Question 1

Preoperative Diagnosis: Esophageal varices
Postoperative Diagnosis: Esophageal varices
Operation: Ligation of esophageal varices
Operation Description: Patient diagnosed with esophageal varices. The patient had the procedure of a direct ligation of the esophageal varices performed for the condition identified. Upon completion of the procedure the patient went to the recovery room in stable condition.
Select the appropriate CPT and ICD-10-CM codes

Accepted Answer

The correct CPT code for ligation of esophageal varices is 43400, and the appropriate ICD-10-CM code for esophageal varices without bleeding is I85.00.

Question 2

Preoperative Diagnosis: Reduced inguinal hernia
Postoperative Diagnosis: Reduced inguinal hernia
Operation: Repair of the reduced hernia
Operation Description: A 3-year-old boy was diagnosed with a reduced inguinal hernia within the past month. The surgeon explained the procedure of a reduced hernia repair and parents understood risks. The consent was obtained and signed. This is the first initial attempt to surgically repair the inguinal hernia. Patient was admitted for a reduced hernia repair. The hernia was manually reduced back into its correct cavity location. Upon completion of the procedure the patient went to the recovery room in stable condition.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Preoperative Diagnosis: Reduced inguinal hernia
Postoperative Diagnosis: Reduced...

Question 3

The physician performed a screening colonoscopy and removed 2 polyps using a snare. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

CPT code 45385 is used for a colonoscopy with polypectomy by snare technique, which matches the procedure described. Z12.11 is the ICD-10-CM code for a screening colonoscopy, and K63.5 is for polyps of the colon, both of which are appropriate for the scenario given.

Question 4

Jane Smith, a 54-year-old female, was diagnosed with gallstones. She was admitted for an outpatient procedure of a cholecystectomy to be performed. Due to safety reasons of the patient, the laparoscopic procedure became an open session in which the gallbladder was removed. The patient was admitted and left the hospital in three days in good recovery. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Jane Smith, a 54-year-old female, was diagnosed...

Question 5

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

99392 is the CPT code for a well-child checkup for an established patient aged 1 through 4 years. 90460-51 and 90461 x 2 are used for the administration of the DTP vaccine, with 90460 for the first component of the vaccine and 90461 for each additional component (DTP is a combination vaccine, hence the need for multiple units of 90461). The -51 modifier indicates multiple procedures. 90700-51 is the CPT code for the DTP vaccine itself, with the -51 modifier again indicating it's part of multiple procedures. Z00.129 is the ICD-10-CM code for a well-child visit without abnormal findings, and Z23 is used for the encounter for immunization.

Question 6

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 patient was seen for 30 minutes of individual psychotherapy, which is coded as 90832. The physician also spent 10 minutes on medication evaluation and management, which is coded as 90833. The patient has schizophreniform disorder, which is coded as F20.81.

Question 7

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

90940 is the correct CPT code for hemodialysis access flow study. Z49.31 is for encounter for adequacy testing for dialysis, N18.6 is for chronic kidney disease, stage 5, and Z99.2 is for dependence on renal dialysis, which accurately reflect the patient's condition and the reason for the study.

Question 8

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

The correct CPT code is 93581 for the percutaneous transcatheter closure of a ventricular septal defect. The ICD-10-CM code Q21.0 is for a ventricular septal defect.

Question 9

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 that involves the insertion of a catheter through the nose, and K21.0 is the appropriate ICD-10-CM code for gastro-esophageal reflux disease with esophagitis.

Question 10

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

The correct CPT codes are 92605 for the evaluation of AAC devices and 92618 for each additional 30 minutes beyond the first hour. The ICD-10-CM code G80.9 is for cerebral palsy, unspecified.

Question 11

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 12

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 procedure performed was a coronary angiography with left ventriculography, which corresponds to CPT code 93453. The ICD-10-CM codes include 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 13

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 answer of Procedure: This 10-year-old female is referred for...

Question 14

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 used for laser treatment of psoriasis for an area of 250 to 500 square centimeters. ICD-10-CM code L40.8 is used for other psoriasis.

Question 15

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 a subarachnoid injection via a subcutaneous reservoir is 96542. The ICD-10-CM codes should include Z51.11 for encounter for antineoplastic chemotherapy, C34.90 for unspecified part of unspecified bronchus or lung as the primary site of the lung cancer, and C80.0 for malignant (primary) neoplasm, unspecified, indicating metastatic cancer.

Question 16

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

The correct CPT codes for the services provided are 97161 (Physical therapy evaluation of low complexity), 97010 (Application of a modality; hot or cold packs), and 97140 (Manual therapy techniques). The ICD-10-CM code M54.2 (Cervicalgia) accurately reflects the diagnosis of cervical pain.

Question 17

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

92020 is the CPT code for gonioscopy, which is the procedure described. H40.10X0 is an ICD-10-CM code for primary open-angle glaucoma, unspecified stage, which matches the diagnosis given.

Question 18

Which of the following terms is not associated with a closed fracture?

Accepted Answer

A closed fracture, also known as a simple fracture, does not break the skin. Therefore, "Compound" is not associated with a closed fracture because a compound fracture involves a break in the skin.

Question 19

A 72-year-old female presents to her PCP with complaints of a sore, swollen left ankle. The patient has severe osteoporosis and Type II diabetes and states that she "tripped last night on her way to the bathroom" and thinks she sprained her ankle. Her PCP orders an x-ray of her left ankle, and the report showed a pathologic closed fracture of the left lateral malleolus. Closed treatment of the lateral malleolus is performed by an orthopedic surgeon. Select the appropriate CPT and ICD-10-CM codes for the surgeon.

Accepted Answer

The correct CPT code for closed treatment of a lateral malleolus fracture without manipulation is 27786, and the LT modifier indicates that the left ankle was treated. The correct ICD-10-CM code for a pathologic fracture of the ankle due to osteoporosis is M80.072A, indicating an initial encounter for a fracture on the left ankle.

Question 20

A 48-year-old female comes to her physician for aspiration of her right ring finger where fluid has accumulated due to a past injury of that finger and she continues to have pain. The physician performs arthrocentesis and follows up with an injection of steroid in the same joint. Select the appropriate CPT code.

Accepted Answer

The correct CPT code for aspiration and/or injection of a small joint or bursa, such as a finger joint, is 20600. The modifier F8 indicates the right ring finger.

Quiz 27: Coding and Surgical Procedures