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A series of multiple-choice questions and answers related to medical coding, specifically focusing on icd-10-cm and cpt coding. It covers topics such as diagnostic coding for various conditions (e.g., alzheimer's, hypertension, anemia), procedural coding (e.g., lesion removal, arthroscopy), and coding guidelines for specific scenarios (e.g., pressure ulcers, adverse effects). The material is presented in a question-and-answer format, which is useful for exam preparation and self-assessment. It also includes questions about the aapc and general coding knowledge. Useful for students and professionals in medical coding and billing.
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The minimum necessary rule is based on sound current practice that protected health information should NOT be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. What does this mean? a. Staff members are allowed to access any medical record without restriction b. Providers should develop safeguards to prevent unauthorized access to protected health information. c. Practices should only provide minimum necessary information to patients. d. All of the above. b. Providers should develop safeguards to prevent unauthorized access to protected health information. EHR stands for: a. Electronic health record b. Extended health record c. Electronic health response d. Established health record a. Electronic health record The AAPC offers over 500 local chapters across the country for the purpose of a. Continuing education and networking b. Membership dues
c. Regulations and bylaws d. Financial management a. Continuing education and networking What does the abbreviation MAC stand for? a. Medicaid Alert Contractor b. Medicare Advisory Contractor c. Medicare Administrative Contractor d. Medicaid Administrative Contractor c. Medicare Administrative Contractor The OIG recommends that provider practices enforce disciplinary actions through well publicized compliance guidelines to ensure actions that are ______. a. Permanent b. Consistent and appropriate c. Frequent d. Swift and enforceable b. Consistent and appropriate Through which vessel is oxygenated blood returned to the heart from the lungs? a. Pulmonary vein b. Bronchial vein
c. A dark vertical line appearing on the abdomen d. Brownish pigmentation appearing on the face d. Brownish pigmentation appearing on the face A gonioscopy is an examination of what part of the eye: a. Anterior chamber of the eye b. Lacrimal duct c. Interior surface of the eye d. Posterior segment a. Anterior chamber of the eye What type of code is assigned when the provider documents the reason for a patient seeking healthcare services that is not for an injury or disease? a. Non-specific code b. External cause code (V00-Y99) c. Z code (Z00-Z99) d. ICD- 10 - PCS c. Z code (Z00-Z99) What is the ICD- 10 - CM code for hay fever? J30.
What is the ICD- 10 - CM code for swine flu? a. J10. b. A08. c. J11. d. J09.X d. J09.X What ICD- 10 - CM code(s) is/are reported for enlargement of the prostate with a symptom of urinary retention? a. N40. b. N40.3, R33. c. N40. d. N40.1, R33. d. N40.1, R33. What diagnosis code(s) is/are reported for behavioral disturbances in a patient with early onset Alzheimer's? a. G30.8, F02. b. F02. c. F02.81, G30. d. G30.0, F02. d. G30.0, F02.
a. D17. b. D17. c. D17.1, D17. d. D17.21, D17. d. D17.21, D17. A 33-year-old patient visits his primary care provider to discuss a lap band procedure for his morbid obesity. His caloric intake is in excess of 4,000 calories per day and his BMI is currently 45. What ICD- 10 - CM code(s) is/are reported? a. E66.01, Z68. b. E66.3, Z68. c. E66. d. E66.01, Z68. a. E66.01, Z68. A 58-year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD- 10 - CM codes are reported? a. F02.80, G30.0, F29, F41. b. G30.0, F02. c. F02.80, G30. d. G30.0, F02.80, F29, R41. b. G30.0, F02.
What would be considered an adverse effect? a. Shortness of breath when running b. Rash developing when taking penicillin c. Hemorrhaging after a vaginal delivery d. Wound infection after surgery b. Rash developing when taking penicillin What is a TRUE statement in reporting pressure ulcers? a. When a pressure ulcer is at on stage and progresses to the higher stage, report the lowest stage for that site. b. Two codes are assigned when a patient is admitted with a pressure ulcer that evolves to another stage during the admission. c. When documentation does not provide the stage of the pressure ulcer, report the unstageable pressure ulcer code(L89.95). d. The site of the ulcer and the stage of the ulcer are reported with two separate codes. b. Two codes are assigned when a patient is admitted with a pressure ulcer that evolves to another stage during the admission. A child has a splinter under the right middle fingernail. What ICD- 10 - CM code is reported?
d. B19.10, B01.9, B26.9, B05.9, B06. c. Z The Table of Drugs in the HCPCS Level II book indicates various medication routes of administration. What abbreviation represents the route where a drug is introduced into the subdural space of the spinal cord? a. IT b. SC c. IM d. INH a. IT A patient is in the OR for an arthroscopy of the medial compartment of his left knee. A meniscectomy is performed. What is the correct code used to report for the anesthesia services? a. 01400 b. 01402 c. 29880-LT d. 29870 - LT a. 01400
What is the correct CPT® code for a MRI performed on the brain first without contrast and then with contrast? a. 70554 b. 70553 c. 70552 d. 70551 b. 70553 How are ambulance modifiers used? a. They identify the time elements of the ambulance service. b. They identify the mileage traveled during the encounter. c. They identify ambulance place of origin and destination. d. they identify emergency or non-emergency transport types. c. They identify ambulance place of origin and destination. What is the correct CPT® code for the wedge excision of a nail fold of an ingrown toenail? 11765 Rationale: In the CPT® Index, look for Excision/Nail Fold referring you to 11765.
The patient is seen for removal of fatty tissue of the posterior iliac crest, abdomen, and the medial and lateral thighs. Suction-assisted lipectomy was undertaken in the left posterior iliac crest area and was continued on the right and the lateral trochanteric and posterior aspect of the medial thighs. The medial right and left thighs were suctioned followed by the abdomen. The total amount infused was 2300 cc and the total amount removed was 2400 cc. The incisions were closed and a compression garment was applied. What CPT® codes are reported? a. 15877, 15878- 50 - 51 b. 15877, 15879 - 50 - 51 c. 15830, 15839- 50 - 51, 15847 d. 15830, 15832- 50 - 51 b. 15877, 15879- 50 - 51 The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a fragment of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, and we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it; the mass was removed. There was a granuloma capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal. He wanted me a. 10121, L92.3, Z18.10, Z85.
In ICD- 10 - CM, what classification system is used to report open fracture classifications? a. Gustilo classification for open fractures b. PHF classification of fractures c. Danis-Weber classification d. Muller AO classification of fractures a. Gustilo classification for open fractures A patient presented with a right ankle fracture. After induction of general anesthesia, the right leg was elevated and draped in the usual manner for surgery. A longitudinal incision was made parallel and posterior to the fibula. It was curved anteriorly to its distal end. The skin flap was developed and retracted anteriorly. The distal fibula fracture was then reduced and held with reduction forceps. A lag screw was inserted from anterior to posterior across the fracture. A 5-hole 1/ tubular plate was then applied to the lateral contours of the fibula with cortical and cancellous bone screws. Final radiographs showed restoration of the fibula. The wound was irrigated and closed with suture and staples on the skin. Sterile dressing was applied followed by a posterior splint. What CPT® code is reported? a. 27823-RT b. 27792-RT c. 27814-RT d. 27787-RT
entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4- 0 Ethilon suture. Clean dressing was applied. What CPT® codes are reported? a. 20553-F6, 20610- 51 - LT b. 20552-F6, 20605- 52 - LT c. 26055-F6, 20610- 76 - LT d. 26055-F6, 20610- 51 - LT d. 26055-F6, 20610- 51 - LT A 3-year-old is brought into the ED crying. He cannot bend his left arm after his older brother twisted it. X-ray is performed and the ED physician diagnoses the patient has a dislocated nursemaid elbow. The ED physician reduces the elbow successfully. The patient is able to move his arm again. The patient is referred to an orthopedist for follow-up care. What CPT® and ICD- 10 - CM codes are reported? a. 24640- 54 - LT, S53.091A, W50.2XXA b. 24600- 54 - LT, S53.002A, W49.9XXA c. 24640- 54 - LT, S53.032A, W50.2XXA d.24565- 54 - LT, S53.194S, Y33.XXXA c. 24640- 54 - LT, S53.032A, W50.2XXA What CPT® code is reported for an emergency endotracheal intubation to save the patient's life?
Rationale: In the CPT® Index, look for Intubation/Endotracheal Tube. This directs you to code 31500, which is for an emergency endotracheal intubation. An 18-month-old patient is seen in the ED unable to breathe due to a toy he swallowed which had lodged in his throat. Soon brain death will occur if an airway is not established immediately. The ED provider performs an emergency transtracheal tracheostomy. What CPT® and ICD- 10 - CM codes are reported? a. 31603, T17.220A b. 31603, T17.290A c. 31601, J34.9, T17.298A d. 31601, 31603, T17.228A b. 31603, T17.290A What ICD- 10 - CM code is reported for pyopneumothorax with fistula? J86. A patient with chronic pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos free talc was introduced into the pleural space via the catheter. What CPT® and ICD- 10 - CM codes are reported?
c. 30420, 30140- 51 d. 30620, 30999- 51 b. 30520, 30140- 51 Which main coronary artery bifurcates into two smaller ones? a. Left b. Right c. Inverted d. Superficial a. Left In the cath lab a physician places a catheter in the aortic arch from a right femoral artery puncture to perform an angiography. Fluoroscopic imaging is performed by the physician. What CPT® code(s) is/are reported? a. 36222 b. 36200, 75605- 26 c. 36215, 75605- 26 d. 36221 d. 36211
Rationale: The aorta is the trunk of the system, so this is a non-selective catheterization. Look in CPT Index for Angiography/Cervicocerebral Arch. Only one code is reported for the catheterization and fluoroscopic imaging which is code 36221 Which statement is TRUE regarding codes for hypertension and heart disease in ICD- 10 - CM? A) Only one code is required to report hypertension and heart failure. B) Hypertension and heart disease have an assumed causal relationship. C) Hypertension and heart disease without a stated causal relationship must be coded separately. D) Hypertension with heart disease is always coded to heart failure. B) Hypertension and heart disease have an assumed causal relationship. Rationale: ICD- 10 - CM Coding Guidelines I.C.9.a states a causal relationship is presumed between hypertension and heart involvement. Only if the documentation specifically states they are unrelated, are they to be coded separately. ICD- 10 - CM guideline I.C.9.a.1 indicates two codes are required to report hypertension and heart failure. A patient presents for extremity venous study. Complete noninvasive physiologic studies of both lower extremities were performed. Which CPT® code is reported? 93970