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A series of questions and answers related to medical coding and billing, specifically focusing on the aapc cpc exam. It covers various medical terms, procedures, and codes, offering a valuable resource for individuals preparing for the aapc cpc certification exam. Questions on medical terminology, anatomical structures, surgical procedures, medical necessity, coding guidelines, and icd-10-cm and cpt coding.
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Surgical removal
The suffix - ectomy means
Magnetic Resonance Imaging
MRI stands for
The removal of the fallopian tubes and ovaries
The term "Salpingo-Oophorectomy" refers to
Freezing
Cryopreservation is a means of preserving something through
Paracentesis
Which of the following describes the removal of fluid from a body cavity
Gastrotomy
If a surgeon cuts into a patient's stomach he has performed a
Muscle
In the medical term myopathy the term pathy means disease. What is diseased?
Measles, Mumps, Rubella, and Varicella
The acronym MMRV stands for
Outer bone located in the forearm
The Radius is the
Hemic and Lymphatic
The spleen belongs to what organ system?
The distal portion
The portion of the femur bone that helps makes up the knee cap is considered what?
Middle
The Midsagittal plane refers to what portion of the body?
Cecum
Which of the following is not part of the small intestine?
Teres
One of the six major scapulohumeral muscles
What is the correct ICD- 10 - CM code(s) for malignant hypertension with stage III kidney disease?
Lucy was standing on a chair in her apartment's kitchen trying to change a light bulb when she slipped and fell. She struck the glass top stove, which shattered. She presents to the ER with a simple laceration to her left forearm that has embedded glass particles. Which is the correct code(s)?
Jim was at a bonfire when he tripped and fell into the flames and sustained multiple burns. He came to the emergency room via an ambulance and was treated for second and third degree burns on his face, second degree burns on his upper arms and forearms, and third degree burns on the fronts of his thighs Which is the correct code(s)?
. A 35 year old woman who is pregnant in her 38th week with her first child is admitted to the hospital. She experiences a prolonged labor during the first stage and eventually births a healthy baby boy. Which is the correct code(s)?
Henry was playing baseball at the town's sports field and slid for home base where he collided with another player. He presents to the emergency department complaining of pain in the distal portion of his right middle finger. It is swollen and deformed. The physician orders an x-ray and diagnoses Henry with a displaced tuft fracture. He splints the finger, provides narcotics for pain, and instructs Henry to follow-up with his orthopedist in two weeks. Which is the correct code(s)?
A 60 year old male is admitted for detoxification and rehabilitation. He has continuously abused amphetamines to the point that he cannot voluntarily stop on his own and has become dependent upon them. He also has a long documented history of alcohol abuse and alcoholism. He experiences high levels of anxiety due to PTSD, which causes him to use and abuse substances. Which is the correct code(s)?
A patient with uncontrolled type II diabetes is experiencing blurred vision and an increase in floaters appearing in her vision. She is diagnosed with diabetic retinopathy. Which is the correct code(s)?
A patient who is known to be HIV positive but who has no documented symptoms would be assigned code
A patient fell asleep on the beach and comes in with blistering on her back. She is diagnosed with second degree solar radiation burns. Which is the correct code(s)?
True
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by classification.
A patient has a home health aide come to his home to clean and dress a burn on his lower leg. The aide uses a special absorptive, sterile dressing to cover a 20 sq. cm. area. She also covers a 15sq. cm. area with a self-adhesive sterile gauze pad.
A three year old child is brought into the ER after swallowing a penny. A detailed history and exam are taken on the child and medical decision making is of moderate complexity. The child is admitted to observation for three hours and is then discharged home. Which is the correct code(s)?
A 20 month old child is admitted to the hospital with pneumonia and acute respiratory distress. The physician spends 3 minutes intubating the child and spends 90 minutes of Critical Care time stabilizing the patient. Which is the correct code(s)?
At the request of a physician who is delivering for a high risk pregnancy, Dr. Smith, a pediatrician, is present in the delivery room to assist the infant if needed. After thirty minutes the infant is born, but is not breathing. The delivering physician hands the infant to Dr. Smith who provides chest compressions and resuscitates the infant. The pediatrician then performs the initial evaluation and management and admits the healthy newborn to the nursery. What codes should Dr. Smith submit on a claim?
Mr. Johnson is a 79 year old established male patient that is seen by Dr. Anderson for his annual physical exam. During the examination Dr. Anderson notices a suspicious mole on Mr. Johnson's back. The Doctor completes the annual exam and documents a detailed history and exam and the time discussing the patient's need to quit smoking. Dr. Anderson then turns his attention to the mole and does a complete work up. He documents a comprehensive history and examination and medical decision making of moderate complexity. He also called a local dermatologist and made an appointment for Mr. Johnson to see him the next day for an evaluation and biopsy. Which is the correct code(s)?
History, Exam, Medical Decision Making, Counseling, Coordination of Care, and Nature of Presenting Problem
An E/M is made up of seven components six of which are used in defining the levels of E/M services. The seven components include History, Exam, Medical Decision Making, Counseling, Coordination of Care, Nature of Presenting Problem, and Time. Which six of these seven parts help define the level of the E/M service?
The upper central region of the abdomen
When a patient complains.of epigastric pain. Where is the pain located?
A 2 year-old comes in for an initial WCE, Morn doesn't have the child's immunization record. She states the child's last shot was when he was 5 months old. Medical review and documentation of a new patient supports one element of HPI, five-elements of the ROS, and a complete PFSH. The examination was 8+ organ systems. The physician orders the immunizations to be given in the office today. Immunizations given subcutaneously: MMRV. What CPT codes are reported?
Musculoskeletal
Which system is given credit in the exam component when the provider documents "range of motion, strength, and stability" are adequate in both legs?"
A 25 year-old male is brought in by the EMS to the ER for nausea and vomiting. The patient has elevated blood sugars per EMS. EMS and the physician are unable to get a history due to patient's altered mental status. The ED physician performed a comprehensive eight organ system exam and a high level MDM. Patient was transferred to ICU in stable condition. Total critical care time 25 minutes. What CPT code is reported?
The correct anesthesia code for a ventral hernia repair on a 13 month old child is
A female who is 17 weeks pregnant is rushed into the OR due to a ruptured tubal pregnancy. She has a severe hemorrhage and has an emergency laparoscopic tubal ligation. Which is the correct code(s)?
John was in a fight at the local bar and presents to the ER with multiple lacerations. The physician evaluates John and determines that he has a 2.5 cm gash to his left forearm and a 4cm gash on his right shoulder, both which require layered closure. He also has a simple 3cm laceration on his forehead that requires simple closure. What are the correct codes for the laceration repairs?
A patient presents to her dermatologists office with three suspicious looking lesions. The dermatologist evaluates them and determines that the 1.3cm lesion of the scalp is benign and the 1.5cm lesion of the neck is premalignant. The 2.5 cm on the dorsal surface of the patient's hand is also evaluated and is determined to be malignant. The dermatologist chooses to ablate all three lesions using electrosurgery. Which is the correct code(s)?
An 18 year old female presents with a cyst of her left breast and her physician performs a puncture aspiration. Which is the correct code(s)?
Preoperative Diagnosis: Basal Cell Carcinoma
Postoperative Diagnosis: Basal Cell Carcinoma
Location: Mid Parietal Scalp
Procedure: Prior to each surgical stage, the surgical site was tested for anesthesia and re-anesthetized as needed, after which it was prepped and draped in a sterile fashion.
The clinically-apparent tumor was carefully defined and de-bulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a
narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis. No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
Preoperative Size: 1.5 x 2.9 cm
Postoperative Size: 2.7 x 2.9 cm
Closure: Simple Linear Closure, 3.5cm, scalp
Total # of Mohs Stages: 2
Stage Sections Positive
I 6 1
II 2 0
Which is the correct code(s)?
A patient with a non-healing burn wound on her right cheek, and is admitted to the OR for surgery. The physician had the patient prepped with a Betadine scrub and draped in the normal sterile fashion. The cheek was anesthetized with 1% Lidocaine with 1:800,000 epinephrine (6 cc), and SeptiCare was applied. A skin graft of the epidermis and a small portion of the dermis was taken with a Goulian Weck blade with a six-thousands-of-an-inch-thick shim on the blade. The 25 sq cm graft was flipped and sewn to the adjacent defect with running 5-0 Vicryl. The wound was then dressed with Xeroform and the patient was taken to recovery. Which is the correct code(s)?
A child is brought into the emergency department after having her fingers on her right hand closed in a car door. The physician evaluates the patient and diagnosis her with a 3cm laceration to her second finger and a subungual hematoma to her third finger. The physician then proceeds to cleanse the fingers with an iodine scrub and injects both digits with 2 mL of 1% lidocaine with epinephrine. The wound on the second finger was then irrigated with 500 cc of NS and explored for foreign bodies or structural
Medial and lateral meniscus repair performed arthroscopically. Which is the correct code(s)?
A patient comes into the emergency department complaining of sever wrist pain after falling onto her out stretched hands. The physician evaluates the patient taking a detailed history, a detailed exam, and medical decision making of moderate complexity. Upon examination the physician notes that there is a small portion of bone protruding through the skin. After ordering x-rays of the forearm and wrist the patient is diagnosed with an open distal radius fracture of the right arm. The physician provides an IV drip of morphine to the patient for pain and reduces the fracture. 5¬0 absorbable sutures were use to close the subcutaneous layer above the fracture and the surface was closed with 6-0 nylon interrupted sutures. Wound length was measured at 2.5 cm. It was then dressed with sterile gauze and the wrist was stabilized with a Spica fiberglass cast. The physician provided the patient with a prescription for Percocet for pain and instructions for her to follow up with her orthopedist in 7 days. Which is the correct code(s)?
Repair, Revision, and/or Reconstruction
A Scapulopexy is found under what heading
A patient with muscle spasms in her back was seen in her physician's office for treatment. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. After isolating it between two palpating fingertips a 25-gauge 5" needle was placed in the center of the myofascial spasms and a negative aspiration was performed. Then 4 cc of Marcaine 0.5% was injected into three points in the muscle. The patient tolerated the procedure well without any apparent difficulties or complications. The patient reported feeling full relief by the time the block had set. Which is the correct code(s)?
PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-
C5 and C5-C6.
POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.
PROCEDURE PERFORMED:
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 60 mL.
COMPLICATIONS: None.
INDICATIONS: This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. I then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C6. The disc was then completely removed at C5-C6. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Part of the body of C5 was taken down to assure that all fragments were removed and that there was no additional constriction. The nerve root was then widely decompressed. Machine bone allograft was placed into C5-C6 and then a Zephyr plate was placed in the body C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.
Which is the correct code(s)?
General: 22224-62 Neurosurgeon: 22224-
compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted. Which is the correct code(s)?
Tendon, aponeuroses and directly to bone
Muscle is attached to bone by what method?
Operative Note
PREOPERATIVE DIAGNOSIS: Angina and coronary artery disease. POSTOPERATIVE DIAGNOSIS: Angina and coronary artery disease.
PROCEDURE DETAILS: The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy and phrenic nerve protectors were used to protect the phrenic nerve. All were removed at the end of the case. A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.
The Femoropopliteal vein was resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed. The left internal mammary artery is sewn to the left anterior descending using 7- running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta. Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldog clamps were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun. The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 6-0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition. Which is the correct code(s)?
A 50-year-old gentleman with severe respiratory failure is mechanically ventilated and is currently requiring multiple intravenous drips. With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position, the right neck was prepped and draped with Betadine in a sterile fashion. A single needle stick aspiration of the right subclavian vein was accomplished without difficulty and the guide wire was advanced and a dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire and the wire was then removed. No PVCs were encountered during the procedure. All three ports to the catheter were aspirated and flushed blood easily and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x- ray was obtained at the completion of the procedure to ensure proper placement of the tip in the subclavian vein. Which is the correct code(s)?
A patient with chronic emphysema has surgery to remove both lobes of the left lung. Which is the correct code(s)?
A thoracic surgeon makes an incision under the sternal notch at the base of the throat, introduces the scope into the mediastinal space and takes two biopsies of the mediastinal mass. He then retracts the scope and closes the small incision. Which is the correct code(s)?
A patient has endoscopic surgery done to remove his anterior and posterior ethmoid sinuses. The surgeon dilated the maxillary sinus with a balloon using a transnasal approach, explored the frontal sinuses, remove two polyps from the maxillary sinus, and then performed the tissue removal. Which is the correct code(s)?
A cardiologist manipulates a catheter through the patient's atrial system, starting in the femoral artery and manipulating to the third order, using intravascular ultrasound. The cardiologist performs radiological supervision and interpretation. Which is the correct code(s)?
True
An indirect laryngoscopy, as described in code 31505, utilizes a mirror in which the physician can view the reflection of the larynx. A direct laryngoscopy, as described by code 31515, utilizes a scope in which the physician peers through and views the larynx.
A patient was taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution and draped in a sterile fashion. An incision was made at the hairline and carried down by sharp dissection through the clavipectoral fascia. The lymph node was palpitated in the armpit and grasped with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node was sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition. Which is the correct code(s)?
The patient was scheduled for an esophagogastroduodenoscopy. Upon arrival they were placed under conscious sedation and instructed to swallow a small flexible camera. The camera was then manipulated into the esophagus, and through the entire length of the esophagus. The esophagus appeared to be slightly inflamed, but there was no sign of erosion or flame hemorrhage. A small 2cm tissue sample was taken to look for gastroesophageal reflux disease. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach were normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed an abnormal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum were normal. Which is the correct code(s)?
After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, and to the splenic flexure. There was a large amount of stool at the flexure which appeared to be impacted. The physician decided not to advance to the cecum due to the impaction and the scope was pulled back into the descending colon and then slowly withdrawn. The mucosa was examined in detail along the way and was entirely normal. Upon reaching the rectum, retroflex examination of the rectum was normal. The scope was then straightened out, the air removed and the scope withdrawn. The patient tolerated the procedure well. Which is the correct code(s)?
Operative Note
The 45 year old male patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved, prepped, and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push. A transverse incision was made in the intraabdominal crease and carried through the skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to, and through, the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied. Which is the correct code(s)?
True
The vestibule is part of the oral cavity outside the dentoalveolar structures and includes the mucosal and submucosal tissue of the lips and cheeks.
Gallbladder
