Question 1

A 49-year-old patient has arthritis of the right and left knee with ongoing pain and swelling. The physician performed an arthrocentesis for the patient's condition. Patient was prepped and fluid withdrawn from the left knee joint. The patient tolerated the procedure well and was instructed to return for a follow up visit in one week to aspirate the right knee joint. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

20610-LT, M17.0 is the correct combination because 20610 represents an arthrocentesis procedure with aspiration and/or injection for a major joint or bursa (such as a knee), and the modifier LT indicates that the procedure was performed on the left side. M17.0 is the ICD-10-CM code for bilateral primary osteoarthritis of the knee, which matches the patient's condition of arthritis in both knees, even though the procedure was only performed on one knee during this visit.

Question 2

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 answer of A mother brings in her 3-year-old son...

Question 3

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 answer of A patient with schizophreniform disorder, who participated...

Question 4

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 correct CPT code for an access flow study in a hemodialysis patient is 90940, which specifically relates to hemodialysis access flow studies. The ICD-10-CM codes include Z49.31 (Encounter for adequacy testing for dialysis), N18.6 (End stage renal disease), and Z99.2 (Dependence on renal dialysis), accurately reflecting the patient's condition and the reason for the study.

Question 5

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

CPT code 93581 describes a 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, accurately reflecting the diagnosis.

Question 6

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

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

Question 7

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 for the initial 60 minutes of evaluation for a non-speech-generating device, and 92618 is for each additional 30 minutes. Since the evaluation took 100 minutes, one unit of each code is appropriate. G80.9 is the ICD-10-CM code for cerebral palsy, unspecified.

Question 8

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 specifically refers to percutaneous transluminal pulmonary balloon angioplasty. The appropriate ICD-10-CM code for pulmonary artery stenosis is I28.8, which covers other specified diseases of pulmonary vessels.

Question 9

CARDIAC CATH LAB REPORT
History: The patient is a 44-year-old with a family history of coronary artery disease. He is a heavy cigarette smoker with dependence. He had an electrocardiogram showing an old anterior septal myocardial infarction. MRI showed a fixed anterior defect. He is referred today for coronary angiography due to episodes of chest pain.
Description of the Procedure: The patient arrived in the procedure room and was administered 100 mcg Fentanyl and 2 mg Versed. 1% lidocaine was infiltrated over the right femoral artery. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography was performed with a 6-French JL-4 and 6-French JR-4 diagnostic catheters. There was no aortic stenosis on left heart pullback. There was no significant obstructive coronary artery in the right coronary artery, the left circumflex artery or left anterior descending coronary artery. There is a 10% to 20% stenosis in the distal left main.
Hemodynamic measurements were taken and repeated to evaluate hemodynamic response. Opening aortic pressure was 103/58. Following coronary angiography, the left ventricular pressure was 107/12.
Following coronary angiography, a 6-French pigtail catheter was placed in the left ventricle where left ventriculography was performed with 36 cc of contrast injected at 12 cc per second for 2 minutes. The left ventricular systolic function is normal. There are no regional wall motion abnormalities and no mitral regurgitation.
At the conclusion of the procedure, the catheter and sheath were removed and Angio-Seal plug was deployed.
Impression: There is no significant obstructive coronary artery disease. There is plaque in the distal left main, but no significant obstruction.
Left ventricular systolic function is normal. There is no evidence of previous anterior wall myocardial infarction.
Plan: Patient is urged to discontinue smoking and was referred to a smoking cessation program. Continue daily low-dose aspirin therapy. Nitroglycerin as needed.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code is 93453 for combined right and left heart catheterization with coronary angiography. Code 93463 is for pharmacologic agent administration during the procedure. The ICD-10-CM codes are R07.9 for chest pain, F17.200 for nicotine dependence, Z82.49 for family history of ischemic heart disease, and Z79.82 for long-term use of aspirin.

Question 10

Procedure: This 10-year-old female is referred for a 16-channel electroencephalogram due to unexplained seizures. During wakefulness, the posterior background is comprised predominately of 9 Hertz alpha activity, which is well modulated, symmetric, and responsive to eye opening. The anterior background contains 15-20 Hertz low voltage beta activity. With drowsiness there is attenuation of the posterior alpha rhythms, and 5-7 Hertz bi-temporal and sensual beta rhythms are noted. With early stage 2 sleep, there is 3-4 Hertz slowing of the record with occasional midline vertex waves and synchronous sleep spindle formation. No lateralizing asymmetries or epileptiform discharges are noted. Total duration was 4 hours.
Impression: This is an unremarkable awake, drowsy, and stage 2 sleep electroencephalogram. No evidence of ictal discharges or lateralizing asymmetries.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The CPT code 95819 is for a routine EEG with 16 or more channels, and ICD-10-CM code R56.9 is for unspecified convulsions, which aligns with the unexplained seizures described.

Question 11

A patient with psoriasis was seen for laser treatment of 300 square centimeters. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

CPT code 96921 is for laser treatment of psoriasis for an area of 250-500 square centimeters, and ICD-10-CM code L40.8 is for other psoriasis.

Question 12

A 62-year-old female patient with metastatic lung cancer reports to the infusion center for chemotherapy. She receives a subarachnoid injection consisting of doxorubicin, cyclophosphamide, and etoposide via a subcutaneous reservoir. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for chemotherapy administration into the subarachnoid space via a subcutaneous reservoir is 96542. The ICD-10-CM codes include Z51.11 for encounter for antineoplastic chemotherapy, C34.90 for unspecified part of the lung as the primary site of the cancer, and C80.0 for malignant (primary) neoplasm, unspecified, indicating metastatic cancer without specifying the site of the metastasis.

Question 13

A patient was referred by her primary care physician to a physical therapist due to cervical pain. The PT performs physical therapy evaluation of low complexity and applies heat packs, followed by 15 minutes of manual traction and mobilization. The patient will return 3 times a week for 3 weeks, at which time a re-evaluation will be performed. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

97161 is for a low complexity physical therapy evaluation, 97010 is for the application of a modality (heat pack), 97140 is for manual therapy techniques (such as mobilization/ manipulation, manual lymphatic drainage, manual traction), and M54.2 is the ICD-10-CM code for cervicalgia, which aligns with the patient's condition of cervical pain.

Question 14

A 36-year-old patient is currently diagnosed with glaucoma and is having occurrences of blurry vision. The patient had a gonioscopy performed to determine the type of glaucoma. The physician has determined that the type is open angle. The patient tolerated the procedure well in the outpatient hospital setting and was sent home in good condition. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The CPT code 92020 is for gonioscopy, and the ICD-10-CM code H40.10X0 is for unspecified open-angle glaucoma, which matches the diagnosis.

Question 15

Shelley presents to her endocrinologist for final determination on how the physician will proceed with her hyperthyroidism. He orders a thyroid uptake and scan for single determination to be done at the radiology department in his building. Choose the appropriate CPT and ICD-10-CM codes for the radiologist.

Accepted Answer

The answer of Shelley presents to her endocrinologist for final...

Question 16

Description: Diagnostic Mammogram and ultrasound of the breast.
Exam: Bilateral diagnostic mammogram and right breast ultrasound. History of palpable abnormality at 11 o'clock in the right breast. Family history of mother with breast cancer at age 45.
Technique: CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with 10/31/11.
Findings: The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications.
Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or solid mass.
Impression:
1) Stable mammographic appearance from 10/31/11.
2) No sonographic evidence of a mass at 11 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically.
Select the appropriate CPT codes for this encounter.

Accepted Answer

The correct CPT codes are 77066 for the bilateral diagnostic mammogram and 76641-RT for the right breast ultrasound. The "-RT" modifier indicates that the ultrasound was performed on the right side.

Question 17

Description: CT scan of the abdomen and pelvis without and with intravenous contrast.
Exam: CT scan of the abdomen and pelvis without and with intravenous contrast.
Clinical Indication: Left lower quadrant abdominal pain.
Comparison: None.
Findings: CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.
The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses. The adrenal glands, pancreas, spleen, and right kidney are normal.
A 9-mm simple cyst is present in the inferior pole of the left kidney. There is no hydronephrosis or hydroureter.
The appendix is nonremarkable.
There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.
The aorta is normal in contour and caliber.
Impression: Findings consistent with diverticulitis.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

74178 is the correct CPT code for a CT scan of the abdomen and pelvis with and without contrast, which matches the procedure described. K57.92 is the correct ICD-10-CM code for diverticulitis of the large intestine without perforation or abscess, which matches the findings.

Question 18

A patient is referred for a renal ultrasound following transplantation of his right kidney 6 months ago. The patient's creatinine clearance is elevated and the scan is directed to the renal vein only. Select the appropriate CPT code.

Accepted Answer

The answer of A patient is referred for a renal...

Question 19

Which of the following statements is false for Diagnostic Ultrasound?

Accepted Answer

M-mode (motion mode) ultrasound is primarily a one-dimensional ultrasonic measurement technique used to display the timing and amplitude of moving structures, particularly useful in cardiac imaging. It does not provide a two-dimensional measurement procedure.

Question 20

A patient is referred to the Radiology Department for a repeat gastric emptying study. This 63-year-old female has been diagnosed with dumping syndrome and her symptoms have worsened over the past two weeks, so her gastroenterologist has requested another study be done. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a gastric emptying study is 78264, which specifically refers to a study that measures how quickly food leaves the stomach. The appropriate ICD-10-CM code for dumping syndrome, which is not directly listed under its own code, falls under K31.89 (Other diseases of stomach and duodenum). K91.1 is used for postgastric surgery syndromes, which might include dumping syndrome post-surgery, but since the scenario does not specify that the patient's condition is post-surgical, K31.89 is more accurate.

Quiz 27: Coding and Surgical Procedures