Question 1

A patient with a recent total detached retina on the left eye underwent scleral buckling. A vitrectomy was also performed in order for the surgeon to adequately visualize the structures using the operating microscope. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A patient with a recent total detached...

Question 2

The physician used cryotherapy to correct an ingrown eyelash on the left upper lid. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

67825 is the CPT code for correction of trichiasis (ingrown eyelash) without mucous membrane grafting, and H02.054 is the ICD-10-CM code for trichiasis of the left upper eyelid, making this combination correct for the described procedure.

Question 3

Procedure Description: Under anesthesia via endotracheal intubation, the ears were inspected with the operating microscope. Anterior inferior quadrant myringotomy incisions were performed bilaterally. Armstrong tubes were inserted.
Diagnosis: Recurrent acute otitis media, bilateral middle ear effusions
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for the procedure described (myringotomy with insertion of tube, bilateral) is 69436-50, and the appropriate ICD-10-CM code for recurrent acute otitis media with bilateral middle ear effusions is H65.196.

Question 4

A patient with a benign tumor on the parotid gland had a parotidectomy. Nerves were dissected off the gland and left intact. A suction drain was inserted, which will be removed in two days. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

42420 is the CPT code for parotidectomy without neck dissection, which matches the procedure described. D11.0 is the ICD-10-CM code for a benign neoplasm of the parotid gland, which aligns with the diagnosis of a benign tumor on the parotid gland.

Question 5

A 22-year-old patient presents to the physician's office with a migraine headache, stiff neck, and fever. Dr. Blue performs a lumbar puncture in the office and confirms the condition of meningitis. The patient tolerated the procedure well. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

62270 is the CPT code for a diagnostic lumbar puncture, which is the procedure performed. G03.9 is the ICD-10-CM code for meningitis, unspecified, which matches the given diagnosis since the type of meningitis isn't specified.

Question 6

Preoperative Diagnosis: ear infection
Postoperative Diagnosis: otitis media
Operation: Tympanostomy of the right ear
Operation Description: A 9-month-old male was diagnosed with chronic ear infections, which keep occurring and resulted with otitis media. The risks of the operation, such as infection, hearing loss, and bleeding, were discussed. The parents 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. General anesthesia was then administered to the patient. An incision to the tympanic membrane was completed to relieve pressure and fluid from the middle ear. A small tube was then inserted through the tympanic membrane to the middle ear to assist with pressure. The patient was in good stable condition and brought to the recovery room.
Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

Accepted Answer

The correct CPT code for anesthesia for procedures on the external, middle, and inner ear in a patient younger than 1 year old is 00126-P1 (P1 modifier indicates a normal, healthy patient). The additional code 99100 is for anesthesia for patients of extreme age, under one year and over 70 (which applies here due to the patient's age). The correct ICD-10-CM code for otitis media is H66.91 (unspecified otitis media, right ear), which matches the postoperative diagnosis and the side operated on.

Question 7

Preoperative Diagnosis: Cleft palate
Postoperative Diagnosis: Cleft palate
Operation: Repair of cleft palate
Anesthesia: General
Operation Description: A 3-year-old patient was diagnosed with cleft palate and was advised by the surgeon to complete the surgical procedure repairing the cleft palate. The risks were discussed and identified with the family. Consent was obtained and the operation performed.
Select the appropriate CPT and ICD-10-CM codes for the anesthesia service for the procedure.

Accepted Answer

The correct CPT code for anesthesia services for a cleft palate repair is 00172, and the appropriate ICD-10-CM code for cleft palate is Q35.9. The modifier P1 indicates a normal, healthy patient, which is appropriate for the described scenario.

Question 8

Tom Smith, who is 45 years old, was recently diagnosed with a liver mass. The family physician ordered a liver biopsy to be performed. At the outpatient surgery area the patient was treated by Dr. Jane, who performed a percutaneous liver biopsy. Select the appropriate CPT and ICD-10-CM codes for the anesthesia for this procedure.

Accepted Answer

The correct CPT code for anesthesia for a percutaneous liver biopsy is 00702, and the P1 modifier indicates a normal, healthy patient. The ICD-10-CM code R16.0 is for hepatomegaly, not elsewhere classified, which could be related to the liver mass diagnosis. The other options either include incorrect CPT codes, unnecessary additional codes (99100), or incorrect ICD-10-CM codes for the scenario described.

Question 9

Preoperative Diagnosis: Knee pain
Postoperative Diagnosis: Juvenile Arthritis of the knee
Operation: Arthroscopy of the right knee
Operation Description: A 33-year-old patient was diagnosed with right knee pain. Patient is admitted to have an arthroscopy of the right knee. The risks were discussed with the patient and consent obtained.
Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Accepted Answer

The correct CPT code for anesthesia for knee arthroscopy is 01382. The physical status modifier for a normal healthy patient is P1. The ICD-10-CM code for juvenile arthritis of the right knee is M08.961.

Question 10

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 code for the anesthesia service, as well as the ICD-10-CM code.

Accepted Answer

The answer of Preoperative Diagnosis: Uterine Mass
Postoperative Diagnosis: Uterine Mass
Operation:...

Question 11

Preoperative Diagnosis: Tonsillitis
Postoperative Diagnosis: Tonsillitis
Operation: Tonsillectomy
Anesthesia: General
Operation Description: A 12-year-old patient is diagnosed with tonsillitis and was recommended to have a tonsillectomy. Family consented to the surgery and patient was admitted. Patient was positioned supine for the procedure. The right and the left tonsils were removed. The tonsillar area was irrigated. There was no bleeding before or after the suturing. The patient tolerated the procedure well.
Select the appropriate CPT code for the anesthesia service, as well as the ICD-10-CM code.

Accepted Answer

The answer of Preoperative Diagnosis: Tonsillitis
Postoperative Diagnosis: Tonsillitis
Operation: Tonsillectomy
Anesthesia: General
Operation...

Question 12

The Anesthesia reimbursement services follow a formula approved by the American Society of Anesthesiologists (ASA). Identify the correct order for the formula used to calculate the charges and payment.

Accepted Answer

The correct formula for calculating anesthesia charges and payment according to the American Society of Anesthesiologists (ASA) is: base units + time units + modifying factors. This formula takes into account the complexity of the procedure (base units), the duration of the anesthesia care (time units), and any specific circumstances that might modify the standard calculation (modifying factors).

Question 13

A 54-year-old patient presents to his primary physician office for a preoperative evaluation for a bilateral vasectomy. The patient's past history consists of controlled diabetes with no other known conditions. Identify which physical status modifier will be used for the surgery.

Accepted Answer

The correct physical status modifier for this patient is P2. This classification is used for patients with mild systemic disease. In this case, the patient has controlled diabetes, which qualifies as a mild systemic disease, but does not have a severe systemic disease, which would be classified as P3 or higher. P1 is for a normal healthy patient, and P4 is for a patient with a severe systemic disease that is a constant threat to life, neither of which applies to this patient.

Question 14

Anesthesia was provided for a 75-year-old patient who was having a biopsy performed on the salivary gland to determine the nature of a mass. He also had chronic essential benign hypertension. Select the appropriate CPT codes for the anesthesia service, as well as the ICD-10-CM codes.

Accepted Answer

The answer of Anesthesia was provided for a 75-year-old patient...

Question 15

Sarah Jones has suffered with severe menorrhagia for many years. She also has severe rheumatoid arthritis. Dr. Jones performed a radical hysterectomy. General anesthesia was administered. The surgery was a success and the patient left the recovery room in good condition. Select the appropriate CPT code(s) for the anesthesia services, as well as the ICD-10-CM code.

Accepted Answer

00846 is the correct CPT code for anesthesia for radical hysterectomy. P3 indicates a patient with severe systemic disease, which fits the description of severe rheumatoid arthritis. N92.0 is the ICD-10-CM code for excessive and frequent menstruation with regular cycle, which corresponds to severe menorrhagia.

Question 16

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 correct CPT code is 99202, which is for a new patient office or other outpatient visit that includes an expanded problem-focused history and examination, and straightforward medical decision-making. Since the patient has not been seen in the office for over three years, for coding purposes, he is considered a new patient despite the physician ordering prescription medicine for him during that time.

Question 17

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 an established patient if they have received professional services from the physician or another physician of the same specialty who belongs to 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 18

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 answer of A 30-year-old male, who is a new...

Question 19

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 ICD-10-CM code for unspecified pneumonia, which matches the diagnosis given.

Question 20

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

99284 is the correct CPT code for an emergency department visit that requires a detailed history and examination with moderate complexity decision making, which matches the scenario. R04.0 is the ICD-10-CM code for epistaxis, which is the reason for the visit.

Quiz 27: Coding and Surgical Procedures