Question 1

Gross Description: Specimen labeled "sesamoid bone, first metatarsal, right" is received in formalin. Contains three irregular fragments of grey-brown, hard, bony tissue. Multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 2.8 x 1.7 x 0.8 cm. Specimen was decalcified and gross examination showed acute osteomyelitis, with foci of marrow fibrosis.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct answer is C because it includes the codes for decalcification (88300) and gross examination (88311-51), which are necessary for the diagnosis of acute osteomyelitis.

Question 2

Clinical history: Nevus, R pinna
Postoperative diagnosis: same
Tissue/specimen: skin of external ear nevus of R pinna
Impression: microscopic sections show the specimen shows a nevus identified as a melanoma of right ear and auricular canal.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

CPT code 88305 is used for pathology examination of skin specimens, and ICD-10-CM code C43.21 is for melanoma of the right ear and external auricular canal.

Question 3

Preoperative Diagnosis: Kidney Mass
Postoperative Diagnosis: Kidney Mass
Operation: Kidney Biopsy
Operation Description: A 20-year-old male was noted to have a kidney mass per the ultrasound results. Patient was advised to have a kidney biopsy of the mass. All risks understood and consent obtained. The patient was prepped in the outpatient surgical unit. A single needle biopsy was obtained of the kidney. The radiologist assisted the surgeon with the procedure. The kidney biopsy was sent to the pathology department. The patient entered the recovery room in stable condition.
Select the appropriate CPT and ICD-10-CM codes for the service(s) of the surgeon only.

Accepted Answer

The correct CPT code for a kidney biopsy performed by a surgeon is 50200. The ICD-10-CM code N28.89, which represents other specified disorders of the kidney and ureter, is appropriate as the specific nature of the kidney mass is not identified in the provided information.

Question 4

Preoperative Diagnosis: Dysfunctional Uterine Bleeding
Postoperative Diagnosis: Dysfunctional Uterine Bleeding
Operation: Dilation and Curettage
Operation Description: A 32-year-old woman was diagnosed with dysfunctional uterine bleeding. The physician ordered a dilation and curettage (D&C) to be performed. Risks of the operation, such as infection, were discussed. The patient understood all risks and wanted to proceed with the operation. Consent was obtained. The patient was prepped and draped in the usual sterile fashion in the operating room. The D&C procedure was performed. The patient was in good stable condition and brought to the recovery room.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Preoperative Diagnosis: Dysfunctional Uterine Bleeding
Postoperative Diagnosis: Dysfunctional...

Question 5

Patient presents for cesarean section with no other deliveries or pregnancies noted in the chart. She was prepared and draped in the usual sterile manner for an abdominal procedure. An incision was made and carried down through the subcutaneous tissue, muscular fascia, and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was then removed as well. With removal of the placenta and baby, cord blood was obtained.
The infant was handed off to the nurses in attendance. We then closed the uterine incision in the usual manner. A Foley catheter had been inserted. Clear urine was noted. The patient was then awakened and taken to the recovery room in good condition.
Select the appropriate CPT and ICD-10-CM codes for the delivery only.

Accepted Answer

The correct CPT code for a cesarean delivery only is 59514. The ICD-10-CM code for a single live birth is Z37.0. The code 082 is used for a cesarean delivery.

Question 6

Description: Microscopic hematuria with lateral lobe obstruction, mild.
Preoperative Diagnosis: Microscopic hematuria.
Postoperative Diagnosis:
1) Microscopic hematuria with lateral lobe obstruction, mild.
2) Mild benign prostatic hyperplasia.
Procedure Performed: Flexible cystoscopy.
Procedure: The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct codes are 52000, N40.1, and N13.8. 52000 is the code for flexible cystoscopy. N40.1 is the code for microscopic hematuria. N13.8 is the code for mild benign prostatic hyperplasia.

Question 7

Preoperative Diagnosis: Urethritis
Postoperative Diagnosis: Urethritis
Operation: Urethral biopsy
Operation Description: A 22-year-old male was diagnosed with urethritis. The PCP referred the patient to an urologist, who ordered a urethral biopsy. The patient understood the risks and consent was obtained. The patient was prepped and the biopsy obtained then sent to pathology. Patient left the procedure room in stable condition.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

53200 is the correct CPT code for a urethral biopsy, and N28.89 is not the correct ICD-10-CM code for urethritis. The correct ICD-10-CM code for urethritis is N34.1.

Question 8

Preoperative Diagnosis: Uterine Mass
Postoperative Diagnosis: Uterine Mass
Operation: Hysteroscopy
Operation Description: A 43-year-old patient was diagnosed with a uterine mass as noted on an ultrasound. Patient was administered general anesthesia upon arrival to the operating room. The patient was prepped. The hysteroscope was introduced and biopsy was obtained. Specimen was sent to pathology. Patient tolerated the procedure well.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a hysteroscopy with biopsy is 58558, and the appropriate ICD-10-CM code for a uterine mass, when not further specified, is N85.8.

Question 9

Preoperative Diagnosis: Ovarian Cyst
Postoperative Diagnosis: Ovarian Cyst
Operation: I&D of ovarian cyst
Operation Description: A 20-year-old female patient was diagnosed with a left ovarian cyst. After being admitted, the patient was prepped in the surgical suite for the drainage of the ovarian cyst, using an abdominal approach. The left ovarian cyst was drained. Patient tolerated the procedure well.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Preoperative Diagnosis: Ovarian Cyst
Postoperative Diagnosis: Ovarian Cyst
Operation:...

Question 10

A 24-year-old female patient completed her 40th week of pregnancy. Her physician had noted that her antepartum visits were all within normal ranges. She had a vaginal delivery with episiotomy. A single live newborn was delivered in the hospital. Patient had a successful delivery with no complications. Select the appropriate CPT and ICD-10-CM codes for the delivery only.

Accepted Answer

59409 is the CPT code for vaginal delivery only, without antepartum or postpartum care. O80 is the ICD-10-CM code for a full-term uncomplicated delivery, and Z37.0 is the code for a single live birth.

Question 11

Procedure: Epididymectomy
Preoperative diagnosis: Scrotal pain, right side
Postoperative diagnosis: Scrotal pain, ride side
Operation description: The patient was placed in the supine position and prepped and draped in the usual manner. A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened. The tunica vaginalis was opened and the testicle was brought out through this incision. The epididymis was separated off the surface of the testicle using a scalpel. With blunt and sharp dissection, the epididymis was dissected off the testicle. The vessels going to the testicle were preserved without any obvious injury, and a viable testicle was present after the epididymis was removed from this. The testicle was replaced in the scrotum. Skin was closed in two. A dry sterile dressing and compression were applied, and patient was sent to the recovery room in stable condition.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code is 54860-RT for the epididymectomy procedure on the right side. The ICD-10-CM code N50.82 is appropriate for scrotal pain, which matches both the preoperative and postoperative diagnoses.

Question 12

A 52-year-old patient was treated for endometriosis with ovarian and endometrial ablation. The surgeon inserted the endoscope through the vagina into the uterus to cauterize the endometrium. He then withdrew the endoscope, applied a new tip, and made three incisions on the lower abdomen. He inserted the endoscope to fulgurate the lesions on each ovary, withdrew the instrument, and closed with sutures. Patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct codes are 58563 for hysteroscopic endometrial ablation, 58662-50-51 for laparoscopic fulguration or excision of lesions of the ovary, -50 for bilateral procedure, and -51 for multiple procedures. ICD-10-CM codes N80.0 for endometriosis of uterus and N80.1 for endometriosis of ovary.

Question 13

Preoperative Diagnosis: Phimosis
Postoperative Diagnosis: Phimosis
Operation: Circumcision
Operation Description: A four-year-old male who had spraying of urine when voiding was diagnosed with phimosis. It seemed the urine collected in the foreskin when voiding. Risks of the operation, such as infection and bleeding were discussed. In addition, the options of a dorsal slit were reviewed. The family understood all risks and wanted to proceed with the operation. Consent was obtained.
The patient was prepped and draped in the usual sterile fashion in the operating room. LMA general anesthesia applied. The extra foreskin was marked; 1x3 Gamco clamp used. Then, using 5-0 Monocryl, 4 stitches were placed and suturing was done. Hemostatis was good and dermabond applied. The patient was in good, stable condition and was brought to the recovery room. The entire procedure was completed as discussed with family.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Preoperative Diagnosis: Phimosis
Postoperative Diagnosis: Phimosis
Operation: Circumcision
Operation Description:...

Question 14

A mother brings in her 3-year-old son for a well-child checkup. In addition to the physical examination for this established patient, the physician administers the DTP vaccine via IM injection and discusses the vaccines and possible side effects with the mother. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct coding includes 99392 for the well-child checkup (appropriate for a 3-year-old), 90460 for the first component of the vaccine administration with counseling by the physician, 90461 for each additional vaccine component (assuming the DTP vaccine has multiple components), 90700 for the DTP vaccine itself, Z00.129 for a routine child health examination without abnormal findings, and Z23 for the encounter for immunization. The use of modifier -51 indicates multiple procedures.

Question 15

A patient with schizophreniform disorder, who participated in a partial hospitalization program, was seen for 30 minutes of individual psychotherapy and 10 minutes of medication evaluation and management, which required a problem-focused history and straightforward medical decision making. The physician spent 30 minutes face-to-face with the patient. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct codes are 99232 for the inpatient or observation hospital care (since it's a partial hospitalization program, this code reflects the setting and the services provided, including the time and complexity of care), 90833 for the individual psychotherapy session of 30 minutes (when performed with an evaluation and management service), and F20.81 for schizophreniform disorder, as it is the specific diagnosis code for this condition.

Question 16

A patient with stage V CKD and on hemodialysis was seen for an access flow study. The physician used the indicator method to evaluate blood flow in the AV fistula. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A patient with stage V CKD and...

Question 17

An infant was born with a hole in the septum dividing the ventricles of the heart. A right heart catheterization was performed using a percutaneous catheter to repair the defect and implant an occlusive device. The outcome was successful. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

93581 is the CPT code for percutaneous transcatheter closure of a congenital ventricular septal defect, which matches the procedure described. Q21.0 is the ICD-10-CM code for ventricular septal defect, which is the condition being treated. The other codes and modifiers in options A, B, and C are not necessary for this specific scenario.

Question 18

A patient was seen for administration of a gastroesophageal reflux test. The pH electrodes were inserted through the nose. The physician supervised the procedure, reviewed the results, and determined the test was positive for GERD. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

91034 is the correct CPT code for a gastroesophageal reflux test with pH electrodes, and K21.0 is the correct ICD-10-CM code for gastro-esophageal reflux disease (GERD).

Question 19

A patient with cerebral palsy was seen for evaluation for a non-speech-generating augmentative and alternative communication (AAC) device. The evaluation took one hour and forty minutes, including evaluation of motor, visual, cognitive, language and communication strengths and weaknesses, and discussion with family members. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

92605 is used for the initial 60 minutes of evaluation for a non-speech-generating device, and 92618 is used for each additional 30 minutes. Since the evaluation took 100 minutes, both codes are appropriate. G80.9 is the ICD-10-CM code for cerebral palsy, unspecified, which matches the patient's condition.

Question 20

A patient with pulmonary artery stenosis was treated with balloon angioplasty of the pulmonary artery to crush the plaque into the walls of the artery. To accomplish this, a catheter was inserted through the skin into the femoral artery and threaded up to the pulmonary artery. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for balloon angioplasty of the pulmonary artery is 92997, which is specific for percutaneous transluminal pulmonary angioplasty. The appropriate ICD-10-CM code for pulmonary artery stenosis is I28.8, which covers other specified diseases of pulmonary vessels.

Quiz 27: Coding and Surgical Procedures

Clinical history: Nevus, R pinna Postoperative diagnosis: same Tissue/specimen: skin of external ear nevus of R pinna Impression: microscopic sections show the specimen shows a nevus identified as a melanoma of right ear and auricular canal. Select the appropriate CPT and ICD-10-CM codes.

A patient with stage V CKD and on hemodialysis was seen for an access flow study. The physician used the indicator method to evaluate blood flow in the AV fistula. Select the appropriate CPT and ICD-10-CM codes.

An infant was born with a hole in the septum dividing the ventricles of the heart. A right heart catheterization was performed using a percutaneous catheter to repair the defect and implant an occlusive device. The outcome was successful. Select the appropriate CPT and ICD-10-CM codes.

A patient was seen for administration of a gastroesophageal reflux test. The pH electrodes were inserted through the nose. The physician supervised the procedure, reviewed the results, and determined the test was positive for GERD. Select the appropriate CPT and ICD-10-CM codes.