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質問 # 65
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
- A. J9312, J1200
- B. J9312 x 80, J1200 x 2
- C. J9312 x 80, 00163 x 2
- D. J9312, Q0163
正解：C
質問 # 66
Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
質問 # 67
Dr. Burns sees newborn baby James at the birthing center on the same day after the cesarean delivery. Dr. Burns examined baby James, the maternal and newborn history, ordered appropriate blood test tests and hearing screening. He met with the family at the end of the exam.
How would Dr. Bums report his services?
- A. 0
- B. 1
- C. 2
- D. 3
正解：B
質問 # 68
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. 44204, C18.2
- B. 44160, C18.2
- C. 44140, C18.9
- D. 44205, C18.9
正解：A
解説：
The procedure involves a laparoscopic partial colectomy where the surgeon removes the proximal colon and terminal ileum, then reconnects the cut ends of the distal ileum and remaining colon.
* Procedure Description:
* Laparoscopic partial colectomy.
* Removal of the proximal colon and terminal ileum.
* Anastomosis of the distal ileum and remaining colon.
* CPT Coding:
* 44204: Laparoscopy, surgical; colectomy, partial, with anastomosis.
* ICD-10-CM Coding:
* C18.2: Malignant neoplasm of ascending colon.
References:
* AMA's CPT Professional Edition (current year).
* ICD-10-CM for corresponding diagnosis codes.
質問 # 69
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 CPTand diagnosis codes are reported?
- A. 44950, K35.80
- B. 44970, K36
- C. 44970, K36, R11.2, R10.31
- D. 44950, K35.80, R11.2, R10.31
正解：B
解説：
1. Procedure and CPTCode 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.
CPTCode 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 CPTCoding 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.
質問 # 70
A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.
What CPT coding is reported?
- A. 36252, 75625-26
- B. 0
- C. 1
- D. 36253, 75625-26
正解：A
解説：
CPT code 36252 describes selective catheter placement of the main renal artery with angiography of both kidneys, which matches the procedure of selectively catheterizing the right and left renal arteries and performing angiography. Additionally, CPT code 75625-26 is for an abdominal aortography with interpretation and report. The -26 modifier indicates that the professional component of the service was performed.
References:
* AMA's CPT Professional Edition (current year), Codes 36252, 75625-26
質問 # 71
View MR 099401
MR 099401
Established Patient Office Visit
Chief Complaint: Patient presents with bilateral thyroid nodules.
History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can "feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.
Review of Systems:
Constitutional: Negative for chills, fever, and unexpected weight change.
HENT: Negative for hearing loss, trouble swallowing and voice change.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting Endocrine: Negative for cold Intolerance and heat intolerance.
Physical Exam:
Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97% Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65") General Appearance: Alert, cooperative, in no acute distress Head: Normocephalic, without obvious abnormality, atraumatic Throat: No oral lesions, no thrush, oral mucosa moist Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD Lungs: Clear to auscultation, respirations regular, even, and unlabored Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click Lymph nodes: No palpable adenopathy ASSESSMENT/PLAN:
1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
What E/M code is reported for this encounter?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
質問 # 72
A patient presents with recurrent spontaneous episodes of dizziness of unclear etiology. Caloric vestibular testing is performed irrigating both ears with warm and cold water while evaluating the patient's eye movements. There is a total of three irrigations.
What CPT coding is reported?
- A. 92537-50-52
- B. 92537-52
- C. 92538-50
- D. 92537-50
正解：B
質問 # 73
Ten-year-old boy has a painful felon abscess of the deep tissues of the palmar surface of his right thumb. The provider makes an incision on one side of the nail and then across the fingertip parallel to the end of the nail.
He identifies the area of abscess and drains it. A drainage tube is inserted.
What CPTand ICD-10-CM is reported?
- A. 26010-F5, L02.511
- B. 26011-F5, L03.011
- C. 10061-F5, L03.011
- D. 10140-F5, L02.511
正解：A
解説：
1. Procedure and CPTCode Selection:
The procedure involves an incision and drainage (I&D) of a deep abscess (felon) on the palmar surface of the right thumb. A felon is an abscess in the pulp of the fingertip, often involving deep tissue.
Code 26010 is specific for incision and drainage of a finger abscess, which includes the thumb. This code applies to cases where the abscess is drained from a deep tissue level.
Code 26011 is similar but involves the use of extensive drainage or debridement, which is not indicated in this case. Therefore, 26011 is not appropriate here.
Code 10061 refers to incision and drainage of abscesses at different locations on the body but not for specific areas such as the thumb, making it inappropriate in this context.
Code 10140 pertains to the evacuation of hematoma, seroma, or fluid but does not apply to abscesses, so it is not suitable for this scenario.
2. Modifier:
Modifier F5 is added to specify that the procedure was performed on the right thumb.
3. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code L02.511 is appropriate for cutaneous abscess of the right finger, as it accurately describes the diagnosis of a felon on the thumb.
L03.011 would represent cellulitis but does not specify an abscess, making it less precise for this case.
4. AAPC and CPTCoding Guidelines:
The AAPC guidelines for coding finger abscess drainage emphasize the selection of specific codes for deep tissue drainage procedures in extremities. Additionally, correct laterality should be included with the use of modifiers and specific ICD-10-CM codes for an accurate representation of the site and nature of the condition.
Thus, based on the coding standards and guidelines, the verified answer is B. 26010-F5, L02.511.
質問 # 74
Which statement is TRUE for an Excludes2 note that is under a code in the Tabular List for ICD-10-CM?
- A. It indicates that the code excluded should always be reported with an Excludes1 code.
- B. It is acceptable to report both the code and the excluded code together, when applicable.
- C. That the two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
- D. It is a pure excludes note, meaning "NOT CODED HERE!"
正解：B
解説：
In ICD-10-CM coding, an Excludes2 note under a code indicates that the condition listed in the note is not included in the definition of the code, but it does not necessarily mean they cannot coexist. This type of note means that while the conditions are distinct, it may be appropriate to report both codes if a patient has both conditions at the same time.
A: is incorrect because Excludes1, not Excludes2, indicates that certain codes should not be reported together.
C: is a description of an Excludes1 note, which implies that the two conditions should not be coded together because they cannot occur simultaneously.
D: is also a description of an Excludes1 note, which serves as a "NOT CODED HERE!" directive.
Therefore, the correct answer is B. It is acceptable to report both the code and the excluded code together, when applicable.
質問 # 75
An interventional radiologist performs an abdominal paracentesis in his office utilizing ultrasonic imaging guidance to remove excess fluid. What CPT coding is reported?
- A. 49083, 76942-26
- B. 49082, 76942
- C. 0
- D. 49082, 76942-26
正解：C
解説：
CPT code 49083 describes an abdominal paracentesis with imaging guidance, such as ultrasound. This code includes the imaging guidance as part of the procedure, so it is not necessary to separately report the ultrasonic guidance.
References:
* AMA's CPT Professional Edition (current year), Code 49083
質問 # 76
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. 52325, 52332-51
- B. 52352, 52332-51
- C. 0
- D. 52353, 52332-51
正解：C
解説：
* Cystourethroscopy: This is a procedure that involves the use of a cystoscope to look inside the urethra and bladder.
* Pyeloscopy: Involves the examination of the upper urinary tract, typically done through the cystoscope.
* Lithotripsy: A procedure that uses shock waves or a laser to break up stones in the kidney, bladder, or ureter.
* Indwelling stent insertion: A procedure to place a stent in the ureter to help urine flow from the kidney to the bladder.
* 52356: Cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization and/or ureteral stent placement).
The code 52356 includes all components mentioned: cystourethroscopy, pyeloscopy, lithotripsy, and stent insertion performed in the same operative session.
References:
* AMA's CPT Professional Edition (current year)
* ICD-10-CM (current year), HCPCS Level II (current year)
質問 # 77
Patient with erectile dysfunction is presenting for same day surgery in removal and replacement of an inflatable penile prosthesis.
What CPTcode is reported for this service?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
解説：
1. Procedure and CPTCode Selection:
The scenario describes the removal and replacement of an inflatable penile prosthesis due to erectile dysfunction.
CPTCode 54416 is specifically used for the removal and replacement of a multi-component inflatable penile prosthesis. This code accurately describes the procedure performed.
2. Rationale for Excluding Other Options:
Code 54401 represents the initial insertion of a multi-component inflatable penile prosthesis but does not cover removal and replacement, making it inappropriate for this scenario.
Code 54400 is for the insertion of a non-inflatable (malleable) penile prosthesis, which does not apply here as the prosthesis is inflatable.
Code 4417 does not exist in the CPTcoding system and is likely a typo or incorrect option.
3. AAPC and CPTCoding Guidelines:
According to AAPC and CPTguidelines, 54416 is the correct code when an inflatable prosthesis requires both removal and replacement, without the need for additional modifiers for this procedure.
Therefore, the correct answer based on CPTguidelines is D. 54416.
質問 # 78
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. 77067-50
- B. 0
- C. 77065-LT, 77065-RT
- D. 77066-50
正解：B
質問 # 79 
Refer to the supplemental information when answering this question:
View MR 874276
What E/M code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：B
解説：
To accurately code this emergency department visit, we need to assess the three key components: history, examination, and medical decision making (MDM).
* History:
* The documentation supports an expanded problem-focused history. This includes a chief complaint, a brief history of present illness (HPI), a review of systems (ROS) with pertinent positives and negatives, and a past medical history.
* Examination:
* The examination is also expanded problem-focused. The physician focused on the relevant systems (constitutional, HENT, respiratory) and documented specific findings related to the chief complaint (appears tired).
* Medical Decision Making:
* The MDM complexity is low. The physician is assessing a new problem (shortness of breath and weakness) with a low level of risk. No further testing or treatment is documented in this encounter.
Based on these components, 99283 is the most appropriate code.
Why other options are incorrect:
* 99282: Requires a problem-focused history and examination, which is less comprehensive than what was documented.
* 99284 and 99285: Require a higher level of MDM (moderate or high complexity) and/or a more detailed examination. The documentation doesn't support this level of service.
References:
* CPT Codes 99281-99285: Emergency department visits
* 1995 and 1997 Documentation Guidelines for Evaluation and Management Services: These guidelines provide detailed criteria for selecting the appropriate E/M code based on history, examination, and MDM.
* AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.
質問 # 80
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
正解：A
解説：
* 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)
質問 # 81
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
正解：A
質問 # 82
A 49-year-old patient arrives with hearing loss in his left ear. Impedance testing via tympanometry is performed.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：A
解説：
* Procedure: Impedance testing via tympanometry is performed to assess hearing loss in the left ear.
* CPT Code:
* 92567: This code is for tympanometry (impedance testing) without reflex threshold measurements.
* Code Selection Justification: The procedure involved tympanometry without reflex threshold, which is specifically coded as 92567.
References:
* AMA CPT Professional Edition (current year)
質問 # 83
A patient with jaundice was seen by the physician to obtain liver biopsies. A needle biopsy was taken using CT guidance for needle placement. The physician obtained two core biopsies, which were then sent to pathology. What CPTcodes are reported?
- A. 47000, 47001, 77012
- B. 47001, 76942
- C. 47000,77012
- D. 47000, 77002
正解：C
解説：
1. Procedure and CPTCode Selection:
The patient underwent a needle biopsy of the liver using CT guidance to obtain two core biopsy samples.
CPTCode 47000 is for a percutaneous needle biopsy of the liver, which covers the liver biopsy procedure.
CPTCode 77012 is the correct code for CT guidance for needle placement in soft tissue, which includes the guidance required to obtain accurate liver biopsy samples.
2. Rationale for Excluding Other Options:
Code 47001 in option A is an add-on code for a liver biopsy performed during another procedure (such as a laparoscopic or open procedure) and is not applicable in this case, as 47000 is sufficient for a percutaneous approach.
Code 76942 (in option A) represents ultrasound guidance, not CT guidance, and thus is incorrect.
Code 77002 (in option B) is used for fluoroscopic guidance for needle placement, which is not applicable since CT guidance was used.
Option C incorrectly includes 47001, which is not needed as 47000 fully covers the percutaneous needle biopsy.
3. AAPC and CPTCoding Guidelines:
According to AAPC guidelines, 47000 is used for percutaneous liver biopsies, and 77012 should be reported for CT guidance for needle placement in the liver.
Therefore, the correct answer is D. 47000, 77012.
質問 # 84
A 20-year-old female is being seen for the first time by a primary care physician to have a yearly physical. During the examination for the physical, the provider discovers non-inflammed lesions on her legs and arms. The physician performs a complete physical and additional separate documentation for the treatment of the lesions on the bilateral upper and lower extremities. The provider has the patient buy an over-the-counter ointment and will continue to watch them.
What CPT coding is reported for this visit?
- A. 0
- B. 99385, 99203-25
- C. 99385-25, 99203
- D. 1
正解：C
質問 # 85
A patient has a bone infection being treated with vancomycin. A therapeutic drug assay is performed to measure the concentration of vancomycin in the patient's blood.
What lab test is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：B
解説：
1. Procedure and CPTCode Selection:
The test performed is a therapeutic drug assay to measure the concentration of vancomycin in the patient's blood.
CPTCode 80184 is specific for a therapeutic drug assay of vancomycin, making it the correct code to report for this test.
2. Rationale for Excluding Other Options:
Code 80197 is used for therapeutic drug assays of another antibiotic, gentamicin, and does not apply to vancomycin.
Code 80202 is for measuring the levels of cyclosporine, another drug, and is not relevant to vancomycin.
Code 80299 is for an unlisted therapeutic drug assay, which is unnecessary since a specific code (80184) exists for vancomycin.
3. AAPC and CPTCoding Guidelines:
According to AAPC guidelines, specific therapeutic drug assay codes, like 80184 for vancomycin, should be used when available.
Therefore, the correct answer is C. 80184.
質問 # 86
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