). Modifier 59 is appended to indicate that a different vascular family was examined in one session. Contrast materials and catheterization into the aorta are inclusive to the nvo procedures and are not to be separately coded.
質問 # 74
If a cardiologist bills an electrocardiogram (93010) in the emergency department and then follows up with the patient a week later for arteriosclerosis, he should bill an established patient E/M.
- A. True
- B. False
正解：B
解説：
The statement is false. According to CPT, a new patient is one who has "not received professional services from the physician." In lieu of this, because the cardiologist only interpreted an electrocardiogram and did not actually provide care to the patient, a new patient E/M service should be billed.
質問 # 75
A radiation oncologist reviews the port films, dose delivery, and treatment parameters of a 52-year-old female patient who has received external beam therapy three times in the current week He also spends 15 minutes examining the patient and collecting an intake of her response to the treatment program. Which CPT code(s) should the physician report?
- A. 0
- B. 1
- C. 99213-25, 77401x3units
- D. 77435, 99213-25
正解：B
解説：
Treatment management of a patient undergoing radiation therapy is reimbursed by reporting CPT codes 77427-77470. Treatment management includes a review ofthe port films, dosimetry, dose delivery, treatment parameters, a physical examination, and related counseling. It would therefore not be appropriate to bill for a separate evaluation and management. CPT 77435 describes treatment management for a course of stereotactic body radiation therapy (SBRT), which the patient is not receiving. CPT 77401 describes the actual radiation and not the evaluation from the physician. CPT 77431 is reported when the entire course of therapy consists of one or nvo treatment sessions: however, a coder can infer from the documentation that the patient in this scenario has or will receive multiple sessions over the course of one or more weeks. Additionally, CPT guidelines advise that only three treatment sessions must occur to support the face-to-face encounter described in CPT 77427.
質問 # 76
Which healthcare professional may NOT report medical nutrition therapy?
- A. Endocrinologist
- B. Registered nurse
- C. Dietician
- D. Nutritionist
正解：A
解説：
Medical nutrition therapy describes nutritional assessments and interventions in a face-to- face or group patient setting and is reported with CPT codes 97802-97804. These codes are used by nonphysician healthcare professionals only. When a physician provides nutritional advice, a preventative service or evaluation and management code should be reported.
質問 # 77
An established 27-year-old female patient is seen with complaints of fatigue and muscle aches that began 3 days ago. The physician draws two vials of blood, collects a urine sample, and performs a pregnancy test. The patient is instructed to drink 8 ounces of water daily, rest, and follow up in 3 days for her results. What CPT codes should be reported for this encounter?
- A. 99213, 81025, 36415, 81002
- B. 99213, 81025, 36410, 81005
- C. 99212, 81025, 36410x2, 99000, 81020
- D. 99212, 81025, 36416, 81007
正解：A
解説：
The documentation demonstrates that the number and complexity of problems addressed is low (fatigue and muscle aches are self-limited problems), the amount or complexity of data to be reviewed and analyzed is moderate (three unique tests), and the risk of complications, morbidity, or mortality of patient management is minimal (the patient was advised to drink more water). (To determine the final level of medical decision making, choose the lowest of the highest two elements. In this scenario, the final level of medical decision making is low, and the CPT code is
99213. Vihen reporting a routine venipuncture, use CPT code 36415. CPT code 36410(a) is reported when it is medically necessary for the physician to draw a patient's blood, and 36416 describes capillary blood collected through a skin prick-certainly not enough to fill two vials. CPT code 99000 can be used to report a specimen being transported to an outside laboratory, but that is unknown in this scenario. A generic urinalysis is reported with CPT code 81002 unless specifically stated that an automated analyzer (81005), a commercial kit (81007), and/or an agar test (81020) was utilized.
質問 # 78
Which service would NOT be covered under Medicare part A?
- A. Inpatient hospital care
- B. Home health care
- C. Observation hospital care
- D. Hospice care
正解：C
解説：
Observation hospital care is provided to patients who are not sick enough to be admitted.
Therefore, it is considered an outpatient service and is covered under Medicare part B.
質問 # 79
Assign the appropriate procedure and diagnosis codes for a biopsy of a posterior mediastinal mass that was obtained through an incision at the base of the neck.
- A. 39000, D38.3
- B. 39401, R22.1
- C. 39000, R22.2
- D. 39401, D49.89
正解：C
解説：
The procedure performed was a mediastinotomy with a biopsy, represented by CPT 39000.
CPT code 39401 is reported for a mediastinoscopy, which is the insertion of a scope through an incision in the notch above the sternum. ICD-IO-CM crosswalk for a mass found on the chest wall is R22.-. Although the approach is cervical, the location ofthe mass is mediastinal, falling under the anatomical site of the trunk
質問 # 80
A physician performs an esophagogastroduodenoscopy on a patient who has GERD. A single tissue sample is obtained from the upper gastrointestinal tract using biopsy forceps. A reflux test was also done and a bravo capsule temporarily attached to the esophageal wall to monitor pH levels. What procedures should the physician report?
- A. 43239, 91035
- B. 43235, 91035
- C. 43239, 91034
- D. 43235, 91034
正解：A
解説：
To report an esophagogastroduodenoscopy, see CPT code range 43233-43259. In this scenario, the procedure is not considered diagnostic (43235) because the physician is stating the patient has GERD. Additionally, the tissue sample was obtained by means of biopsy forceps and not by brushing or washing. The secondary procedure is a reflux test and an esophageal pH test by means of a bravo capsule, which evaluates the level of acid refluxing into the esophagus. Although CPT 91035 doesn't specifically state a capsule in the description of the code, it would fall under a
"mucosal attached" placement. A nasal catheter was not used, so reporting CPT 91034 would be incorrect.
質問 # 81
Which is NOT part of the upper respiratory tract?
- A. Nasal cavity
- B. Trachea
- C. Pharynx
- D. Larynx
正解：B
解説：
The upper respiratory tract consists of the nose, nasal cavity, pharynx, and larynx. The lower respiratory tract includes the trachea, primary bronchi, lungs, and the bronchioles and alveoli within the lungs.
質問 # 82
A 74-year-old patient presents with a fever. She is admitted into observational care after her labs confirm a diagnosis of pneumoni a. She has a medical history of being HIV positive. How should this be reported?
- A. 99223, 118.9, B20
- B. 99236, 118.9, B20
- C. 99235, B20, 118.9
- D. 99222, B20, 118.9
正解：D
解説：
Hospital inpatient and observation care services (99221-99236) are selected based on the level of medical decision-making. In this scenario, reporting a code from the initial hospital inpatient and observation care services would be most appropriate (99221-99223), as the documentation indicates the patient is being admitted. When leveling this service, consider that the patient has an acute illness with systemic symptoms (pneumonia) and a stable, chronic illness (HIV). Labs were reviewed to confirm the diagnosis, and a decision was made to admit the patient into observation. Therefore, the final level of medical decision-making is moderate, making the E/M code 99222. Even though pneumonia is the reason for admission, ICD-IO-CM guidelines stipulate that a confirmed HIV diagnosis takes precedence in sequencing when the reason for admission is HIV related.
質問 # 83
If a physician administers cyclophosphamide over 154 minutes, irinotecan over 72 minutes, and panitumumab over 15 minutes intravenously to a patient with pancreatic cancer, how should this be reported?
- A. 96413, 96413-59, 9641512, 96417
- B. 96413, 96415x3, 96417x2
- C. 94613, 96415x2, 96417x2
- D. 96413, 96413-59x2, 96415, 96417
正解：B
解説：
Unless a separate IV site is established for a secondary or tertiary administration, CPT
96413 should be reported only once to represent the initial drug infusion. In this case, it is the cyclophosphamide. The remaining 94 minutes are reported with Ovo units of add-on CPT 96415, which may be reported ifthe time spent beyond the first hour is between 31 and 60 minutes. CPT
96417 is reported only once per subsequent infusion of a different drug up to the first hour.
Consequently, the 72 minutes of irinotecan is reported with a single unit of CPT 96417, and the 15 minutes of panitumumab is also reported with one unit ofthat same CPT code.
質問 # 84
A physician performs a thyroidectomy on a 26-year-old female patient with thyroid cancer. A radical neck dissection with a partial parathyroidectomy and autotransplantation of two parathyroid glands is also completed in the same session. W'hat CPT code(s) should the physician report?
- A. 60254, 60512-52
- B. 60254, 60500-51, 60512-51
- C. 0
- D. 60254, 60500-51, 60512
正解：A
解説：
The CPT code for a thyroidectomy with a radical neck dissection is 60254 and sequenced first because it is the primary procedure with the highest RVU. CPT 60500, which describes a parathyroidectomy, is bundled into a thyroidectomy. Therefore, the two procedures should never be reported together. Parathyroid autotransplantation (CPT 60512) involves the removal of all four parathyroid glands. If not all four glands are removed, report the code with modifier 52 to indicate reduced services. As this is an add-on code, do not append modifier 51.
質問 # 85
Alzheimer's disease with early onset usually presents itself in which age group?
- A. 50-60 years old
- B. 30-40 years old
- C. 40-50 years old
- D. 60-70 years old
正解：C
解説：
According to CPT, the rarest form of Alzheimer's disease occurs before 30 years of age.
Early onset Alzheimer's disease usually affects those between the age of 40 and 50 years old. The most common form of Alzheimers disease occurs after the age of 65 and is largely contributed to a combination of environmental and genetic factors.
質問 # 86
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