Question 1

To accurately identify that a procedure was performed on the second lumbar vertebra, which of the following would be documented in the operative report?

Accepted Answer

The second lumbar vertebra is correctly denoted as "L2." The "L" stands for lumbar, and the number indicates the specific vertebra within the lumbar spine.

Question 2

A patient is seen in the outpatient clinic for a colonoscopy due to a family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. The colonoscopy revealed a colonic polyp that was removed by hot biopsy forceps. What should the CPT and diagnosis codes for this case be?

Accepted Answer

CPT code 45384 is correct for a colonoscopy with removal of a polyp by hot biopsy forceps. The diagnosis codes are correctly ordered with Z12.11 (encounter for screening for malignant neoplasm of colon) as the primary reason for the encounter, followed by Z80.0 (family history of malignant neoplasm of digestive organs) for the family history of colon cancer, and K63.5 (polyp of colon) for the finding during the procedure.

Question 3

The nervous system is divided into two major systems. Which system includes the brain and the spinal cord?

Accepted Answer

The central nervous system (CNS) consists of the brain and the spinal cord, serving as the primary processing center for the entire nervous system and controlling all the functions of the body.

Question 4

An endoscopy procedure was started on a patient who was scheduled and prepped for a total colonoscopy. The physician was unable to advance the scope beyond the splenic flexure due to unforeseen circumstances. Which of the following modifiers is appended to the colonoscopy code?

Accepted Answer

Modifier 53 is used to indicate a procedure that was started but discontinued due to unforeseen circumstances, which applies to the scenario where the colonoscopy could not be completed as planned.

Question 5

The patient is a 35-year-old female who has been having prolonged and heavy bleeding during menstruation. After other testing, the patient opted to have an elective uterine ablation using NovaSure.
Procedure: After the patient was put under general anesthesia, the patient was placed in the dorsolithotomy position, after which the perineum and the vagina were prepped, the bladder was straight catheterized, and the patient was draped. After a bimanual exam was performed, a speculum was placed and the cavity integrity assessment performed. The NovaSure system uses a small amount of CO2 to verify cavity integrity prior to performing the procedure. The NovaSure thermal endometrial ablation procedure then delivered radiofrequency energy until tissue impedance reached 50 ohms; the electrode array was retracted for easy removal, leaving the uterine lining desiccated down to the superficial myometrium. The patient was awakened from anesthesia and sent home to recover.
Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The correct CPT code for the NovaSure thermal endometrial ablation procedure is 58353, as it specifically refers to endometrial ablation without hysteroscopic guidance, which matches the description of the NovaSure procedure. The correct ICD-10-CM code is N92.0, which is used for excessive and frequent menstruation with regular cycle, aligning with the patient's symptoms of prolonged and heavy bleeding.

Question 6

When multiple surgeons perform the complete skull base procedure (approach procedure, definitive procedure, reconstruction/repair), each surgeon reports only the code for the specific procedure each performed. If one surgeon performs all of the procedures, then all the applicable codes are reported and a modifier is added to the secondary procedure code(s). Which modifier is added?

Accepted Answer

Modifier 51 is used to indicate that multiple procedures were performed by the same surgeon during the same surgical session.

Question 7

A 39-year-old female presents with an ectopic pregnancy. Due to previous abdominal surgeries, the surgeon is unable to perform a laparoscopic fallopian tube removal and must use an open procedure to successfully perform the removal. The physician elects to surgically treat this patient by using an open approach to her abdomen to remove her left fallopian tube and ovary, along with the products of conception. Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The correct CPT code for an open surgical procedure to remove an ectopic pregnancy, including the removal of the fallopian tube and ovary, is 59120. The modifier -LT indicates that the procedure was performed on the left side. The appropriate ICD-10-CM code for an ectopic pregnancy without intrauterine pregnancy is O00.90, which does not specify the location of the ectopic pregnancy, making it the most suitable choice given the information provided.

Question 8

A 55-year-old male patient is coming to the hospital for an outpatient service for a prostate biopsy. The patient has a family history of prostate cancer, had recent blood work showing elevated PSA levels, and has problems urinating. The patient presents and is placed under anesthesia and prepped and draped. Ultrasonic guidance is used for needle placement, and a needle biopsy is taken. The biopsy is sent to pathology, and the patient is awaiting the results. Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The correct CPT codes for a prostate biopsy using ultrasonic guidance are 55700 for the biopsy itself and 76942 for the ultrasonic guidance. The ICD-10-CM codes include R97.20 for the elevated PSA levels and Z80.42 for the family history of prostate cancer.

Question 9

Operation: LEEP procedure
Diagnosis: Cervical polyp
Procedure: With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilation and curettage in a routine fashion.
An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The cervical polyp on the posterior lip of the cervix was excised.
Then changing to a 40 of coagulation and 4 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding and then it was closed with figure-of-eight 3-0 Vicryl sutures.
Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.
Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The correct CPT code is 57460 for a LEEP procedure with excision of a cervical polyp, and the ICD-10-CM code N84.1 is for a cervical polyp.

Question 10

Preoperative diagnosis: Right eustachian tube dysfunction
Postoperative diagnosis: Right eustachian tube dysfunction
Anesthesia: General mask
Name of operation: Eustachian tube catheterization
Procedure: The patient was taken to the operating room and placed in the supine position. After general anesthesia was given, the operating microscope was brought in for full use throughout the case. The right tympanic membrane was approached using a transnasal approach. An anterior-inferior radial incision was made in the right tympanic membrane. Suction revealed a substantial amount of mucopurulent drainage. A Sheehy pressure equalization tube was placed in the site. Floxin drops were added. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.
Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The answer of Preoperative diagnosis: Right eustachian tube dysfunction
Postoperative diagnosis:...

Question 11

Preoperative diagnosis: (1) Cholelithiasis, (2) acute cholecystitis
Postoperative diagnosis: (1) Cholelithiasis, (2) acute cholecystitis
Name of operation: Laparoscopic cholecystectomy
Anesthesia: General
Findings: The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There were nine stones impacted in the cystic duct. The gallbladder contained numerous stones, which were small. With the stones impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.
Procedure: Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered.
After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled.
Select the appropriate CPT and ICD-10-CM codes:

Accepted Answer

The correct CPT code for a laparoscopic cholecystectomy is 47562, and the ICD-10-CM code for cholelithiasis with acute cholecystitis is K80.00.

Question 12

A 23-year-old patient, is seen by Dr. Johnson for a cough with wheezing and green-colored mucus for the past four days, as well as four days of external bleeding hemorrhoids and diarrhea. Dr. Johnson gives her Augmentin for acute viral bronchitis, instructions on the care of external hemorrhoids, and a diet plan to assist with the diarrhea. What diagnoses should Dr. Johnson use for this encounter?

Accepted Answer

J20.8 is for acute bronchitis caused by other specified organisms, which aligns with the symptoms of cough, wheezing, and green mucus. K64.4 is for external hemorrhoids with thrombosis, fitting the description of external bleeding hemorrhoids. R19.7 is for diarrhea, unspecified, matching the symptom of diarrhea.

Question 13

Which of the following is the gland that secretes a factor that causes T cells to mature and is larger in infants?

Accepted Answer

The thymus gland secretes thymosin, which causes T cells to mature. It is larger in infants and children and gradually shrinks after puberty.

Question 14

The medical term that can be used for pain in the head is:

Accepted Answer

Cephalgia specifically refers to pain in the head, whereas the other options refer to different conditions: neuralgia (nerve pain), agraphia (inability to write), and paraplegia (paralysis of the legs and lower body).

Question 15

Which of the following terms refers to an abnormal accumulation of fluid in the peritoneal cavity that is often a complication of a malignancy?

Accepted Answer

Ascites refers to the abnormal accumulation of fluid in the peritoneal cavity, which can be a complication of malignancy, liver disease, heart failure, and other conditions.

Question 16

The patient is a female transgender patient who has undergone hormonal therapy, along with other services, to prepare her for her sex change to a male. The patient is counseled on the adverse effects of surgery, as well as complications that may occur. The patient signs the consent for surgery and is taken to the operating room, prepped for surgery, and placed under general anesthesia. The patient successfully comes through surgery. Select the appropriate CPT code:

Accepted Answer

The correct CPT code for a female-to-male sex reassignment surgery is 55980. This code is used for intersex surgery; female to male.

Question 17

There are two main types of glaucoma. Which type of glaucoma describes when fluid does not flow through the orbicular meshwork properly?

Accepted Answer

Open angle glaucoma is characterized by the improper flow of fluid through the trabecular meshwork, even though the angle between the iris and the cornea remains open. This leads to increased pressure in the eye, which can damage the optic nerve.

Question 18

Select the appropriate CPT and ICD-10-CM codes to report the removal of 35 percent of the left thyroid lobe through an isthmusectomy. The patient's diagnosis is benign thyroid neoplasm.

Accepted Answer

60210 is the correct CPT code for partial thyroid lobectomy without mention of isthmusectomy, which is appropriate for the removal of 35 percent of the left thyroid lobe. D34 is the correct ICD-10-CM code for a benign neoplasm of the thyroid gland.

Quiz 26: Coding for Surgical Procedures on Digestive, Urinary, Male and Female Reproductive Systems, Maternity Care, Nervous System, and Eyes, Ears, and Endocrine System