CPC Certified Professional Coder (CPC) Exam Questions and Answers

For Mohs micrographic surgery, CPT® coding is based on the anatomic location of the lesion, the number of stages, and the number of tissue blocks per stage.

17311: This code is used for Mohs surgery on body areas such as the trunk, arms, or legs for the first stage.

17315: This is an add-on code used when more than five tissue blocks are examined in a single stage. Since this case involved six tissue blocks, 17315 is appropriate.

Explanation of incorrect answers:

A. 17313, 17314, 17315: Incorrect, as 17313 applies to the head, neck, hands, feet, or genitalia, not the arm.

C. 17313, 17315: Incorrect, as 17313 is not appropriate for the arm.

D. 17311, 17312, 17315: 17312 is used for additional stages beyond the first, which is not applicable here since only one stage was performed.

E. 85B2-335 is not a valid CPT code for Mohs surgery.

Thus, the correct answer is B. 17311, 17315, which accurately reflects a single-stage Mohs surgery with six tissue blocks on the arm.

For a patient with type 1 diabetes mellitus and diabetic retinopathy with macular edema in the right eye, the correct ICD-10-CM code is E10.3511. This code specifically captures:

E10: Type 1 diabetes mellitus.

35: Diabetic retinopathy with macular edema.

1: Right eye.

Each choice addresses different severities or eye specifications:

A. E10.3211: Indicates mild nonproliferative diabetic retinopathy with macular edema in the right eye, not the general diabetic retinopathy category.

B. E10.3519: Refers to diabetic retinopathy with macular edema without specification to the right eye.

D. E10.311: Refers to nonproliferative diabetic retinopathy without macular edema in the right eye.

Thus, the correct answer is C. E10.3511, as it fully captures type 1 diabetes with diabetic retinopathy with macular edema in the right eye.

1. Procedure and CPT® Code Selection:

The procedure described is a craniectomy to access and remove a supratentorial intracerebral hematoma using a suction device.

CPT® Code 61314 is specific for a craniectomy or craniotomy for evacuation of a hematoma, supratentorial (within the upper portion of the brain), and includes any required dural repair and closure. This code precisely describes the procedure performed to remove the hematoma.

2. Rationale for Excluding Other Options:

Code 61154 is used for a burr hole procedure for the evacuation of a hematoma, which is a less invasive approach and does not involve a craniectomy.

Code 61313 is for a craniectomy or craniotomy to evacuate an infratentorial hematoma, which is located in the lower portion of the brain (posterior fossa) and is not applicable here.

Code 61312 is for evacuation of an epidural or subdural hematoma and does not apply to an intracerebral hematoma as described in this case.

3. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 61314 is the appropriate code for craniectomy procedures aimed at removing supratentorial intracerebral hematomas, as it covers the full scope of the documented procedure.

Thus, the correct answer is A. 61314.

1. Procedure Type: This scenario describes a secondary repair of two extensor tendons in the wrist with a free graft. According to CPT® coding guidelines, the secondary repair with a free graft suggests a more complex repair than primary closure.

2. CPT® Code Selection:

Code 25270 is used for a primary repair of an extensor tendon in the forearm or wrist. Since this is a secondary repair, 25270 does not apply, ruling out options A and C.

Code 25272 represents the repair of a single extensor tendon in the forearm or wrist, which includes both primary and secondary repairs. However, it does not involve free grafts, ruling out option D.

Code 25274 specifically addresses the secondary repair of an extensor tendon with free graft in the forearm or wrist, which is the correct scenario described in the question.

3. Applying the Code for Multiple Tendons:

Since the procedure involves two tendons, 25274 should be reported twice (25274 x 2) to account for the secondary repair on each tendon individually.

4. Reference from AAPC CPC Guidelines:

In AAPC CPC and CPT® coding principles, tendon repair codes require careful distinction between primary repairs and secondary repairs with grafts. The guidelines specify that multiple tendons should be coded with individual codes when performed on separate anatomical structures, hence the use of 25274 twice for both tendons.

Therefore, the verified and precise answer based on CPT® guidelines and AAPC coding standards is B. 25274 x 2.

The CPT code 10005 is for fine needle aspiration biopsy, including ultrasound guidance, for the first lesion. CPT code 10006 is for each additional lesion with ultrasound guidance. Since the provider aspirated tissue from three nodules, the coding should be 10005 for the first nodule and 10006 x 2 for the additional two nodules.References: AMA's CPT® Professional Edition (current year)

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)

Bilateral salpingo-oophorectomy: This involves the removal of both fallopian tubes and ovaries.

Right and left fallopian tubes: Both fallopian tubes are removed.

Left ovary: Only the left ovary is removed.

Abdominal incision: The procedure is performed via an abdominal approach.

58720: Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure).

The procedure involves the removal of both fallopian tubes and one ovary, making 58720 the appropriate code.

References:

AMA's CPT® Professional Edition (current year)

ICD-10-CM (current year), HCPCS Level II (current year)

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

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)

Medicare Part B provides coverage for outpatient services, including physician services, preventive care, outpatient procedures, diagnostic tests, and durable medical equipment. Part B is a key component of Medicare, covering medically necessary services and some preventive services.

A. Part C (Medicare Advantage) includes all benefits and services covered under Parts A and B and often additional services, but it is provided through private insurance companies.

C. Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health services.

D. Part D provides coverage for prescription drugs.

Therefore, the correct answer is B. Part B.

CPT Code 00811: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing

This code is reported for anesthesia services provided during a colonoscopy that is diagnostic in nature.

ICD-10-CM Code D62: Acute posthemorrhagic anemia

This is the most accurate postoperative diagnosis. The operative report states "Anemia due to acute blood loss."

ICD-10-CM Code N18.6: End stage renal disease

This code captures the patient's documented history of ESRD.

ICD-10-CM Code Z99.2: Dependence on renal dialysis

This code is necessary to report the patient's dialysis status, as it affects the overall risk of the procedure.

Why other options are incorrect:

00812: This code is for therapeutic colonoscopies, not diagnostic.

D64.9: This code is for anemia, unspecified. D62 is more specific to the patient's condition.

K62.5: This code is for lower gastrointestinal bleeding, but the anemia is the primary diagnosis in this case.

References:

CPT Code 00811: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing

ICD-10-CM Code D62: Acute posthemorrhagic anemia

ICD-10-CM Code N18.6: End stage renal disease

ICD-10-CM Code Z99.2: Dependence on renal dialysis

AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.

For this scenario, two surgeons are working together, each as a primary surgeon. Therefore, the correct coding requires the use of the modifier -62, which indicates co-surgeons.

The transthoracic approach to excise the damaged portion of the vertebral body is coded with 63087.

The insertion of the bone graft and metal plate is coded with 63088.

Both codes are appended with modifier -62 to indicate that two surgeons worked together as primary surgeons on this case.

References:

AMA's CPT® Professional Edition (current year)

ICD-10-CM (current year)

HCPCS Level II (current year)

Modifier 53 is used to report a discontinued procedure. It indicates that a procedure was started but terminated due to the patient's well-being being at risk. In this scenario, the percutaneous transluminal coronary angioplasty was attempted but stopped because of an anatomical problem that created a risk for the patient, preventing the completion of the procedure.References: AMA's CPT® Professional Edition, coding guidelines on the use of modifiers.

The emergent endovascular repair of an infrarenal abdominal aortic aneurysm with an aorto-aortic tube endograft is coded with CPT 34702. This code includes the deployment of the endograft and the necessary balloon angioplasty for sealing the proximal and distal attachment zones.

References:

AMA's CPT® Professional Edition (current year)

For a patient with a mass in the left lower lung suspected to be cancer that is currently documented as a tumor of uncertain behavior, with existing ovarian cancer with metastases to the liver, the ICD-10-CM codes are:

D38.1: Neoplasm of uncertain behavior of bronchus and lung.

C56.9: Malignant neoplasm of unspecified ovary.

C78.7: Secondary malignant neoplasm of liver and intrahepatic bile duct.

D38.1 is used because the behavior of the lung tumor is uncertain, and C56.9 and C78.7 are used to document the known primary and metastatic cancers.

References:

ICD-10-CM guidelines

AMA's CPT® Professional Edition (current year)

For a mastectomy that involves removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes, the appropriate CPT® code is:

19306: Mastectomy, radical, including pectoral muscles, axillary lymph nodes.

This code captures the extent of the surgery, including the removal of the breast tissue, skin, pectoral muscles, and lymph nodes.

References:

CPT® Professional Edition (current year)

Surgery guidelines for mastectomy procedures

For a physician who owns the equipment and interprets the chest X-rays (both frontal and lateral views), code 71046 is used. This code includes both the technical and professional components, as the equipment is owned by the physician group and the physician also provides the interpretation.

References:

AMA's CPT® Professional Edition (current year)

ICD-10-CM (current year)

1. Procedure and CPT® Code Selection:

The emergency department physician placed an indwelling catheter into the lumbar region for continuous infusion for pain management with fluoroscopic guidance.

CPT® Code 62327 is appropriate for injection or catheter placement for continuous infusion of anesthetic or analgesic in the lumbar or sacral region using imaging guidance.

CPT® Code 77003 represents the fluoroscopic guidance used during the catheter placement, which is separately reportable in this case.

2. Rationale for Excluding Other Options:

Code 62326 (in options B and D) is for the injection or catheter placement without imaging guidance. Since fluoroscopic guidance was specifically mentioned, 62327 is the appropriate choice.

Code 77003 must be reported separately when fluoroscopy is used in conjunction with 62327 for pain management catheter placement.

3. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, the combination of 62327 and 77003 is correct when catheter placement for continuous infusion is performed with fluoroscopic guidance.

Therefore, the correct answer is C. 62327, 77003.

The patient is undergoing a cardiac catheterization with a CRNA providing monitored anesthesia care (MAC). Code 00520 is for anesthesia for heart catheterization procedures. Modifier QX indicates CRNA service with medical direction by a physician, QS indicates MAC, and P5 indicates a patient with a severe systemic disease that is a constant threat to life. Thus, the correct code and modifier combination is 00520-QX-QS-P5.References: CPT® Professional Edition (current year), AMA.

For a follow-up examination after the removal of polyps with no new polyps found, the appropriate diagnosis codes are:

Z09: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm.

Z86.010: Personal history of colonic polyps.

Using Z09 indicates that the follow-up exam is to check the patient after treatment, and Z86.010 indicates a history of colonic polyps, which is relevant to the patient's medical history.

References:

ICD-10-CM guidelines

AMA's CPT® Professional Edition (current year)

When a patient experiences an underdose of insulin due to an insulin pump malfunction, the primary reason for the encounter would be the malfunction itself, which is coded first. The resulting hyperglycemia or hypoglycemia due to the pump failure is a secondary condition. According to ICD-10-CM guidelines, the code for the mechanical complication of the pump (T85.633-) is sequenced first, followed by a code for the diabetes with complication (E11.65 for type 2 diabetes with hyperglycemia).References: ICD-10-CM (current year), Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88), ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.4.

To determine the correct anesthesia code for a cesarean delivery with specific conditions, we review the following codes:

01961 is defined as "Anesthesia for cesarean delivery only," which aligns with this scenario, as the patient is admitted for a cesarean section.

01960 refers to anesthesia for a vaginal delivery, which does not apply here as the delivery is via cesarean.

01967 is for "Anesthesia for planned vaginal delivery," which also does not apply due to the cesarean route.

01958 is used for planned vaginal delivery that may involve a complicated scenario, but since the procedure is a cesarean section, this code is not appropriate.

Given that the patient is in labor for a cesarean section and has had a previous external cephalic version, 01961 is the correct answer.

The human shoulder is composed of three main bones: the clavicle (collarbone), scapula (shoulder blade), and humerus (upper arm bone). These bones form the shoulder joint, which is one of the most flexible and mobile joints in the human body, allowing for a wide range of motion.References: AMA's CPT® Professional Edition (current year), Musculoskeletal System section.

The correct CPT® code for a therapeutic drug test to monitor the total level of carbamazepine is 80156. The ICD-10-CM code G40.909 is used for epileptic seizures, not otherwise specified, which aligns with the patient's condition being treated for seizures.

References:

AMA's CPT® Professional Edition (current year)

ICD-10-CM (current year)

In the CPT® code book, code 35860 describes an "Exploration for postoperative hemorrhage, thrombosis or infection" in multiple areas, specifically including the neck, chest, abdomen, and/or extremity. This code is used when a surgeon explores these areas postoperatively to locate and address complications such as bleeding, clots, or infections.

B, C, and D are incorrect as they do not fully encompass all the areas listed in the actual description of CPT® code 35860, which includes all four regions (neck, chest, abdomen, and extremity).

Thus, the correct answer is A. Exploration for postoperative hemorrhage, thrombosis or infection; neck, chest, abdomen, and/or extremity.

For initial fracture care of a closed scaphoid fracture, code 25622 is used, which includes treatment and initial casting. The application of the cast is part of the fracture care and is not reported separately. CPT® guidelines specify that casting or strapping performed as part of the fracture care is included in the fracture care code.References: AMA's CPT® Professional Edition (current year), Surgery section, Musculoskeletal System.

1. Procedure and CPT® Code Selection:

The patient underwent a cardiac MRI to assess the morphology and function of the heart under stress, involving both non-contrast and contrast-enhanced imaging. Additionally, pharmacological stress testing was performed to evaluate the coronary arteries.

CPT® Code 75563 is appropriate for a cardiac MRI with both stress and rest imaging, including morphology and function studies with contrast and pharmacologic stress testing. This code accurately captures the entire scope of the MRI study described in this case.

Modifier 26 is applied to indicate the professional component of the service if the cardiologist is providing only the interpretation and not the technical component.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code I25.118 is used for atherosclerotic heart disease with unstable angina. This code accurately reflects the diagnosis provided in the scenario.

3. Rationale for Excluding Other Options:

Code 75559 (option B) represents a cardiac MRI without stress testing, which does not cover the pharmacologic stress component performed here.

Code 75557 (in option D) is for a limited cardiac MRI that does not include both stress and non-stress imaging, so it is incorrect for this comprehensive test.

ICD-10-CM Code I25.110 (in options C and D) is for atherosclerosis with angina pectoris without unstable angina, making I25.118 more appropriate given the diagnosis of unstable angina.

4. AAPC and CPT® Coding Guidelines:

AAPC and CPT® guidelines support the use of 75563 for comprehensive cardiac MRI studies with stress testing, both with and without contrast.

Therefore, the correct answer is A. 75563-26, I25.118.

The procedure described involves a LeFort I reconstruction, which is a type of orthognathic surgery performed to correct deformities of the midface. In this scenario, the surgeon performed the reconstruction in two pieces, moving the upper jawbone forward and repositioning the teeth of the maxilla. According to the CPT® guidelines, CPT code 21146 describes a LeFort I (maxilla only) osteotomy, two-piece segment, including bone grafts (includes obtaining autografts). This code matches the description provided.

References:

AMA's CPT® Professional Edition (current year), Code 21146

1. Procedure and CPT® Code Selection:

The obstetric panel ordered includes the following tests: syphilis screening (non-treponemal), automated CBC with manual differential WBC count, HBsAg, rubella antibody, serum antibody screen, and ABO/Rh blood typing.

CPT® Code 80055 is for a comprehensive obstetric panel that includes all these components. This code is intended to report the entire panel of tests as a bundled service rather than itemizing each individual test.

2. Rationale for Excluding Other Options:

Option B lists the individual component codes for each test in the obstetric panel (e.g., 85027, 85007, 87340, etc.), but using 80055 is more appropriate because it provides a single code to report the full obstetric panel and follows CPT® bundling guidelines.

Option C also lists the individual tests separately, which is unnecessary when 80055 includes all these components.

Option D lists 80081, which is for an obstetric panel that includes HIV testing. Since HIV testing is not part of the tests described in this scenario, 80081 is incorrect.

3. AAPC and CPT® Coding Guidelines:

AAPC guidelines recommend using the single code 80055 when all components of an obstetric panel are ordered together, as itemizing each test individually is not necessary.

Therefore, the correct answer is A. 80055.

In medical billing, Place of Service (POS) code 31 is used to indicate that a service was performed in a skilled nursing facility (SNF). POS codes are standardized by the Centers for Medicare & Medicaid Services (CMS) to specify the location where services are provided.

A. 32 refers to a nursing facility (NF), which is different from a skilled nursing facility in terms of the level of care provided.

B. 20 indicates urgent care facility.

C. 22 is used for outpatient hospital services.

Thus, the correct answer is D. 31 for a skilled nursing facility.

The CPT code 12002 is used for simple repair of superficial wounds of 2.5 cm or less. This code includes the repair of both the 3 cm laceration on the right arm and the 2 cm laceration on the nose as both are simple repairs. The other options suggest more complex repairs or multiple separate procedures, which are not necessary in this scenario.References: AMA's CPT® Professional Edition (current year)

A diagnostic mammogram performed on both breasts with computer-aided detection (CAD) is reported with CPT® code 77066. This code is used when CAD is utilized to further analyze the images for possible lesions, and it covers both breasts.

References:

AMA's CPT® Professional Edition (current year)

1. Procedure and CPT® Code Selection:

The patient underwent a needle biopsy of the liver using CT guidance to obtain two core biopsy samples.

CPT® Code 47000 is for a percutaneous needle biopsy of the liver, which covers the liver biopsy procedure.

CPT® Code 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 CPT® Coding 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.

In this case, a CRNA provided anesthesia for an urgent endoscopic procedure. To select the appropriate codes, we consider both the anesthesia code for the procedures performed and the modifiers relevant to the CRNA’s role and the patient’s physical status:

1. 00813: This CPT® code covers "Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum," which is appropriate since the colonoscopy extended to the ileum and into the lower duodenum. 00731 (anesthesia for upper GI endoscopy) would not fully apply, as the main procedure targeted lower intestinal areas as well.

2. QZ Modifier: Indicates the anesthesia was performed by a CRNA without medical direction by an anesthesiologist, which aligns with the scenario where the CRNA independently administered anesthesia.

3. P3 Modifier: Reflects the physical status of "severe systemic disease" for this patient, as she has both end-stage renal failure and myelodysplastic syndrome.

4. 99100: This code is added to reflect "special anesthesia circumstances" given the patient’s extreme frailty (platelet count of 3,000), which warrants additional consideration.

5. 99140: Used for emergency conditions, which applies here due to the urgent nature of the bleeding investigation.

Thus, 00813-QZ-P3, 99100, 99140 accurately reflects the anesthesia services provided by the CRNA in this emergency scenario.

The knee joint consists of three primary compartments:

1. Medial compartment: The inside part of the knee, which includes the femur and tibia interaction on the inner side.

2. Lateral compartment: The outside part of the knee, where the femur and tibia meet on the outer side.

3. Patellofemoral compartment: The area between the patella (kneecap) and the femur.

These three compartments are essential for knee joint stability and function, allowing movement and weight-bearing activities.

B. Trochlea groove and vestibular are not associated with knee anatomy.

C. Posterior malleolus, scapula, and fibular facet do not relate to knee compartments; the malleolus is in the ankle, scapula in the shoulder, and fibular facet is not part of the primary knee compartments.

D. Cochlea is unrelated to knee anatomy and refers to a part of the inner ear.

Thus, the correct answer is A. Medial, lateral, and patellofemoral.

Procedure: Abdominal aorta catheterization and selective placement in the celiac trunk for angiography.

CPT® Codes:

36246: This code is for the catheter placement in the abdominal aorta.

75726-26: This code represents the abdominal angiography with supervision and interpretation, with the -26 modifier indicating the professional component.

Code Selection Justification: The procedure involves the catheterization of the abdominal aorta and the specific imaging performed with supervision and interpretation.

References:

AMA CPT® Professional Edition (current year)

ICD-10-CM (current year)

HCPCS Level II (current year)

CPT code 19081 is used for percutaneous biopsy of breast(s) using stereotactic guidance, which includes the placement of a localization device and imaging of the biopsy specimen when performed. This accurately describes the procedure performed on the right breast with the placement of a Gelmark clip using stereotactic imaging. The other codes either describe open biopsies or separate procedures that are not applicable here.References: AMA's CPT® Professional Edition (current year)

The CPT code 11960 is used for the insertion of tissue expanders for other than breast, which includes the scalp in this case. The procedure involves inserting the tissue expanders, closing the skin, and gradually increasing the volume of the expanders until a satisfactory outcome is achieved for repairing the scalp defect. The other options do not accurately describe the procedure performed on the scalp.References: AMA's CPT® Professional Edition (current year)

1. E/M Code Category Selection:

The patient was placed in observation care on 12/2/20XX for an acute asthma exacerbation and stayed in observation for a total of 16 hours, with discharge occurring on 12/3/20XX.

The appropriate E/M category for patients in observation care for a period that includes both admission and discharge on separate calendar dates is "Hospital Inpatient or Observation Care Services", with specific codes for admission and discharge on different dates.

2. Code Range and Specific Codes:

Code Range 99234-99236 applies to cases where observation care includes both admission and discharge, particularly when they occur on different calendar days and the total duration of care is under 24 hours.

For discharge on the subsequent day, 99238-99239 (Hospital Inpatient or Observation Discharge Services) applies, depending on the time spent on discharge.

3. Rationale for Excluding Other Options:

Option B and Option D include Initial Hospital Inpatient or Observation Care codes (99221-99223), which are typically used for admissions to inpatient care rather than for observation care scenarios as presented here.

Option C incorrectly combines Subsequent Inpatient or Observation Care codes (99231-99233), which are used for follow-up days rather than discharge services.

4. AAPC and CPT® Coding Guidelines:

According to CPT® guidelines, the 99234-99236 code range is used when observation care requires both admission and discharge on different dates, and 99238-99239 is appropriate for discharge services.

Therefore, the correct answer is A. Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services) (99234-99236) and Hospital Inpatient or Observation Discharge services (99238-99239).

According to ICD-10-CM coding guidelines for substance use, abuse, and dependence, when multiple levels (use, abuse, and dependence) of the same substance are documented, only the highest level of severity is coded. The hierarchy is as follows: dependence > abuse > use.

D. If both use and dependence are documented, assign only the code for dependence is correct, as dependence represents the highest severity level and supersedes both use and abuse.

A. is incorrect because if both use and abuse are documented without dependence, only abuse would be coded as it is of a higher severity than use.

B. is incorrect because all three codes (use, abuse, dependence) should not be reported together; only the highest level should be coded.

C. is incorrect because if both abuse and dependence are documented, only dependence (the higher severity level) should be coded, not abuse.

Therefore, the correct answer is D. If both use and dependence are documented, assign only the code for dependence.

1. Procedure and CPT® Code Selection:

The patient underwent a 7-view X-ray of the lumbosacral spine, which included bending views. A complete set of views is captured.

CPT® Code 72114 is appropriate for a complete lumbosacral spine X-ray with a minimum of six views. This code includes comprehensive imaging, such as bending and other specialized views, which were taken in this scenario.

2. Rationale for Excluding Other Options:

Code 72020 is for a single-view X-ray of the spine, which is not adequate to describe a 7-view series.

Code 72080 is for a two- or three-view X-ray of the thoracolumbar spine, which does not cover the full set of seven views described in this scenario.

Code 72084 represents a complete thoracic spine study with multiple views but does not specifically cover the lumbosacral spine, which is the focus of this X-ray examination.

3. AAPC and CPT® Coding Guidelines:

According to AAPC and CPT® guidelines, 72114 is the correct choice for a complete lumbosacral spine study involving multiple views, including specialized views like bending.

Therefore, the correct answer is C. 72114.

1. Procedure and CPT® Code Selection:

The patient underwent a bilateral excisional vasectomy for sterilization.

CPT® Code 55250 represents a bilateral vasectomy with excision, which includes postoperative care. The code already implies a bilateral procedure, so it is not necessary to add the -50 modifier for bilateral designation.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code Z30.2 is used for encounter for sterilization and is the correct code to report for a planned sterilization procedure such as a vasectomy.

Code Z30.012 is specific to encounter for sterilization of a female patient, which does not apply in this male patient scenario.

3. Rationale for Excluding Other Options:

55250-50 (in options C and D) is unnecessary because the CPT® code 55250 inherently covers a bilateral vasectomy, and applying the -50 modifier is redundant.

Z30.012 (options B and D) is incorrect as it pertains to female sterilization procedures, not male.

4. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 55250 is reported without a bilateral modifier, as the procedure inherently covers both sides. Additionally, Z30.2 is the correct ICD-10-CM code for male sterilization procedures.

Thus, the correct answer based on CPT® and ICD-10-CM guidelines is A. 55250, Z30.2.

An esophagogastroduodenoscopy (EGD) was performed with the removal of a polyp using hot biopsy forceps.

Procedure Description:

An EGD was performed.

A polyp was found in the duodenum and removed with hot biopsy forceps.

CPT® Coding:

43250: Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.

References:

AMA's CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on endoscopic procedures.

1. Procedure and CPT® Code Selection:

The patient underwent a suppression study involving five glucose tests and five human growth hormone tests.

CPT® Code 80430 represents a suppression panel specifically for growth hormone studies, which includes various assessments for diagnosing abnormal growth.

CPT® Code 82947 is used for each glucose test performed, and since five glucose tests were conducted, it should be coded as 82947 x 5.

CPT® Code 83003 is used for each human growth hormone test performed, and since five tests were conducted, it should be coded as 83003 x 5.

2. Rationale for Excluding Other Options:

Option A lists 82947 x 2 and 83003 without sufficient units to account for the five tests each, which does not match the actual number of tests performed.

Option B omits the suppression panel code 80430, which is necessary for documenting the overall suppression study.

Option D does not provide the correct quantity of glucose and growth hormone tests, which were each performed five times.

3. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, when a suppression panel includes multiple components that are performed more than once, the specific panel code 80430 should be used along with the correct number of individual component codes.

Therefore, the correct answer is C. 80430, 82947 x 5, 83003 x 5.

The adenoids, tonsils, appendix, and spleen are all part of the lymphatic system, which plays a crucial role in immune function and the filtration of pathogens. These organs contribute to the body's defense by trapping and eliminating bacteria and other pathogens.

Adenoids and tonsils are lymphatic tissues located in the throat and help prevent infection by filtering pathogens from inhaled or ingested particles.

The appendix contains lymphoid tissue and is thought to play a role in gut immunity.

The spleen filters blood, removing old or damaged blood cells and producing lymphocytes for immune response.

The other options are unrelated:

B. Gastrointestinal: Involved in digestion, but not specifically immune response.

C. Cardiovascular: Involved in blood circulation, not immune response.

D. Nervous: Coordinates sensory and motor functions, unrelated to lymphatic tissue.

Therefore, the correct answer is A. Lymphatic.

Procedure: Visual field examination of both eyes using Goldmann perimeter testing with four isopters.

CPT® Code:

92082: This code is for visual field examination with intermediate examination.

ICD-10-CM Code:

G43.009: Migraine without aura, not intractable, without status migrainosus.

Code Selection Justification: The visual field exam method and complexity align with 92082. The patient's diagnosis of non-intractable migraine without aura is coded as G43.009.

References:

AMA CPT® Professional Edition (current year)

ICD-10-CM (current year)

1. Procedure and CPT® Code Selection:

The patient underwent an open partial colectomy involving the removal of the proximal colon and terminal ileum with reconnection of the distal ileum to the remaining colon.

CPT® Code 44160 is specific for an open partial colectomy with removal of a portion of the colon and the terminal ileum with an ileocolostomy (reconnection of the ileum to the colon). This accurately describes the procedure performed.

Code 44140 is for a partial colectomy without removal of the terminal ileum, making it inappropriate in this case.

Codes 44205 and 44204 involve laparoscopic approaches for colectomy procedures, but since this procedure was open, these codes are not suitable.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code C18.2 is for a malignant neoplasm of the ascending colon, which is specified in this case as colon adenocarcinoma.

Code C18.9 represents an unspecified malignant neoplasm of the colon, which is less specific than C18.2. Therefore, C18.2 is the most accurate choice based on the location of the adenocarcinoma.

3. AAPC and CPT® Coding Guidelines:

Per AAPC guidelines, selecting the correct colectomy code involves identifying the specific approach (open vs. laparoscopic) and anatomical structures resected, both of which align with 44160 for this open ileocolic resection.

Thus, the correct answer, based on CPT® and ICD-10-CM guidelines, is D. 44160, C18.2.

The patient has undergone a left total knee arthroplasty and subsequently received a femoral nerve block for postoperative pain management. CPT code 01402 is used for anesthesia for total knee arthroplasty. Code 64447-59-LT is for a femoral nerve block (single injection) for postoperative pain management, with modifier 59 indicating a distinct procedural service and LT indicating the left side. Therefore, the appropriate codes are 01402 and 64447-59-LT.References: CPT® Professional Edition (current year), AMA.

For a patient diagnosed with sepsis and associated acute respiratory failure, the ICD-10-CM codes are:

A41.9: Sepsis, unspecified organism.

R65.21: Severe sepsis with septic shock.

J96.00: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia.

These codes appropriately capture the severity of the sepsis and the presence of acute respiratory failure.

References:

ICD-10-CM guidelines

AMA's CPT® Professional Edition (current year)

The spleen is a part of the lymphatic system, which is responsible for filtering blood, removing damaged blood cells, and supporting immune function. The spleen contains lymphocytes that help fight infections and regulate the immune response.

A. Nervous: The nervous system includes the brain, spinal cord, and nerves, unrelated to immune function.

B. Endocrine: The endocrine system regulates hormones through glands like the thyroid and pancreas, not directly involved with blood filtration or immune cell production.

C. Digestive: While the spleen is located near digestive organs, it does not play a role in digestion.

Thus, the correct answer is D. Lymphatic.

Procedure: Caloric vestibular testing performed on both ears with three irrigations.

CPT® Code:

92537: Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear).

Modifier -50: Bilateral procedure.

Code Selection Justification: The procedure performed was bilateral caloric vestibular testing with bithermal irrigation, appropriately coded with 92537 and modifier -50 for bilateral procedures.

References:

AMA CPT® Professional Edition (current year)

According to the CPT® guidelines for Repair (Closure), an intermediate repair includes the closure of a wound with one or more layers of subcutaneous tissue and superficial fascia in addition to the skin (epidermal and dermal) closure. It also involves extensive cleaning of the wound, which includes copious irrigation and the removal of particulate matter. This description fits the scenario provided in the question.References: AMA's CPT® Professional Edition, Repair (Closure) guidelines.

The mediastinum is an anatomical region located in the thoracic cavity. It is bounded by the sternum in front, the vertebral column at the back, and is situated between the lungs. It contains the heart, trachea, esophagus, thymus, and other structures, but it is not itself an organ. Therefore, the correct answer is that it is a location in the chest.References: ICD-10-CM, Medical Anatomy and Physiology textbooks

1. Procedure and CPT® Code Selection:

The patient underwent a thyroidectomy for malignancy in the right lobe, as well as the removal of the parathyroid gland due to a suspected malignant lesion.

CPT® Code 60505 is for the parathyroidectomy with exploration of parathyroid glands and is appropriate for the removal of the parathyroid gland due to a suspected malignancy.

CPT® Code 60220 represents a thyroid lobectomy (total removal of one lobe of the thyroid), which applies to the removal of the right thyroid lobe in this case.

2. Modifier 59:

Modifier 59 is added to 60220 to indicate that the thyroid lobectomy is a distinct procedure from the parathyroidectomy, performed in a separate anatomical site during the same surgical session.

3. Rationale for Excluding Other Options:

Code 60500 (in options A and C) is for a parathyroid exploration only, not including the actual removal of the parathyroid gland, so it does not apply here.

Code 60240 (in option D) is for a total thyroidectomy, which involves removal of the entire thyroid gland. Since only the right lobe was removed, 60220 (thyroid lobectomy) is correct.

4. AAPC and CPT® Coding Guidelines:

Per AAPC guidelines, 60505 is the appropriate code for parathyroidectomy procedures involving exploration or suspected malignancy, and 60220 with Modifier 59 accurately reflects the separate and distinct thyroid lobectomy procedure.

Thus, the correct answer is B. 60505, 60220-59.