Question 1

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 2

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

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 fits the description of unexplained seizures without a specific diagnosis.

Question 3

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 unspecified bronchus or lung as the primary site of the lung cancer, and C80.0 for malignant (primary) neoplasm, unspecified, indicating metastatic lung cancer.

Question 4

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 the CPT code for a low complexity physical therapy evaluation, 97010 is for the application of heat packs, 97140 is for manual therapy techniques, and M54.2 is the ICD-10-CM code for cervicalgia (cervical pain).

Question 5

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

Gonioscopy is coded as 92020, and the specific diagnosis of open-angle glaucoma without mention of stage is coded as H40.10X0 (where X is a placeholder for the unspecified stage).

Question 6

A patient is seen in the office. His last visit was four years ago, although documentation in his record reveals that the physician has ordered prescription medicine several times in the past three years. The physician performed an expanded problem-focused history; expanded problem focused exam; straightforward medical decision-making. Which CPT code should be reported for the E/M service?

Accepted Answer

The patient is considered a new patient because he has not been seen in the office for over three years. The correct code for a new patient with an expanded problem-focused history and exam, and straightforward medical decision-making is 99202.

Question 7

A physician who is a member of a family practice group treats a patient for a sprained ankle. Two years later, a different physician from the same group practice sees the same patient for a knee injury. According to CPT definitions, this patient would be considered:

Accepted Answer

According to CPT (Current Procedural Terminology) definitions, a patient is considered established if they have received any professional services from the physician or another physician of the same specialty and in the same group practice within the past three years. Since the patient was seen by another physician within the same group practice for a related service within the past three years, they are considered an established patient.

Question 8

A 30-year-old male, who is a new patient, is brought into the physicians' office for the treatment of dermatitis. The physician's focus on the problem is a detailed history and examination. The MDM complexity is moderate. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code is 99203, which is for a new patient office visit with a detailed history and examination and moderate complexity MDM. The ICD-10-CM code L30.9 is for unspecified dermatitis.

Question 9

Patient is admitted as an inpatient to the hospital on 11-01 and discharged on 11-05 for pneumonia. Select the appropriate evaluation and management CPT code and ICD-10-CM code to report for the 11-05 discharge date.

Accepted Answer

99238 is the correct CPT code for hospital discharge day management, 30 minutes or less, and J18.9 is the correct ICD-10-CM code for unspecified pneumonia.

Question 10

A 10-year-old male is seen in the emergency department for epistaxis. The hemorrhaging was controlled with nasal packing. The physician performs a detailed history and examination. The MDM complexity is moderate. Selectthe appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a moderate complexity emergency department visit is 99284. The ICD-10-CM code for epistaxis (nosebleed) is R04.0.

Question 11

Jane Smith is a 44-year-old patient who returns back this month to her primary care physician office for a well woman exam. The exam reveals a normal pelvic exam; no masses in the vaginal and cervical area. Breast exam shows no masses or abnormalities. All other systems are normal. The patient is to return in one year. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

99396 is the correct CPT code for a preventive visit for an established patient aged 40-64. Z01.419 is the correct ICD-10-CM code for an encounter for gynecological examination (general) (routine) without abnormal findings.

Question 12

Patient Susie Jones, a 32-year-old female, was admitted to the intensive care unit for acute respiratory distress syndrome. She was given critical care services by her provider Dr. Mark Smith for an hour and twenty minutes. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

CPT code 99291 is used for the first hour of critical care, and 99292 is used for each additional 30 minutes. J80 is the ICD-10-CM code for Acute Respiratory Distress Syndrome (ARDS).

Question 13

John Smith is seen by his PCP Dr. Ron Blue at home for his monthly visit in regards to monitoring his diabetes. John's diabetes is still stable as noted the previous month. No changes were made to his medications. The history is problem focused and exam is expanded problem focused. Medical decision making is noted as moderate. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a home visit by a physician for an established patient with a problem-focused history and an expanded problem-focused examination, where the medical decision making is of moderate complexity, is 99348. The correct ICD-10-CM code for stable diabetes without further specification is E11.9, indicating type 2 diabetes mellitus without complications.

Question 14

A 55-year-old established female patient was seen for management of uncontrolled diabetes due to taking oral corticosteroids for rheumatoid arthritis. She reported elevated glucose readings of 180, 210, 195, and 205 in recent weeks. The physician performed a brief history to update her record since the last visit, a detailed examination, and medical decision making of high complexity. He counseled the patient on diet and lifestyle factors and prevention of serious diabetic manifestations. He decided to start her on insulin to see how she responds. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code is 99214 for an established patient with high complexity medical decision making. The ICD-10-CM codes are E09.9 for drug-induced diabetes mellitus without complications, M06.9 for rheumatoid arthritis, and Z79.52 for long-term use of systemic steroids.

Question 15

A 54-year-old patient made an emergency department visit for gastritis, and it was also noted that the patient had melena based on the laboratory diagnostic tests. The patient was treated and released to follow up with the primary physician. History and examination are detailed. The medical decision making was noted at a moderate complexity. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The patient's age, the complexity of the medical decision-making, and the presence of melena support the use of CPT code 99284. The ICD-10-CM code K29.71 is appropriate for gastritis with melena.

Question 16

Bill was involved in a MVA. He was taken to the ED where the following was performed: A 3 cm simple repair of the left ear, an intermediate repair of the left thigh which was 7.8 cm, and an intermediate repair of the left calf muscle which was 2.0 cm.
Select the appropriate CPT code(s) for the repairs only.

Accepted Answer

The correct CPT codes are 12034 for the intermediate repair of the left thigh (7.8 cm) and 12013-51 for the simple repair of the left ear (3 cm). The intermediate repair of the left calf muscle (2.0 cm) is included in the 12034 code as it is in the same anatomic group and repair type.

Question 17

A 36-year-old female developed a sebaceous cyst on her left upper thigh. Lidocaine was injected to the area without complication. An elliptical incision around the cyst was made with a total excised diameter of .8 cm. After excision the wound was irrigated and the wound was closed with 3-0 Vicryl. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A 36-year-old female developed a sebaceous cyst...

Question 18

Joe Arrow came in to have a small lesion on his right cheek removed. After examination, his dermatologist decided to remove the 0.5 lesion by shaving. Select the appropriate CPT code(s).

Accepted Answer

The answer of Joe Arrow came in to have a...

Question 19

A 27-year-old female comes to her OB/GYN office for removal of her Norplant capsule because it is at the end of its efficacy. She is undecided on whether to have this capsule replaced. After discussion with her physician, she decides to continue the Norplant as a contraceptive. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A 27-year-old female comes to her OB/GYN...

Question 20

A patient was seen for a 2.0 cm scalp wound which required a simple repair, and a 7.5 cm scalp wound which required an intermediate repair. In addition, a 4.0 cm laceration on the face required a simple repair. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A patient was seen for a 2.0...

Quiz 27: Coding and Surgical Procedures