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COC 2020 FINAL EXAM STUDY QUESTIONS SET 1-3, 5-8, 10-12 BUNDLE
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COC 2020 Final Exam Study Questions - Set 12 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 12 (Complete Solutions, Answered) Which HCPCS Level II code category allows for pass-through payment devices? C... [Show More] codes Which is the correct statement regarding AAPC members per AAPC's Code of Ethics? Conduct themselves in all professional activities in a manner consistent with ethical principles of professional conduct. Which is the ICD-10-CM code for GERD? K21.9 Which is the unit of measurement for documenting the size of a skin graft? Square centimeters Which is true about the role of a co-surgeon? Handles a particular area of expertise. Which layer is the middle layer of the eyeball? Choroid Which layer of the epidermis is normally found on the palms of the hands and the soles of the feet? Stratum Lucidum Which layer of the heart covers the heart's outer surface? Epicardium Which leukocyte does the body use to protect against allergic reactions and parasites? Eosinophils Which leukocyte is the body's second line of defense against infection? Monocytes Which leukocyte protects the body from viral infections? Lymphocytes Which medical term refers to the cheek? Buccal Which of the following are also known as the lesser vestibular glands? Skene's glands Which of the following belongs to the appendicular skeleton as opposed to the axial skeleton? Pelvic Girdle Which of the following best describes constituent components of the human lymphatic system? Lymph nodes, lymphatic vessels, spleen, thoracic duct Which of the following charges are NOT excluded from Medicare payment based on statutory exclusions? Hip replacement Which of the following conditions are NOT on the 2019 major complications and comorbidities list on the CMS website? D15.0 Benign neoplasm of thymus Which of the following conditions are on the 2019 complications and comorbidities list on the CMS website? IO1.0 Acute rheumatic pericarditis Which of the following describes "dystonia"? Neurologic movement disorder causing abnormal postures Which of the following does NOT require documentation for a cause-and-effect relationship to be coded? (Reference guidelines I.C.9.a.2 and I.C.9.a.3) Hypertension and chronic kidney disease Which of the following facilities must have no more than 25 inpatient beds? Answer: CAH Rationale: CAHs can have no more than 25 inpatient beds used for either inpatient or swing bed services. Which of the following is also referred to as the voice box? Larynx Which of the following is an example of a DRG payment sys? All Pt Dx Related Groups (APDRG), Severity Diagnosis Related Groups (SDRG), Medicare Severity Diagnosis Related Groups (MSDRG) Which of the following is not a cardiac valve? Intraventricular septum Which of the following is NOT a packaged service? Anesthesia professional services Packaged items are: >Costs for operating room (OR), procedure room, treatment room, recovery room, and materials, including supplies and equipment for the administration and monitoring of anesthesia >Observation services Certain pharmaceuticals (except for transitional passthrough), drugs, and biologicals that function as supplies >Medical and surgical supplies and equipment other than those in which separate payment is allowed >Ancillary services >Clinical diagnostic laboratory tests >Procedures described by add-on codes >Implantable medical devices (such as pacemakers) >Inexpensive drugs under a per-day drug threshold packaging amount >Guidance services >Image processing services >Intraoperative services >Imaging supervision and interpretation services >Professional services, such as anesthesia professional services are paid by Part B under the Physician Fee Schedule (PFS). Which of the following is NOT used to determine the MS-DRG? Services billed by the Physician Which of the following is the normal pacemaker in the heart? SA node Which of the following is true about the typmpanic membrane? It separates the external ear from the middle ear Which of the following is true of the stratum germinativum? It lies on top of the dermis and has access to a rich supply of blood Which of the following procedures is the removal of the gallbladder? Cholecystectomy Which of the following providers are in their first year after graduation from medical school? Answer: Intern Rationale: Interns are usually in their first year following graduation from medical school and are completing a one-year rotation in various departments of the teaching facility departments of the hospital that depend on specialties. Residents are licensed physicians and depending the specialty, have two to five years of training in that specialty. Which of the following services can be billed as observation services to Medicare? Patients undergoing same-day procedures that have a complication arise from the procedure that requires monitoring beyond the usual recovery room period. Which of the following should be on each page of the patient's medical record? Patient's name or ID number. Which of the following statements does NOT describe the Medicare Outpatient Prospective Payment System? Multiple surgical services are not reimbursed separately. Rationale: Although multiple surgical services may be discounted, the procedures are reimbursed separately unless it is a composite payment. [Show Less]
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COC 2020 Final Exam Study Questions - Set 11 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 11 (Complete Solutions, Answered) What is the purpose of the Operation Restore Trust program? An effort to rest... [Show More] ore integrity in the Medicare program and to find and stop fraud and waste in the Medicare and Medicaid programs. What is the reported HCPCS code for a diaphragm for contraceptive use? A4266 What is the reported HCPCS code for a Levine type stomach tube? B4083 What is the reported HCPCS code for Mitomycin, 40 mg, given intravenously? J9280 x 8 What is the reported HCPCS code for two leg straps for a wheelchair? K0038 x 2 What is the root meaning joint? Arthr/o What is the root operation for Laparotomy with exploration and adhesiolysis of right ureter? Release What is the root operation for removal of foreign body, right cornea? Extirpation What is the root operation for sigmoidoscopy with sigmoid polypectomy? Excision What is the Status Indicator for CPT code 78807? S What is the study and diagnosis of diseases on a cellular level? Cytopathology What is the term for inflammation of the heart and vessels? Angiocarditis What is the term for the first portion of the small intestine? Duodenum What is the term for two hollow organs joined together surgically? Anastomosis What is the tubular, muscular canal leading from the uterus to outside the body? Vagina What is the Two-Midnight Rule? A clause stating the decision to admit a Pt should be based on an expectation that the Pt will require at least a two-midnight stay. What is the unit of measurement for coding the length of lacerations? Centimeters What is the white outer skin of the eye called? Sclera What is/are the CPT" code(s) for replacement of a long arm cast with a short arm plaster cast in the hospital outpatient orthopedic clinic by a physician in the same group not employed by the hospital? Report for the facility. 29705, Q4009 What is/are the ICD-10-CM code(s) for acute bronchiolitis with bronchospasm? J21.9 What is/are the ICD-10-CM code(s) for bilateral hip pain? M25.551, M25.552 What is/are the ICD-10-CM code(s) for trichomoniasis infection of the prostate? A59.02 What lCD-10-CM code is reported for a congenital heart block? Q24.6 What lCD-10-CM code is reported for a malignant pericardial tumor? C38.0 What lCD-10-CM code is reported for acute diastolic heart failure? 150.31 What lCD-10-CM code is reported for acute systolic heart failure? 150.21 What lCD-10-CM code is reported for Barlow's syndrome? 134.1 What lCD-10-CM code is reported for Mobitz (type) II atrioventricular block? 144.1 What modifier indicates the procedure or service was discontinued prior to administration of anesthesia? 73 What modifier is required when two distinct E/M visits are provided by the hospital to the same patient on the same date of service? Modifier 27 What modifier is required when two distinct E/M visits are provided by the hospital to the same patient on the same date of service? Modifier 27 What must HIPAA-covered entities do to protect patient privacy? Create Privacy Policies and Procedures consistent with the Privacy Rule; Designate a privacy official responsible for developing and implementing its privacy policies and procedures; Provide training on their privacy policies and procedures for the workforce member (employees, volunteers, etc.); mitigate any harmful effect it learns was caused by use or disclosure of PHI by its workforce or business associates in violation of its privacy and policy procedures; Maintain reasonable and appropriate administrative, technical, and physical safeguards to protect PHI; Have procedures for individuals to complain about its compliance with its privacy policies and procedures and the Privacy Rule; Maintain written or electronic documentation until six years after the later date of their last effective date, its privacy policies and procedures, privacy practices notices, disposition of complaints. What payment methodology is used to reimburse inPt rehabilitiation groups? Case-Mix Groups (CMGs) What payment methodology used to reimburse skilled nursing facilities? Patient Driven Payment Models (PDPM) What prevents the eyeball from collapsing? Vitreous humor What procedure code is reported when a colposcopy is used conization of the cervix with a loop electrosurgical excision procedure? 57461 What procedure code is used to report a sling operation performed transvaginally for stress incontinence? 57288 What procedure is performed when the spleen is removed? Splenectomy What resources can the professional coder turn to for information? [Show Less]
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COC 2020 Final Exam Study Questions - Set 10 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 10 (Complete Solutions, Answered) What ICD-10-CM is reported for fatigue during a patient's 26th week of pregna... [Show More] ncy? O26.812, Z3A.26 What ICD-10-PCS code should be assigned for total excision of pituitary gland, open? 0GT00ZZ What ICD-10-PCS codes should be assigned for laparoscopic vaginal assisted hysterectomy with bilateral salpingo-oophorectomy for dysplasia? 0UT9FZZ, 0UT7FZZ, 0UT2FZZ What information can be found on the RA from Medicare? Payment amount, adjusted amount and patient responsibility Rationale: A Remittance Advice (RA) from Medicare or other insurance carriers is a notice of payments and adjustments sent to the billing department after a claim has been processed. If payment is denied, the RA includes the reason for the denial. The RA also includes the patient's responsibility for the claim. What is a default code? Refer to ICD-10-CM guideline I.A.18. The code that represents the condition most commonly associated with the main term. What is a PATH Audit? OIG audits performed on medical schools. What is a revenue code? The code reported to identify the department Rationale: A revenue code identifies a specific revenue center, accommodation, and ancillary charges. The revenue code identifies where, within the hospital's revenue, or cost center, the service was rendered.nt where the services were performed What is a tendon sheath? A tube shaped sheath that lines the compartment where some tendons pass-through, such as those found around the ankle and wrist What is a term for enlargement of the heart? Cardiomegaly What is a thoracotomy? Incision into the chest wall What is a TRUE statement when reporting outpatient observation care? Observation services for Medicare are reported with HCPCS Level II code G0378. What is affected by mysathenia gravis? Neuromuscular jumction What is an abscess? Cavity created by localized infection that contains a purulent exudate What is an acute exacerbation of asthma or COPD? (Reference ICD-10-CM guideline I.C.10.a.l) Worsening or decompensation of asthma or COPD What is an example of a long bone? Metacarpals Long bones are named for their shape, not their size. Metacarpals are long bones found in the hand that form the skeletal structure of the palm. What is an example of an eponym? Paget's disease What is an MDC? Major Diagnostic Category What is an ovum? An oocyte or egg What is another word for the sclerocorneal junction? Limbus What is Bowman's capsule? C-shaped structure partially surrounding the glomerulus What is colporrhaphy? Surgical repair of the vagina What is considered a partial-thickness wound? Damage does not penetrate below the dermis and may be limited to the epidermal layers only. What is COPD and what category is it found under in the ICD-10-CM code book? Chronic airway obstruction that is not elsewhere classified. A nonspecific condition characterized by a chronic and recurrent reduction in expiratory airflow within the lung;J44 What is in vivo? Studies performed within the living body. What is modifier JW used for? To indicate part of a vial was used on a patient requiring the rest to be discarded. What is NOT an example of active treatment for pathological fractures? Surgical treatment What is one of the major differences when coding DX for inPt admission vs outPt admission reported by the facility? Suspected Dx are reported for inPt hospital if not definitive Dx was determined in this hospital stay with the exception of HIV/AIDs coding. What is repair of a coronary vessel called? Angioplasty What is the complete description of CPT ® code 45307? Proctosigmoidoscopy, rigid; with removal of foreign body What is the CPT ® code for a flexible bronchoscopy with placement of catheters for remote after loading high dose rate brachytherapy (radiotherapeutic agents). 31643 What is the CPT ® code for a Keller Procedure? 28292 What is the CPT ® code for a modified radical mastectomy? 19307 What is the CPT ® code for excision of the parathyroid gland? 60500 What is the CPT ® code for incision and drainage of postoperative wound infection, complex, with removal mesh with from the abdominal wall? 10180, 11008 What is the CPT ® code for laparoscopic removal of 6 uterine leiomyomata (myomas/fibroids) weighing more than 250g? 58546 What is the CPT" code for open treatment of a humeral shaft using an intramedullary implant and locking screws? 24516 What is the CPT" code for repair of nonunion of carpal bone? 25431 What is the CPT° code for closed treatment of a tibial shaft fracture with manipulation? 27752 [Show Less]
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COC 2020 Final Exam Study Questions - Set 8 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 8 (Complete Solutions, Answered) Somatic nerve Part of the peripheral nervous system Special payments under OPP... [Show More] S may be made for new technology items under what circumstance? Pass-through payments for certain drugs, biological agents, brachytherapy devices, and other medical devices for a period of at least two years but no more than three years. Rationale: Special drugs, such as chemotherapy drugs and devices or supplies that are considered "new technology" items will need to be assigned new "pass-through" codes to receive additional reimbursement. The HCPCS Level II C codes are used under the OPPS to identify pass-through drugs and biologicals. The additional payment for a given item is established for at least two, but not more than three years. Squamous cell carcinoma and basal cell carcinoma are cancers of cell tissue of the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems. These carcinomas are found in what type of tissue? Epithelial tissue Status indicator G indicates services are: Paid under OPPS;separate APC payment Status indicator G is: Paid under OPPS; separate APC payment Status indicator H is: Separate cost-based pass-through payment; not subject to copayment Status indicator V is used to indicate: Clinic or emergency department visits Stopping, or attempting to stop, post-procedural bleeding is coded to the root operation of: Control Strangulation Constriction of a body part to cut off blood or oxygen Subcarinal means beneath the carina. Where is the carina located? At the bifurcation of the trachea into two bronchi Supplementary words enclosed in parentheses in the ICD-10-CM code book have what effect on the coding? Refer to ICD-10-CM guideline I.A.7. They do not affect code assignment. Sweat is collected from a patient suspected of having cystic fibrosis. The specimen is taken by iontophoresis. What CPI® code is reported? 89230 Syrinx A synonym for syringomyelia, a cyst within the spinal cord Teaching facilities are: Answer: Affiliated with a medical school Rationale: Teaching hospitals are affiliated with medical schools to train physicians. Tendon sheath: a layer of synovial membrane around a tendon. It permits the tendon to stretch and not adhere to the surrounding fascia. It has two layers: synovial sheath. fibrous tendon sheath. The must include: albumin (82040), bilirubin (total) (82247), bilirubin (direct) (82248), phosphatase (alkaline) (84075), protein (total) (84155), transferase alanine amino (ALT) (SGPT) (84460), transferase aspartate amino (AST (SGOT) (84450). Hepatic Function Panel (80076) The abbreviation RML stands for: Right middle lobe. The abbreviation RTP indicates: The claim must be returned to the provider for correction The acronym ACEP means: American College of Emergency Physicians The admitting office is responsible for: Answer: Obtaining demographic information, insurance information, recording the type of service the patient requires, establishing an account, and obtaining consent for treatment Rationale: Insurance information, demographics, and the type of services the patient requires are recorded. The patient's insurance card is generally copied for verification purposes. An account is established through a computerized system that transfers patient information for hospital-wide availability during patient care. The admitting office is also responsible for obtaining consent for treatment or surgical services from the patient as well as other pertinent information required for patient management. The background relating to OPPS and APCs can be located in which publication? Federal Register The beneficiary's principal Dx and up to how many secondary Dx that may include comborbidites or complications deterine the DRG assignment? Twenty-four The brain and spinal cord are part of which system? Central Nervous System The bronchi are found in what body cavity? Thoracic cavity The cardiologist performs a percutaneous stent placement through a right common femoral access into the left iliac vessel. Report the CPT ® code(s). 37221 The Chargemaster includes: Revenue codes Rationale: The chargemaster is a master inventory list of everything that can be reported or performed in the hospital. Also listed are Uniform Billing (UB) revenue codes, charge descriptions, and other services. These services are identified by the department performing the service. The CPT®/HCPCS Level II code is already built into the system; it is not entered manually. The complete ICD-10-PCS is presented in what three parts? the tables, the index, and the list of codes The corpus luteum secretes progesterone. What is an effect of this secretion? Thickens the endometrium for implantation and is necessary to sustain pregnancy The correct diagnosis code(s) for a patient admitted to observation with severe sepsis and septic shock following an induced abortion is: O04.87, R65.21 The department responsible for coding procedures and services in the hospital facility is: Answer: HIM department Rationale: The Health Information Department includes sections for coding, chart construction or organization, transcriptions (some hospitals and facilities contract with transcription companies), release of information, birth and death certification, scanning or filing to input information into charts, and other sections required to maintain a consistent flow of patient information throughout the hospital or facility. The department that is not open 24 hours a day but provides emergent care is called: Answer: Emergency department type B Rationale: A T ype B emergency department is a facility meeting specific licensing requirements for emergent or urgent care patients not open 24 hours per day. The diagnosis caudal cervical inflammatory spondylopathy is assigned ICD-10-CM code M46.82 and is an example of what ICD-10-CM coding convention? NEC The dome-shaped muscle under the lungs flattening during inspiration is the: Diaphragm The ENT performs a diagnostic nasal endoscopy bilaterally, followed by right partial ethmoidectomy and removal of tissue from the maxillary sinus bilaterally. The diagnosis is chronic sinusitis of the ethmoid and maxillary sinuses. 31254-RT, 31267-50, J32.8 The first character in the code determines the broad _____________________ category, or _________________, where the code is found. procedure, section The following applies to C-APCs: Comprehensive APCs include the cost of blood and blood products The following are true for the SCHIP Balanced Budget Act EXCEPT: The SCHIP Balanced Budget Act is part of HIPAA. Rationale: A transitional pass-through payment for innovative and generally expensive medical devices, drugs, and biologicals is included in the OPPS, as required by the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA), also known as the Balanced Budget Refinement Act (BBRA). HIPAA is not part of BBRA. The following is TRUE about the chargemaster: It must be updated when coding changes occur. Rationale: A department review should be performed at least annually to ensure accurate coding. It is also recommended to review when coding changes or payment policy changes occur. A comprehensive overview is recommended at least every three years. The following is true concerning outlier payments: The cost-to-charge ratio is based on the hospital’s total revenue minus expenses. The following items must be included in the: HAAb, IgM antibody (86709), HBcAb, IgM antibody (86705), HBsAg (87340) and hepatitis C antibody (86803). This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the time of exposure or the stage of the disease is not known, a patient with continued symptoms ofliver disease despite a completely negative hepatitis panel may need a repeat panel approxi mately two weeks to two months later to exclude the possibility of hepatitis. When a diagnosis is established, specific tests can be used to monitor the course of the disease. Acute hepatitis panel (80074) [Show Less]
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COC 2020 Final Exam Study Questions - Set 7 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 7 (Complete Solutions, Answered) Medicare payment for inPt eligible new tech is based on the cost to the hospit... [Show More] al for the new tech. Medicare pays: 50% for the costs of the new tech in excess of the full MS-DRG payment Medicare reimbursable drugs are found in this code book. HCPCS Level II Rationale: Medicare reimbursable drugs are found in the HCPCS Level II code book. Medicare reimbursable drugs must be billed in the appropriate dosage amount defined by the long descriptor of their respective HCPCS Level II codes and adjusted for the units to reflect the amount of drug administered. MeV: Radiation dosage in million electron volts = maximum energy level of the X-ray beam Modifier TC is reported on the UB-04 claim form. True or False? Why? False. Modifier TC indicates the technical component. This is understood in the facility setting and is not reported on the UB-04. Mr. Elliot visits the surgeon for evaluation for a wedge resection ofleft lung cancer. During the admission, the patient reports pain in the chest due to the malignancy. Applying the coding concept from ICD-10-CM guideline I.C.6.b.5, what ICD-10-CM code(s) should be reported? C34.92, G89.3 Mr. McFarland visits his oncologist for prostate cancer. He is reporting more fatigue than usual. Lab tests determine the patient has anemia due to the cancer. Applying the coding concept from ICD-10-CM guideline I.C.2.c.l, what ICD-10-CM codes should be reported for the visit? C61, D63.0 Mr. Smith is scheduled for a splenectomy for hypersplenism. Before his splenectomy, he is required to have clearance from his pulmonologist. The pulmonologist performs a pre-operative screening. Applying the coding concept from ICD-10-CM guideline IV.M, which ICD-10-CM codes would be reported for the pre-operative clearance? Z01.811, D73.1 Mr. Smith presents to the office for a screening test to detect sickle cell disorder. What ICD-10-CM code(s) is/are reported? Z13.0 Mr. Timmins fell off a roof and suffered a spinal injury. As a result of the injury, he has been suffering from chronic pain in his lower back for several years. Today, he presents for insertion of a neurostimulator for pain control. Applying the coding concept from ICD-10-CM guidelines I.C.6.b.l.a and I.C.6.b.l.b.ii, what ICD-10-CM codes should be reported for the pain? (Do not code the external cause.) G89.21, M54.5 Mrs. Bixby, 83, is being admitted for dehydration and anorexia. The probable cause is dementia. She was brought in by her daughter who is visiting from out of town. Her daughter will take her from our office to St. Mary's. The gerontology unit will evaluate her mental condition tomorrow after she is stabilized. How would you code the diagnoses? R63.0, E86.0 Mrs. Fryer visits her nephrologist for an erythropoietin (EPO) injection for her anemia. She has Stage 3 chronic kidney disease, which is the cause of the anemia. Applying the coding concept from ICD-10-CM guideline I.A.13, what ICD- 10-CM code(s) should be reported for the EPO injection? N18.3,D63.1 Mrs. Johnson is here today to receive an intercostal nerve block to mitigate the debilitating pain of her malignancy. Her cancer has metastasized to her bones in her thoracic spine Primary cancer is unknown. What ICD-10-CM codes are reported? G89.3, C79.51,C80.1 Mrs. Smith is visiting her mother and is 150 miles away from home. She is in the 26th week of pregnancy. In the late afternoon she suddenly feels a gush of fluid followed by strong uterine contractions. She is rushed to the hospital but the baby is born before they arrive. In the ED, she and the baby are examined, and the retained placenta is delivered. The baby is in the neonatal nursery doing okay. Mrs. Smith has a 2nd degree perineal laceration secondary to precipitous delivery, which was repaired by the ED physician. She will return home for her postpartum care. What codes does the facility ED report (CPT® and ICD-10-CM codes)? 59414, 59300, O73.0, O70.1, Z37.0, Z3A.26 Multifield: Use of three or more fields to deliver dosage Muscle is attached to bone by what method? Tendons, aponeurosis and directly to the bone Myocardial Perfusion Imaging Indications: Chest pain. Procedure: Resting tomographic myocardial perfusion images were obtained following injection of 10 mCi of intravenous Cardiolite (technetium tc 99 sestamibi for injection). At peak exercise, 30 mCi of intravenous Cardiolite was injected, and post-stress tomographic myocardial perfusion images were obtained. Post stress gated images of the left ventricle were also acquired. Myocardial perfusion images were compared in the standard fashion. Findings: This is a technically fair study. No stress induced electrocardiographic changes noted. There are no significant reversible or fixed perfusion defects noted. Gated images of the left ventricle reveal normal left ventricular volumes, normal left ventricular wall motion, and an estimated left ventricular ejection fraction of 50%.Impression: No evidence of myocardial ischemia or infarction. Normal left ventricular ejection fraction. What CPT ® and ICD-10-CM codes are reported by the facility? 78452, 93017, A9500, R07.9 Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes. Refer to ICD- 10-CM guideline I.C.4.a.5.a. When a patient's insulin pump malfunctions Name four reasons why chronological documentation of patient care is important. 1. Enable the physician and other healthcare professionals to plan and evaluate the patient's immediate treatment, and to monitor his or her healthcare.; 2. Enhance communication and promote continuity of care among physicians and other healthcare professionals involved in the patient's care.; 3. Facilitate claims review and payments.; 4. Assist in utilization review and quality of care evaluations.; 5. Reduce complicated medical reviews.; 6. Provide clinical data for research and education.; 7. Serve as a legal document to verify the services (for example, in defense of an alleged professional liability claim). Name three benefits of an effective compliance plan. Faster, more accurate payment of claims, Fewer billing mistakes, Diminished chances of payer audit, Last chance of running afoul of self-referral and anti-kickback statutes Neuroendocrine glands Exerts chemical control over the human body by maintaining homeostasis NI is a: Payment indicator Oblique: Body part is rotated so it does not produce an AP/PA projection. The X-ray beam enters at an angle that is neither frontal (AP or PA) nor lateral. Observation services provided for more than 8 hours are considered packaged in which circumstance? When reported with a procedure assigned a status indicator T. OCE Edit 22-Invalid modifier is applied to a facility claim. The claim has modifier 63 appended to one of the procedure codes. Which appendix might help determine the reason for this edit? Appendix F OCE is an abbreviation for: Outpatient Code Editor Oculomotor Controls movement of four of the six muscles of the eyeball, the upper eyelid, and the muscles that constrict the pupils Olfactory Sense of smell On the UB-04 claim form: Sequence by revenue codes in ascending order OPER ATION: Left stapedotomy for conductive hearing loss. Operating microscope. SURGEON: ANESTHESIA: General. FINDINGS AT SURGERY: The patient had intact tympanic membrane. The incus and malleus were intact and mobile. The superstructure was absent, the footplate was not mobile. A 4.5 x 0.6 smart piston was used. DESCRIPTION OF OPERATION: After the establishment of general anesthesia and administration of appropriate IV antibiotics, the left ear was prepped and draped in the usual fashion, with a microscope and a canal knife, a tympanome-atal flap was incised and elevated. The middle ear was entered with a Rosen needle. The middle ear was explored with the previous mentioned findings. A measurement was taken, and then a fenestra was created in the footplate with a laser. A 4.5x 0.6 SMart stapes piston prosthesis was placed through the fenestra and crimped with a laser to the incus. It was mobile. The oval window was sealed with autologous venous blood. The eardrum was returned to the original position and packed with Gelfoam packing. A sterile dressing was placed upon the wound. What CPT® code and ICD-10-CM code is reported by the facility for the surgery? 69660-LT, H90.12 Operative Note Indications: This 67 year-old man with some compressive symptoms. A large left thyroid goiter was brought to surgery today for a left total thyroid lobectomy. He understood the risks of the procedure including nerve injury and bleeding and hypoparathyroidism. Procedure: After induction of anesthesia by the anesthesiologist, the neck was prepped and draped. A low collar incision was made and subplatysmal flaps were raised. The midline fascia was divided and retracted. The right lobe was essentially normal along with the isthmus; however, there was a huge fist-sized multiple colloid nodule goiter in the left thyroid lobe. This was mobilized. Care was taken to protect the recurrent nerve in the parathyroid. The superior pole was ligated between heavy silks along with the middle thyroid vein and inferior thyroid artery. A total left thyroid lobectomy was performed using hemostat and silk ligatures. This was confirmed as benign histologically. After checking for hemostasis, the neck was drained with a Jackson-Pratt and closed in layers with Vicryl and PDS. He tolerated this well and returned to the PACU in stable condition. Needle and sponge counts were correct. What CPT® code is reported? 60220-LT Operative Note Preoperative Diagnosis: Abdominal pain, thrombocytopenia, eosinophilia Postoperative Diagnosis: Acute gastritis, rule out eosinophilic gastritis Anesthesia: Demerol 100 mg, Versed 4 mg The patient's pulse, blood pressure, and pulse oximetry were monitored continuously and remained stable throughout the procedure and medication was administered by the anesthesia team. With the patient in the left lateral position, the endoscope was placed in the oropharynx. My visualization of larynx and laryngeal structures was good and these appeared normal. The esophagus was readily intubated and the proximal, mid, and distal esophageal mucosa appeared essentially unremarkable. There was perhaps some subtle felinization, but it was within normal limits. With the stomach, however, there were patches of erythema in the antrum and body and these were photographed and subsequently biopsied. In the more proximal body, there was subtle edema. This was photographed. Careful inspection of the stomach was made in forward and in retroflexed views, looking at cardia, fundus, annulus, body, antrum, and pylorus. The duodenal bulb and second portion of the duodenum appeared entirely normal. I await the biopsies with interest. The patient did have HIDA scan imaging and his gallbladder ejection fraction seems low at 31 percent, which in someone with biliary colic is highly suggestive of dysfunctional gallbladder. I will follow him into the GI hospital clinic. I am awaiting the results of the hematology assessment with interest, along with the biopsies and we will tie everything together when I see him again. What CPT® and ICD-10-CM codes are reported? 43239, K29.00 Operative Note Preoperative Diagnosis: History of anal ulcerations, hemorrhoids Postoperative Diagnosis: Hemorrhoids present posterior aspect, small and stable Procedure Performed: Anoscopy was performed. No ulcerations, no fissures, hemorrhoids present posterior aspect, small. Hemorrhoids are stable. Plan: 1- Continue avoiding foods and liquids as recommended in the first visit. 2- Stop Anusol suppositories.3-Can restart suspended food and liquids, one at a time, for ten days. If there is no recurrence, add a second food, and so forth. 4-Follow-up visit in two months. Select the correct ICD-10-CM and CPT® codes. 46600, K64.8, Z87.19 Operative Note Preoperative Diagnosis: Hypertrophic obstruction tonsils and adenoids. Postoperative Diagnosis: Same. The 27 year-old patient was intubated and the airway was secured. The adenoid region was palpated and the adenoid tissue was found to be obstructive and encroaching on the Eustachian tube orifices and the posterior choana. The palate was also palpated. The muscular sling was intact and the palate was felt to be of adequate length to result in good closure. The uvula was normal. The adenoids were gently removed with the curette. I did not disturb the Passavant's ridge. Only superior lymphoid tissue was removed. Hemostasis was achieved with a tonsillar pack. The tonsils were removed with blunt dissection, followed by selective electrocautery to prominent vessels in each fossa. Good hemostasis was achieved. Packing was removed at the end of the case at the time of extubation. The patient was in good cardiac and pulmonary condition without significant bleeding. What CPT® and ICD-10-CM codes are reported? 42821, J35.3 [Show Less]
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COC 2020 Final Exam Study Questions - Set 6 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 6 (Complete Solutions, Answered) Each page of the medical record should contain the patient's or . name, patien... [Show More] t ID number. Electrocautery Instrument for directing electrical energy through tissue for lesion destruction Electrodessication The use of monopolar high frequency electrical current for lesion removal Exam: CT Abdomen Admitting Diagnosis: Pt states gallbladder problem Clinical History: Right upper quadrant abdominal pain; history of colon cancer; colostomy Comparison: None Result: The study was performed with oral and intravenous contrast material (Isovue 300, 150 mL). The lung bases appear normal. The liver, spleen, both kidneys and adrenal glands appear normal. There is faint calcification density in the dependent portion of the gallbladder, suspicious for a possible gallstone. Recommend ultrasound correlation. Visualized portions of the pancreas appear unremarkable. There is no retroperitoneal lymphadenopathy. Opacified bowel loops are unremarkable. Note is made of left lower quadrant colostomy. No abnormality is noted within the pelvis. Impression: Small calcification-appearing density in the dependent portion of the gallbladder, suspicious for gallstone. Recommend ultrasound correlation. What CPT ® and ICD-10-CM codes are reported by the facility? 74160, Q9967 x 150, R10.11, Z85.038, Z93.3 Exam: CT Maxillofacial Admitting Diagnosis: Allergic rhinitis nasal congestion Clinical History: Allergic rhinitis; nasal congestion; no comparison Result: The paranasal sinuses are clear except for a small mucus retention cyst in the base of the right maxillary sinus. This measures about 5 mm. The osteomeatal complexes are patent. There are no air fluid levels. There is mild nasal septal deviation towards the left side. The bones appear intact. There are no soft tissue masses. Impression: Mild acute right maxillary sinusitis, mild nasal septal deviation towards the left side. What CPT ® and ICD-10-CM codes are reported by the facility? 70486, J01.00, J34.2 Exam: CT Maxillofacial WO contrast Admitting Diagnosis: Chronic Sinusitis Clinical History: Chronic sinusitis Result: There has been a mild increase in the amount of mucosal thickening seen anteriorly in the right sphenoid sinus. There is opacification of multiple bilateral ethmoid air cells mildly increased as well over the interval. There is an increasing amount of lobulated mucosal disease seen along the floor of the frontal sinuses. There is less than 1 cm of mucosal thickening seen along the floor of the left maxillary sinus, probably not significantly changed. The left osteomeatal unit is patent. There are a few millimeters of mucosal thickening along the floor and lateral wall of the right maxillary sinus, slightly increased. The osteomeatal unit is patent. There is bowing of the nasal septum to the right. Impression: Sinusitis, mildly increased What CPT ® and ICD-10-CM codes are reported by the facility? 70486, J32.9 Exam: CT of the chest with intravenous contrast (Omnipaque 350, 150 mL) Admitting Diagnosis: Difficulty swallowing Result: The transverse aorta is prominent in size and measures approximately 3 centimeters in transverse dimension. There are a couple of small right peritracheal lymph nodes measuring a centimeter or less in size. No infiltrate or evidence of effusion is seen. There is evidence of old granulomatous exposure. Impression: Slight dilatation of the thoracic aorta. What CPT ®, HCPCS and ICD-10-CM codes are reported for the facility? 71260, Q9967 x 150, R13.10 Exam: MRI brain W/O and W contrast Admitting Diagnosis: Left facial weakness/Bell's palsy Clinical History: Comparison. Left facial weakness in a patient w/hx of Bell's Palsy and MS Result: MRI of the brain was obtained at 1.5 Tesla. Axial T1 weighted pre- and post-Gadolinium (1.6 mL) (iron-based contrast), T2 weighted FLAIR, and diffusion images were obtained. Sagittal T1 weighted and high resolution coronal and axial pre- and post-Gadolinium images of the internal auditory canals were obtained. The old study was available for comparison. The ventricles and sulci are within normal limits. There is no evidence of mass effect or midline shift. There are no extra-axial fluid collections. There are multiple punctuate areas of abnormal increased T2 weighted signal in the periventricular white matter and in the subcortical white matter of the centrum semiovale. Many of the foci are elongated and oriented toward the ventricles. Since the prior exam, there has been an increase in the number of hyperintense plaques. With contrast enhancement, none of the plaques appear to enhance at this time. The enhancement seen previously has resolved. The pattern and distribution is most characteristic for MS. The pituitary gland and cerebellum are unremarkable. There are multiple punctuate areas of hyperintense signal in the brain stem and brachium pontis. These do not enhance with gadolinium. There is no edema or mass effect from the lesions. There is a 7 mm focus of increased signal at the left CP angle. No abnormal signal, enhancement of discrete mass lesion is appreciated within the internal auditory canals. This would correlate with the patient's symptoms of a left facial palsy. Impression: Multiple hyperintense lesions predominately in the periventricular white matter with characteristic pattern for MS. None of the plaques currently enhance. There has been a fairly significant increase in the number of lesions since the last exam. Multiple lesions were also seen in the brain stem and the brachium pontis. Specifically, there is a 7 mm focus in the left CP angle which is probably the cause of the patient's left facial palsy. No discrete abnormality was seen in the internal auditory canals. What CPT ® and ICD-10-CM codes are reported by the facility? 70553, A9579 x 2, G51.0, G93.9, G35 Exam: MRI Lumbar Spine W/O Contrast Admitting Diagnosis: MRI-L spine, low back pain Clinical History: No comparison; low back pain which radiates to the right lower extremity Result: Vertebral body height is normal. The bone marrow signal appears normal. The visualized portions of the spinal cord appear normal. The foramina are patent in the sagittal images. There is normal disc space height and hydration. The intervertebral discs appear normal. There is specifically no evidence of disc herniation, spinal or foraminal stenosis. Impression: Negative What CPT ® and ICD-10-CM codes are reported for the facility? 72148, M54.5 Exam: MRI right upper extremity joint W/O contrast Admitting Diagnosis: RT shoulder pain Indication: Right shoulder pain and numbness; no comparison study Result: There are a few small subchondral cysts in the humeral head adjacent to the greater tuberosity. These lie subjacent to the supraspinatus insertion. No other marrow space abnormality is identified. There are mild degenerative changes in the right acromioclavicular joint with small osseocartilaginous spur inferiorly. Undersurface of the acromion is flat. No joint effusion is seen. No abnormal periarticular fluid collections are identified. Glenoid labrum is intact. Long head of the biceps is intact and is normally positioned. Supraspinatus tendon shows no evidence of full thickness tear and there is no evidence of fluid in the subacromial/ subdeltoid bursa. I cannot exclude a small partial thickness tear along the distal most aspect of the right supraspinatus tendon in its inferior border. Subscapularis and infraspinatus tendons are intact. Impression: Minor localized degenerative diseases of right shoulder. Possible small partial thickness tear along inferior border of right supraspinatus tendon at tendon insertion, otherwise negative. What CPT ® and ICD-10-CM codes are reported by the facility? 73221, M19.011 Examples of procedures considered "inpatient only" include: Surgical thoracoscopy, laminectomies, vertebral corpectomy, enterostomies, risky invasive procedures Facial Controls facial muscles around the eyes, forehead, external ear, and mouth; sensa-tion of taste; and certain salivary and lacrimal (tear) glands Facilities report Medicare outpatient clinic (E/M) visits with code(s): G0463 Rationale: Clinic E/M visits (99201-99215) are reported to Medicare by the facility with HCPCS Level II code G0463. Field: Geometric area defined by a collimator at the skin surface Flow cytometry is performed for DNA analysis. What CPT ® code is reported? 88182 Food moves through the digestive tract by what means? Peristalsis For Medicare how is each claim paid for outpatient facility reimbursement? Each claim is paid based on the determined interim outpatient reimbursement rate. Rationale: During the year-end cost report settlement, the prior year's entire outpatient claims are analyzed via a computer system. This method is to determine an interim reimbursement rate on which to pay the following year's Medicare claims. For OPPS, critical care is paid at two levels. What is the distinguishing factor for payment? One level for critical care services, another level when trauma activation occurs in addition to critical care For surgical procedures involving a primary surgeon and an assistant surgeon, who is the person responsible for the information in the procedural note? Primary surgeon Rationale: For surgical procedures with more than one surgeon, the primary surgeon is responsible for the procedural note. A resident, intern, or assistant can dictate the note, but the primary surgeon must indicate agreement by reading and signing it. For the UB-04 Form, which provider type qualifier is used to report the rendering provider? 82 Fractionation: Division of total planned dose into number of smaller doses given over time Friends brought a young male with type 1 diabetes to the emergency department, in a comatose state. He was admitted with ketoacidosis and was resuscitated with saline hydration via insulin drip. After regaining consciousness, the patient reported that the morning of admission he was experiencing nausea and vomiting and decided not to take his insulin because he had not eaten. He was treated with intravenous hydration and insulin drip. By the following morning, his laboratory work was within normal range and he was experiencing no symptoms. What ICD-10-CM code(s) are reported? E10.11 Ganglion cyst: are noncancerous lumps that most commonly develop along the tendons or joints of your wrists or hands. They also may occur in the ankles and feet. Ganglion cysts are typically round or oval and are filled with a jellylike fluid. Glossopharyngeal Responsible for swallowing, secretion of saliva, sensations of the throat and taste sensations for the back of the tongue Hospitals are required to provide a list of standard charges on the internet and update the list at least annually. True [Show Less]
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COC 2020 Final Exam Study Questions - Set 5 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 5 (Complete Solutions, Answered) After suffering a fracture of the ankle three months ago, a 69 year-old patien... [Show More] t presented with what was found to be a malunion fracture. She was treated with additional surgery and discharged. Which injury diagnosis code(s) is/are assigned? S82.899P All codes in ICD-10-PCS have how many characters? 7 All entries in the medical record must be: Signed and dated by the author with a method to establish the author's identity. All payers employ the same rules concerning coding and reimbursement. B. False Rationale: PPOs, HM Os, Medicaid, TRICARE/CHAMPUS, Workers Compensation, and many private insurers employ their own rules regarding coding and reimbursement. Additional restrictions may apply when participating in a network. All the following are examples of outpatient facilities except: Answer: OPPS Rationale: OPPS stands for Outpatient Prospective Payment System. This is a payment system and not a type of facility such as CORF, CAH, ASC are. Ambulatory surgical centers include: Answer: An independent ASC Rationale: Independent ASCs offer ambulatory surgical services or same-day surgeries to patients who only require services with immediate postoperative care. When the ASC is owned by the hospital, it is generally considered to be an extension of the physical hospital and the same as any other outpatient department. In general, an independent ASC must be financially independent from the hospital, not be included on the hospital's cost reports. Amputation: the surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger. An 18 day-old infant develops bradycardia. What ICD-10-CM code is reported? P29.12 An 18 month-old male with bilateral chronic serous otitis media and hypertrophy of the adenoids presents to the hospital surgery department and undergoes an initial adenoidectomy and insertion of ventilation tubes in both ears under general anesthesia. What is the correct code selection for the procedure and diagnoses? 42830, 69436-50, H65.23, J35.2 An 18 year-old male with complaints of right knee pain, swelling and a pop-like feeling after falling on the sidewalk is seen in the emergency department. It is decided that the patient needs to have an arthrogram of the knee. The patient goes to the outpatient radiology department. Once back in the X-ray room, the patient was placed in supine position with his right knee flexed over a pillow. After the knee was prepped and draped, topical anesthesia was applied. A 20-gauge needle was then inserted into the femoropatellar space of the knee. Air and single contrast media were injected and the patient was instructed to move his knee in order to provide even coating. Multiple arthrographic views were taken. Closed dislocation of the knee was the diagnosis. What are the correct procedure and diagnosis codes for this service? 27369-RT, 73580-RT, S83.104A An 18 year-old with a dislocated patella is in the hospital outpatient orthopedic center for reconstruction. After being prepped and draped, the orthopedist makes an incision on the anteromedial aspect of the left knee, starting above the patella and ending just below the tibial tuberosity. Once the patellar tendon is resected, it is pulled medially and distally on the tibia for reattachment. The vastus medialis muscle is then inserted by transforming it laterally and distally, suturing it into place. Alignment of the patella is achieved, then the patellar tendon is anchored into the tibia with staples. The incision is closed with Steri-strips. The patient had no complications and was released after recovery. What are the correct procedure and diagnosis codes for this scenario? 27422, S83.005A An 18-month-old with chronic serous otitis media and hypertrophy of the adenoids presents to the outpatient surgery department and undergoes an initial adenoidectomy and insertion of bilateral ventilation tubes. General anesthesia was required. What CPT® and ICD-10-CM codes are reported by the facility for the surgery? 42830, 69436-50, J35.2, H65.23 An 8 year-old boy was helping his father install a new window at their house. The window fell, causing some of the glass to cut the boy's left hand, left forearm, and his left thigh. The laceration on the hand was 2 cm, the forearm laceration was 3.3 cm, and the thigh laceration was 1.9 cm. The lacerations were all closed using simple repair. What are the correct procedure and diagnosis codes for this encounter? 12002; S61.412A, S51.812A, S71.112A, W25.XXXA, Y93.H9, Y92.009 An 80-year-old female with a dual chamber pacemaker, used to treat bradycardia caused by Wenckebach type atrioventricular block (type I, second degree block), is admitted for change of the battery in her pacemaker. An electronic analysis at the cardiologist's office indicated that the battery is malfunctioning and needs to be replaced. The battery has been in place for several years and has functioned without problems until recently. The procedure is performed on an outpatient basis at the hospital. 33228, T82.518A, 144.1 An 85-year-old man is seen in the hospital ED after he tripped on a rug while walking in his home. He tried to break his fall and fractured both his wrists. Two view X-rays were taken of both wrists (73100) and short arm plaster casts (29075) were applied. The ED facility resources used were a level 3. An appointment was made for follow-up in the orthopedic clinic. Report the facility services and diagnoses. 99283-25, 73100-50, 29075-50, Q4009 x 2, S62.101A, S62.102A, W18.09XA, Y92.099 An 88 year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment and elects to receive colpocleisis (LeFort type) to prevent further prolapse and avoid more significant surgery like hysterectomy. The treatment is successful. What are the CPT ® and ICD-10-CM codes reported for this procedure? 57120, N81.4 An ABN rendered in a timely manner is important for the facility to receive payment when Medicare does not cover the service, because the diagnosis does not support medical necessity. The facility may: Have the patient sign the ABN after administration of anesthesia. An ABN was presented to a 68-year-old Medicare patient for services that might not be covered. The services facing denial were specified on the ABN. The ABN did not specify the reason Medicare might likely deny the claim. The patient signed the ABN and the claim was denied. The patient received a bill from the facility and insists she did not understand the ABN or what she was signing. Is the patient responsible for payment? The ABN did not specify the reason Medicare might deny the claim, so the patient is not responsible for payment. An active treatment plan for therapy services must identify: Answer: The diagnosis, the goals of the treatment, the date the plan was established, and the type of modality or procedure used. Rationale: An active therapy treatment plan must identify the diagnosis, the anticipated goals of the treatment, the date the plan was established, and the type of modality or procedure used. An allergist in a hospital outpatient clinic prescribed rapid desensitization for a patient with penicillin hypersensitivity. A three-hour session was required to achieve the physician's desired outcome for the patient. What CPT® and ICD-10-CM codes are reported by the facility? 95180 x 3, T78.40XA An ecptopic pregnancy is a complication in which the fertilized ovum is implanted in any tissue other than the? Uterine wall An elderly established Medicare patient is seen in the hospital clinic for an accidental overdose of valium and is vomiting and has slurred speech. He is admitted by his physician to observation for 8 hours and then discharged the next day. The clinic facility use is level 3. Report the facility charges and diagnoses. G0463-25, G0379, G0378 x 8, T42.4X1A, R11.10, R47.81 An ENT specialist performed surgery at an ASC on a 5 year-old who stuck a foam hair roller up her nose. It was decided to remove the roller by lateral rhinotomy because of the position and depth of the foam roller in the nose. What CPT ® and ICD-10-CM codes are reported? 30320, T17.1XXA An established Medicare female patient with a history of breast cancer with metastasis to the right lung is seen in the hospital clinic (level 4) by her oncologist for discussion of treatment options including radiation therapy for the lung cancer. Report the facility services and diagnoses. G0463, C78.01, Z85.3 An established patient comes in complaining of nausea and vomiting and states she has not gotten her menstrual period. A complete CBC and automated differential WBC were ordered. Also, Hepatitis B surface antigen, HIV testing, Rubella, RPR, Antibody Screen, Blood Typing for Rh and ABO along with a urine pregnancy test. Report the CPT ® code(s) for the laboratory service(s). 80081, 81025 An established patient is in the outpatient clinic to evaluate three (3) plantar warts on the right foot that are bothering the patient and a small lesion on the left arm that looks suspicious. After examining the patient, the internist uses cryosurgery to destroy the three (3) warts and takes a punch biopsy of the left arm lesion. The pathology report of the biopsy demonstrates a blue nevus without any atypical features. What are the procedure and diagnosis codes? 17110, 11104-59, B07.0, D23.62 An excision of chalazion left upper eyelid and a biopsy of left lower eyelid are performed during the same operative session. Select the appropriate procedure codes. 67800-E1, 67810-E2 An exploratory laparoscopy was performed for right lower abdominal pain. Endometriosis of the pelvic viscera was found and lesions were removed with fulguration (58662). A right ovarian cystectomy was also performed (58661). What is the expected payment (Medicare and Pt responsibility) $4,833.17 An injection procedure for nephrostogram through existing access was performed in the outpatient radiology department. After the procedure was completed, the physician diagnosed the patient with vesicoureteral reflux with bilateral reflux nephropathy. What CPT® and ICD-10-CM codes are reported on a UB-04 form? 50431, N13.722, Z93.6 [Show Less]
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COC 2020 Final Exam Study Questions - Set 3 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 3 (Complete Solutions, Answered) A patient is diagnosed with pressure ulcers on each heel. Each heel displays b... [Show More] one involvement with evidence of necrosis and is identified as stage 4. Select the diagnosis code(s): L89.614,L89.624 A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT code is reported for this service? 20206 A patient is having a decompression of the nerve root involving two segments of the lumbar spine via transpedicular approach. Report the CPT® code(s). 63056, 63057 A patient is having phacoemulsification ofan age-related nuclear cataract of the left eye. What ICD-10-CM code is reported? H25.12 A patient is having surgery to repair a recurrent left inguinal hernia without obstruction. What ICD-10-CM code is reported? K40.91 A patient is in outpatient surgery for a laparoscopic oophorectomy for a right ovarian cyst. After admission, the anesthesiologist discovered the patient had an upper respiratory infection and the surgery was cancelled. Applying the coding concept from ICD-10-CM guideline IV.A.I, what is the appropriate ICD-10-CM code selection? N83.201, J06.9, Z53.09 A patient is in the hospital for a hysterosalpingogram due to her infertility for 10 years. She has no history of pelvic infection or surgery. A 5-F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Contrast was administered through the catheter and multiple images were taken. Findings were possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation. What are the CPT ® and ICD-10-CM codes reported? 58340, 74740, N97.9 A patient is in the outpatient radiology department of the hospital for an MRI of the brain to rule out stroke. His symptoms are slurred speech and headache. The ventricles and sulci are seen within the brain. There is no evidence of space-occupying lesion or intracranial hemorrhage. No abnormal extra-axial cerebral fluid collections are identified. Diffusion weighting imaging shows no abnormality. Impression is negative. What CPT ® and ICD-10-CM codes are reported by the facility? 70551, R47.81, R51 A patient is receiving pain management treatment for chronic cervical pain caused by a motor vehicle accident. Report the ICD-10-CM code(s). G89.21, M54.2, V49.9XXA A patient is referred to the hospital radiology clinic for numbness and tingling in the arms. The radiologist performs a Doppler analog waveform analysis, a volume plethysmography and a flow velocity signal of the arteries of both arms. What procedure and diagnosis codes are reported for the facility services? 93922, R20.0, R20.2 A patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. Under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure. What CPT ® and ICD-10-CM codes are reported? 31830, L90.5, Z43.0, Z99.11 A patient is scheduled for closure of a cystostomy. The patient has a personal history of bladder carcinoma. After removing the sutures that secured the cystostomy tube to the skin and bladder, the surgeon removed the cystostomy tube and sutured the bladder musculature to repair the opening. The physician placed a drain tube, brought it out through a separate stab incision in the skin, and performed a layered closure. What CPT ® and ICD-10-CM codes are reported? 51880, Z43.5, Z85.51 A patient is seen in the outpatient clinic for pain and the physician gives a series of 6 injections for the following muscles on the right side of the back: the rhomboid (1), trapezius (3), and latissimus dorsi (2). Report the CPT® code(s) for the trigger point injections. 20553 A patient is seen in the emergency department to treat a second-degree burn to his right arm (9 percent) and third-degree burns on his chest and left arm (25 percent). Select the diagnosis codes. T21.31XA, T22.30XA, T22.20XA, T31.32 A patient is seen in the hospital outpatient surgery department for anal fistula repair. The surgeon first explores the anal canal and identifies the location of the fistula. The fistula tract is then excised. The perianal skin is incised and a wedge of skin and subcutaneous tissue is mobilized and advanced into the defect that was created by the excision of the fistula. The incisions are closed with sutures. What are the correct procedure and diagnosis codes for this encounter? 46288, K60.3 A patient is seen in the hospital outpatient surgery department for anorectal fistula repair. The surgeon first explores the anal canal and identifies the location of the fistula. The fistula tract is then thoroughly irrigated. A fistula plug was introduced through the fistula tract ensuring that the plug completely occludes the internal fistula opening. The plug was trimmed to insure a flush fit with the mucosal wall and absorbable sutures were used to secure the plug into place. What CPT® code is reported for the procedure? 46707 A patient is seen in the outpatient clinic for follow-up on hypertension. He also has CKD stage 3. The Pts blood pressure is stable at 138/88. The doctor instructs the Pt to continue with the same doses of Vorvasc. He also writes a script for blood work to be drawn at lab:CBC, BMP. I12.9, N18.3 A patient is seen in the outpatient GI lab of the hospital for a screening colonoscopy. A colonoscopy revealed three polyps in the transverse colon. The polyps were removed by snare technique. What are the procedure and diagnosis codes for this procedure? 45385, Z12.11, D12.3 A patient is sent to the hospital for a bone marrow needle biopsy. The specimen is sent to the lab in the hospital for interpretation. The diagnosis is thrombocytopenia. What CPT ® and ICD-10-CM codes are reported by the facility? 38221, 88305, D69.6 A patient presented to outpatient radiology with a 90% lesion of the right iliac, and 85% lesion in the right popliteal artery. From a right femoral artery access, atherectomy was performed in the iliac artery, and angioplasty followed by stent placement was performed in the popliteal artery. What CPT ® codes are reported? 0238T-RT, 37226-RT A patient presented to the ED with an apparent acute MI. He is immediately taken to the cardiac cath lab where diagnostic coronary angiography with left ventriculography was performed. There was an acute total occlusion of the first diagonal of the LAD, and 80% stenosis of the left main coronary artery and 75% stenosis of the proximal left anterior descending coronary artery. The decision was made to stent the left main coronary artery, and the proximal LD. Aspiration thrombectomy was performed in the first diagonal of the LD and a stent was placed. IVUS was used in the diagonal to confirm adequate stent expansion. What CPT ® codes are reported? 93458-59, 92941-LD, 92928-LM, 92978 A patient presented to the emergency department with complaint of left wrist pain due to an imbedded foreign body (thorn entered while trimming bushes, at home, in his backyard). The provider incises the area and dissects the tissue to locate the thorn. The thorn was located deep in the tissues of the wrist. The emergency department physician proceeded to remove the thorn without complication and performs a layered closure. Code this scenario. 25248, S61.542A, W45.8XXA, Y92.017, Y93.H2 A patient presented to the emergency department with second degree burns to both forearms, which makes up 9 percent TBSA (Total Body Surface Area). She is three months pregnant, 12 weeks. The burns are not affecting the pregnancy. Select the diagnosis codes. T22.212A, T22.211A, T31.0, Z33.1 A patient presented to the hospital outpatient facility for chemotherapy for breast cancer. Report only the infusion services. Do not report the drugs. (Hydratione per protocol/500cc/10:00AM-11:00AM; Taxol 35 mg/11:00AM-12:45PM;Decadron 10 mg;10:45-11:15 IV drip concurrent; Aloxi 250 mcg/10:45-11:15 mixed w/Decadron in concurrent IV drip) 96413, 96415, 96368, 96361-59 A patient presented to the hospital outpatient pulmonary clinic for asthma follow-up. During the encounter, the physician performed an expanded problem focused history and exam with moderate decision making for this established patient. The documentation supported a low-level E/M for the facility. Later in the evening, the patient suffered an acute asthma attack and went to the ER in the same hospital for treatment. What modifier is used to indicate multiple E/M services occurred on the same date? 27 A patient presented with a right ankle fracture. After induction of general anesthesia, the right leg was elevated and draped in the usual manner for surgery. A longitudinal incision was made parallel and posterior to the fibula. It was curved anteriorly to its distal end. The skin flap was developed and retracted anteriorly. The distal fibula fracture was then reduced and held with reduction forceps. A lag screw was inserted from anterior to posterior across the fracture. A 5-hole 1/3 tubular plate was then applied to the lateral contours of the fibula with cortical and cancellous bone screws. Final radiographs showed restoration of the fibula. The wound was irrigated and closed with suture and staples on the skin. Sterile dressing was applied followed by a posterior splint. What CPT code is reported? 27792-RT A patient presents for a liver transplant. The provider documents the patient has Laennec's cirrhosis associated with long term alcohol dependent use. What are the diagnosis codes for this encounter? K70.30, FI0.20 A patient presents to the hospital-based ambulatory surgery center for skin grafts due to previous third-degree burns on the abdomen. Burn eschar is removed from the abdomen and the defect size at that time measured 10 cm x 10 cm. An acellular dermal allograft from a donor bank was placed on the defect and sewn into place. What are the correct procedure codes for this service? 15002, 15273 A patient presents to her physician and tells him she drinks each night when she gets home from work. She asks her physician to recommend an alcohol treatment center because her life has become unmanageable and she wishes to quit drinking. The patient is diagnosed with uncomplicated alcohol dependence. Select the diagnosis code. F10.20 A patient presents to outpatient surgery department for freeing of intestinal adhesions to correct an internal hernia. Documentation states that under anesthesia, the surgeon placed a trocar at the umbilicus into the abdominal cavity and insufflated the area. A laparoscope was placed through the umbilical incision and additional trocars were placed. Intestinal adhesions were identified tangled with a loop of small bowel. Dissection and gentle removal of the adhesions were performed releasing the small internal hernia showing viable pink bowel. The trocars were removed and the incision was closed with sutures. What CPT® code is reported for the procedure? 44180 A patient presents to the ambulatory surgery center at the local hospital with a diagnosis of left ureteral stones. After being prepped and draped, the surgeon examines the urinary collecting system with a cystourethroscope that was passed through the urethra and into bladder. The surgeon inserts a special instrument through the cystourethroscope to manipulate the calculi found in the ureter. The stones are not removed. The surgeon then inserts a ureteral stent and removes the cystourethroscope. No complications were noted. What CPT ® and ICD-10-CM codes are reported? 52330-LT, 52332-LT, N20.1 A patient presents to the ASC for a scheduled dilation of the esophagus. After being prepped and draped, anesthesia was administered. An unguided dilator is used. The surgeon passes the dilator into the patient's throat down into the esophagus until the end of the dilator passes the stricture. The dilator is withdrawn after it passes the stricture. As the surgeon prepares to insert the dilator again, the patient begins to seize on the operating table. The procedure is terminated and the patient stabilized before being sent to recovery in stable condition. What are the correct procedure and diagnosis codes for this encounter? 43450-74, K22.2, R56.9 A patient presents to the ED with puncture wounds on the right forearm from a dog bite. The dog was not wearing a collar. The ED physician cleans the wound, gives a rabies vaccination in the deltoid region (IM), and administers human rabies immunoglobulin (RIg) IM. The ED visit is a mid-level visit. What CPT® and ICD-10-CM codes are reported by the facility? [Show Less]
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COC 2020 Final Exam Study Questions - Set 2 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 2 (Complete Solutions, Answered) A 7 year-old female was seen in the ED after being bit by a dog. The child re... [Show More] ceived treatment for the bite to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What are the correct diagnosis codes for this patient encounter? S81.852A, Z20.3, Z23, W54.0XXA A 7 year-old is seen in the outpatient clinic. Blisters have appeared on the face, with some of them bursting open. After examination, the diagnosis is impetigo. What is the correct diagnosis code for this visit? L01.00 A 7 year-old patient with asthma was experiencing acute exacerbation of his condition. The parents rushed their son to the emergency department where the ED physician performed a midlevel E/M service. In addition, an albuterol treatment was performed. When the patient was stabilized, he was released in good condition to his parents. What modifier is appended to the E/M service for the facility? 25 A 70-year -old female patient presents with a complaint of left knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. AP, lateral and sunrise views of the left knee are ordered and interpreted. The diagnosis is left knee pain secondary to underlying primary degenerative arthritis. What ICD-10-CM code(s) is/are reported? M17.12 M17.12, A 70-year-old woman is evaluated in a clinic for symptoms of increasing claudication. After noninvasive vascular studies were performed, the decision was made to proceed with diagnostic angiography and possible angioplasty of the suspected left extern al iliac artery stenosis. After normal preparation for the angiography procedure, the left common femoral artery is punctured and the catheter is passed proximally into the left external iliac artery . Images were then taken and an 85 percent stenosis was noted. The decision was made to perform angioplasty. Using the Seldinger technique, the angiography catheter was removed and an angioplasty catheter with a balloon diameter of 8 mm was advanced into the left external iliac artery and into the lesion without difficulty. After two inflations to 8 mm, the follow-up angiography was performed and showed good flow across the lesion. Pressures measured confirm the adequacy of the therapy and that there is no residual gradient. 37220, 75710-59, 170.212 A 71 year-old patient presents to the outpatient clinic at the local hospital with COPD, congestive heart failure, and hypertension. After a comprehensive evaluation, the physician adjusts to the patient's hypertension medication due to the hypertension being uncontrolled. The patient's other conditions were stable. The patient is to follow-up in two weeks. What ICD-10-CM codes are reported? I11.0, I50.9, J44.9 A 72 year-old female sustained a left radius fracture, resulting in volar angulation, radial shortening and loss of radioulnar inclination. General anesthetic was administered. A standard dorsal central approach to the wrist was made. The capsule was opened in a T fashion and the malunion site was identified. A series of osteotomes was utilized to open the fracture site and the normal distal radial architecture was restored. The pie-plate was placed on the distal radius utilizing a combination of 2.0 and 1.8 screws and threaded pins for the distal segment and 2.7 screws proximally. Fragments were secured, and Norian SRS was packed into the defect and allowed to harden. With this completed, the wounds were copiously irrigated with normal saline. Soft tissue was closed over the plate and distal radius secured with 2-0 Vicryl. What CPT ® code is reported? 25400-LT A 74 year-old male Medicare patient was admitted to a trauma center ED. The ambulance personnel notified the trauma center of expected time of arrival and gave pertinent information on the patient's condition. Upon arrival the patient was examined immediately by the ED physician. 2 hours and 40 minutes of critical care were provided before the patient was transferred to another hospital for his head injury. In addition to critical care services the following services were performed: intubation (31500), EKG (93005), chest X-ray (71045), CT of cervical spine without contrast (72125), and CT of the head without contrast (70450). The critical care did not include time for the procedures provided. Report the facility services. G0390, 99291-25, 99292-25 x 3, 31500, 93005, 71045, 72125, 70450 A 74 year-old man was admitted by ambulance to a rural hospital ED with severe shortness of breath. Soon after admission the patient went into cardiac arrest. The ED physician intubated the patient and he was placed on a ventilator. Critical care time was 65 minutes and the intubation (31500) was not included in the critical care time. EKG (93005), chest X-ray (71045), and blood gases (82803) were performed. The patient with known congestive heart failure was then transferred to a cardiac facility for acute hypertensive heart failure with pulmonary edema. Report the facility ED services and the ICD-10-CM code(s). 99291-25, 31500, 93005, 71045, 82803, I11.0, I50.1, 146.2 A 75 year-old male who is five days post-coronary bypass grafting, presents today to the Emergency Department with an acute MI. He has no prior history of MIs. In the hospital's cardiac catheterization unit, a cardiac catheterization reveals a fresh thrombus in the saphenous vein graft. PTCA is performed in addition to removal of the thrombus by aspiration. What are the correct CPT ® and ICD-10-CM codes for the procedure? 92941, T82.868A, I21.3, Z95.1 A 75 year-old Medicare patient with type I diabetes was admitted to the ED in a diabetic coma from a pump breakdown, in which he received too much insulin. He was treated in the ED and critical care time for the facility was 70 minutes. The patient was transferred to Observation for 8 hours prior to discharge. Report the facility charge and the diagnoses. 99291, G0378 x 8, T85.614A, T38.3X1A, E10.641 A 78 year-old female patient suffering from rheumatic arthritis and myopathy presents to the clinic's physical therapy department for 30 minutes of ultrasound treatments to the right hand with the physical therapist in continual attendance. What CPT ® and ICD-10-CM codes are reported for this service? 97035 x 2, M05.441 A benign lesion of the trunk measures 1.0 cm and the margin required to adequately excise the lesion includes 0.2 cm on both sides for a total margin of 0.4 cm. Provide the correct CPT® code(s). 11402 A cardiologist performed a transluminal atherectomy on the right femoral artery and the right popliteal vessel by percutaneous approach from the left femoral artery. Report the CPT code(s). 37225-RT A character's position can be understood as which type of classification that allows different specific values to be inserted into that space, and whose physical position remains stable? Semi-independent A child is seen in a hospital-based pediatric clinic for treatment of a first- and second-degree burn to the calf area of the right leg. What are the correct diagnosis codes for this patient encounter? T24.231A, T31.0 A child was admitted for an obstructed airway. The physician scheduled a flexible laryngoscopy. Finding nothing, he progressed to the trachea, then to the bronchial tubes. A biopsy was taken for an abnormal bronchial lesion and a lodged tiny Lego toy was found and removed. What CPT ® and ICD-10-CM codes are reported? 31635, 31625, T17.908A, J98.09 A child was seen in the hospital's pediatric clinic for an 18-month examination and immunization injections. An examination revealed an ear infection; therefore, no immunizations were given at that time. One month later, the child returned for a Hib, PRP-T vaccine. No other services were rendered. The nurse practitioner in the clinic counseled the parents on side effects and provided an information sheet on the vaccine. What CPT ® and ICD-10-CM codes are reported by the facility? 90471, 90648, Z23 A choledochal cyst is a cyst originating from which structure? Common bile duct A code from categories Q00-Q99 can be used until the patient reaches what age? Refer to ICD-10-CM guideline I.C.17. • They can be used throughout the life of the patient unless it has been corrected. A colonoscopy is performed on a Medicare patient for guaiac positive stools. An area of ulceration is noted in the igmoid region and the physician performs a biopsy. The excision of tissue causes bleeding which was controlled endoscop1cally with bipolar cautery. What CPT code is reported? 45380 A condition where the thyroid is overactive is called: Thyrotoxicosis A construction worker who was welding without goggles had a piece of metal embedded in the right eye. The patient was rushed to the emergency department where the ER physician examined the patient and provided a midlevel evaluation and management service. The ER E/M service was determined to be 99282. The ophthalmologist on call examined the patient and determined the foreign body would need to be removed surgically. Because the metal shaving was imbedded, the physician using a slit lamp, made a V shaped incision to penetrate the conjunctiva. The metal shaving was removed and the physician applied an antibiotic to the eye with a pressure patch over the lid. The patient was advised to visit the ophthalmology clinic the next day. Provide the facility CPT ® codes for the surgical service. 99282-25, 65210-RT A couple with inability to conceive has fertility testing. The semen specimen is tested for volume, count motility and a differential is calculated. The findings indicate infertility due to oligospermia. What CPT® and ICD-10-CM codes are reported by the facility? 89320, N46.11 A critical access hospital is: Answer: A facility in a rural area used for hospital inpatient stays, inpatient rehabilitation and psychiatric services, which also offers emergency services Rationale: Medicare beneficiaries in rural areas can receive services from critical access hospitals. CAHs offer 24-hour emergency services seven days a week, hospital inpatient stays, inpatient rehabilitation, and psychiatric services. A CT of the cervical spine C1-C4 was performed in the outpatient department of the hospital using contrast. What CPT® code is reported for the facility? 72126 [Show Less]
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COC 2020 Final Exam Study Questions - Set 1 (Complete Solutions, Answered)
COC 2020 Final Exam Study Questions - Set 1 (Complete Solutions, Answered) 14 year-old status post injury over one year ago to her left wrist presented w... [Show More] ith recurrent wrist pain. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. There was found to be mild synovitis in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. Using outside in technique, a PDS suture was placed across the TFCC and into the capsule. There was synovitis within the midcarpal joint, but there was no articular injury. All instruments were removed and the wounds were closed with interrupted nylon sutures. What CPT ® code is reported? 29846-LT 44-year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. The intraoperative mounting parameters, deformity parameters, and initial strut settings are inserted into the computer prior to Jim's discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) should be reported? 20697 56 year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages? 17311, 17312, 17315 66 year-old male with a history of anemia presents for a liver core biopsy to evaluate for possible cirrhosis. The patient was brought to the CAT scan suite in which limited CT images of the upper abdomen were performed for biopsy needle placement. The appropriate site for the liver core biopsy was chosen. The patient's skin was then marked with the computer coordinates. An 18-gauge needle was advanced into the appropriate site and a sample was obtained. What CPT ® codes are reported for the facility? 47000, 77012 A must include cholesterol, serum total (82465), Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), and Triglycerides (84478) Lipid Panel (80061) A patient presents to the hospital-based outpatient surgery department for a left knee medial meniscus repair. She had recurrent locking, swelling and catching of the knee. A diagnostic arthroscopy was performed. Under direct visualization, a medial portal was established and debridement of the posterior horn of the medial meniscus was performed. A shaver was then introduced to trim the meniscus back to a stable rim. The remainder of the knee was probed. The scope was then withdrawn and the wound was closed with #4-0 Vicryl. The discharge diagnosis was a bucket-handle tear of the medial meniscus. The patient tolerated the procedure well. What are the correct procedure and diagnosis codes for this encounter? 29881, S83.212A A 12 year-old child presents to the ED with an acute exacerbation of asthma. The patient is wheezing and is having difficulty breathing. She is not responding to the therapy. The physician documents as the final diagnosis asthma with status asthmaticus. What ICD-10-CM code(s) is/are reported? J45.902 A 12 year-old's diabetes mellitus is well controlled with oral antidiabetic medications . The patient has no complications. Applying the coding concept from ICD-10-CM guidelines I.C.4.a.l, I.C.4.a.2, and I.C.4.a.3, what ICD-10-CM code(s) is/are reported? E11.9, Z79.84 A 13 year-old is seen in the emergency department with a sudden onset of nausea, fever and diarrhea. A stool culture indicated Salmonella bacterium. The patient stated that she had been at a family reunion and recalls eating some salad, ice-cream and chicken. Diagnosis made was salmonella gastroenteritis. Report the diagnosis code(s) for the visit. A02.0 A 14-year-old male is brought to the ER by his parents after hitting his left knee on the base when sliding into base at a baseball game in a public park. After X-rays were obtained, it revealed a sprain to the knee. The patient was instructed to keep his leg elevated and keep weight off of it as much as possible for the next two weeks. What diagnosis codes are reported for this encounter? S83.92XA, W21.89XA, Y92.830, Y93.64 A 15 year old female undergoing treatment for Hodgkin's lymphoma presents to the behavioral health clinic to be evaluated for increasing acute panic attacks during her cancer treatments. The psychologist spent 1 hour and 15 minutes face-to-face with the patient. The patient was diagnosed with adjustment disorder with anxiety and a treatment plan was initiated. She will be seen for a reassessment in 30 days. What are the correct CPT ® and ICD-10-CM codes to report this service? 96150 x 5, F43.22, C81.90 A 15 year-old has been taken to surgery for crushing his index and middle fingers, injuring his digital nerves of the left hand. The physician located the damaged nerves in both fingers and sutures them to restore sensory function. What CPT® and ICD-10-CM codes are reported? 64831-LT, 64832-LT, S64.491A, S64.493A A 16 year-old male is brought to the ED by his mother. He was riding his bicycle in the park when he fell off the bike. The patient's right arm is painful to touch, discolored, and swollen. The X-ray shows a closed fracture of the ulna. What ICD-10-CM codes are reported? S52.201A, V18.0XXA, Y92.830 A 19 year-old female is seen in the hospital-based outpatient department for surgical implantation of birth control. Once prepped and draped, the surgeon makes a small incision in the skin on the inside of the patient's left upper arm. Using a trocar, six 3.0 cm Norplant II (Levonorgestrel) capsules are implanted subdermally. After all capsules were placed, the incision was closed with a simple repair. What are the correct procedure and diagnosis codes for this encounter? 11981, J7306, Z30.017 A 2 month-old is seeing his pediatrician for a routine health check examination. The physician notices a diaper rash and prescribes an ointment to treat it. What ICD-10-CM code(s) is/are reported? Z00.121, L22 A 2 year-old girl is brought to the ED. She is pulling on her ears. After examination, the ED physician determines the patient has acute serousotitis media in both ears. What diagnosis is reported? H65.03 A 21 year-old male is brought into the ED by his father who states that his son is dizzy and has anxiety. The ED provider runs a drug screen test and the test comes back positive for marijuana use. The final diagnosis is documented as marijuana abuse with anxiety disorder. What ICD-10-CM code is reported? F12.180 A 22 year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.l.d.l.b, what ICD-10-CM codes are reported (in the correct sequencing)? A41.9, R65.20, Nl7.9 A 22 year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened by a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and closed with sutures. What CPT ® code is reported? 20680-F4 A 22 year-old female suffered a 10-cm laceration on her cheek, a 4-cm laceration on her chin, and a 9-cm laceration on the dorsum of her right hand when she slipped on loose pavement while riding her bicycle. All lacerations were contaminated with dirt and gravel and required cleansing with debridement and copious saline irrigation before layered closure. How should this be coded? 13132, 13133 x 4 A 22 year-old is in an outpatient facility for an inguinal hernia repair. Just before surgery, the surgeon discovers the patient is positive for MRSA and the surgery is canceled. Which ICD-10-CM code(s) should be reported for the outpatient service? K40.90, A49.02, Z53.09 A 22 year-old is taken to the ED by her husband. She is in her 16th week of pregnancy and is experiencing dizziness and swelling in the hands and feet. The ED physician performs a detailed history and examination. Final assessment is mild preeclampsia with edema. She is instructed to follow-up with her OB physician tomorrow. What diagnosis and CPT codes are reported for this mid-level visit? 99283, O14.02, Z3A.16 A 24 year-old woman developed a keloid scar as a result of a third degree burn on the left upper arm. What ICD-10-CM code(s) is/are reported? L91.0, T22.332S A 25 year-old female presents to the same day surgery unit for the removal of a dislodged plastic biliary stent. The esophagogastroduodenoscope was inserted in the posterior oropharynx. The previously placed stent, which is now dislodged was identified in the upper duodenum and was removed with a polypectomy snare. What CPT® code is reported for the procedure? 43247 A 26 year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia was harvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high-speed drill, a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT ® code is reported? 69631-LT A 26 year-old male patient with left lower-lobe bronchial cancer has an obstructed bronchus in the left lower lobe of the lung. Airway is viewed using a flexible bronchoscope introduced through the oral airway, following administration of conscious sedation. Fluoroscopic guidance assists in identifying the obstruction. A laser probe is introduced through the scope to eradicate and relieve the tumor obstruction. What CPT ® and ICD-10-CM codes are reported? [Show Less]
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