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NEW QUESTION # 33
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image Reason: Screen Bilateral digital mammography with computer-aided detection (CAD) No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT coding is reported for this case?
- A. 77066-50, Z12.31, Z80.3
- B. 77067, Z12.31, Z80.3
- C. 77066, Z80.3, Z12.31
- D. 77067-50, Z80.3, Z12.31
Answer: B
Explanation:
The procedure performed is a bilateral screening mammogram with computer-aided detection (CAD). CPT code 77067 is for bilateral screening mammography with CAD. ICD-10-CM code Z12.31 is for an encounter for screening mammogram for malignant neoplasm of the breast. Z80.3 is for a family history of malignant neoplasm of the breast. Therefore, the correct coding is 77067, Z12.31, Z80.3. References: CPT Professional Edition (current year), ICD-10-CM (current year).
NEW QUESTION # 34
Patient is diagnosed with dacryocystitis, which is the inflammation of?
- A. Fingernail
- B. Lacrimal sac
- C. Cornea
- D. Eardrum
Answer: B
Explanation:
Dacryocystitis is the inflammation of the lacrimal sac, which is part of the tear drainage system located in the inner corner of the eye. The lacrimal sac is connected to the nasolacrimal duct, which drains tears into the nasal cavity. Inflammation in this area can cause pain, redness, and swelling near the inner corner of the eye.References: ICD-10-CM, medical dictionaries
NEW QUESTION # 35
A 4-year-old, critically ill child is admitted to the PICU from the ED with respiratory failure due to an exacerbation of asthma not manageable in the ER. The PICU provider takes over the care of the patient and starts continuous bronchodilator therapy and pharmacologic support with cardiovascular monitoring and possible mechanical ventilation support.
What is the E/M code for this encounter?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: C
Explanation:
The code 99471 is used for initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill infant or young child. Given the scenario where a 4-year-old critically ill child is admitted to the PICU and requires intensive care management, this code is appropriate as it reflects the critical care provided beyond the emergency department services. References: CPT Professional Edition (current year), AMA.
NEW QUESTION # 36
A surgeon performs midface LeFort I reconstruction on a patient's facial bones to correct a congenital deformity. The reconstruction is performed in two pieces in moving the upper jawbone forward and repositioning the teeth of the maxilla of the mid face.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
Explanation:
The procedure described involves a LeFort I reconstruction, which is a type of orthognathic surgery performed to correct deformities of the midface. In this scenario, the surgeon performed the reconstruction in two pieces, moving the upper jawbone forward and repositioning the teeth of the maxilla. According to the CPT guidelines, CPT code 21146 describes a LeFort I (maxilla only) osteotomy, two-piece segment, including bone grafts (includes obtaining autografts). This code matches the description provided.
References:
* AMA's CPT Professional Edition (current year), Code 21146
NEW QUESTION # 37
The surgeon performs Roux-en-Y anastomosis of the extrahepatic biliary duct to the gastrointestinal tract on a
45-year-old patient.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
Explanation:
The Roux-en-Y anastomosis of the extrahepatic biliary duct to the gastrointestinal tract is a specific surgical procedure that involves connecting the biliary duct to the gastrointestinal tract.
* Procedure Description: Roux-en-Y anastomosis of the extrahepatic biliary duct involves creating a direct connection between the biliary duct and the gastrointestinal tract.
* Procedure Specificity: The procedure is complex and involves extensive surgical technique and anastomosis.
Coding Decision:
* CPT 47780 specifically describes the Roux-en-Y anastomosis of the extrahepatic biliary duct to the gastrointestinal tract.
References:
* AMA's CPT Professional Edition (current year).
* CPT Assistant for detailed coding guidelines on biliary and gastrointestinal procedures.
NEW QUESTION # 38
The CPT code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.
What is the full description of CPT code 69644?
- A. Without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
- B. With intact or reconstructed canal wall with ossicular chain reconstruction
- C. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction
- D. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
Answer: C
Explanation:
CPT code 69644 refers to a tympanoplasty with mastoidectomy, which includes canalplasty, middle ear surgery, and tympanic membrane repair. The specific procedure described by this code is performed with an intact or reconstructed canal wall and includes ossicular chain reconstruction. The use of a semicolon in the CPT description helps distinguish between different variations of the procedure.References: AMA's CPT Professional Edition, specific code descriptions and guidelines.
NEW QUESTION # 39
A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.
What CPT coding is reported?
- A. 36253, 75625-26
- B. 0
- C. 36252, 75625-26
- D. 1
Answer: C
Explanation:
CPT code 36252 describes selective catheter placement of the main renal artery with angiography of both kidneys, which matches the procedure of selectively catheterizing the right and left renal arteries and performing angiography. Additionally, CPT code 75625-26 is for an abdominal aortography with interpretation and report. The -26 modifier indicates that the professional component of the service was performed.
References:
* AMA's CPT Professional Edition (current year), Codes 36252, 75625-26
NEW QUESTION # 40
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
- A. J9312, J1200
- B. J9312 x 80, J1200 x 2
- C. J9312 x 80, 00163 x 2
- D. J9312, Q0163
Answer: C
NEW QUESTION # 41
View MR 006399
MR 006399
Operative Report
Preoperative Diagnosis: Chronic otitis media in the right ear
Postoperative Diagnosis: Chronic otitis media in the right ear
Procedure: Eustachian tube inflation
Anesthesia: General
Blood Loss: Minimal
Findings: Serous mucoid fluid
Complications: None
Indications: The patient is a 2-year-old who presented to the office with chronic otitis media refractory to medical management. The treatment will be eustachian tube inflation to remove the fluid. Risks, benefits, and alternatives were reviewed with the family, which include general anesthetic, bleeding, infection, tympanic membrane perforation, routine tubes, and need for additional surgery. The family understood these risks and signed the appropriate consent form.
Procedure in Detail: After the patient was properly identified, he was brought into the operating room and placed supine. The patient was prepped and draped in the usual fashion. General anesthesia was administered via inhalation mask, and after adequate sedation was achieved, a medium-sized speculum was placed in the right ear and cerumen was removed atraumatically using instrument with operative microscope. The tube is dilated, an incision is made to the tympanum and thick mucoid fluid was suctioned. The patient was awakened after having tolerated the procedure well and taken to the recovery room in stable condition.
What CPT coding is reported for this case?
- A. 69420-RT
- B. 69436-RT
- C. 69421-RT
- D. 69433-RT
Answer: C
NEW QUESTION # 42
A couple presents to the freestanding fertility clinic to start in vitro fertilization. Under radiologic guidance, an aspiration needle is inserted (by aid of a superimposed guiding-line) puncturing the ovary and preovulatory follicle and withdrawing fluid from the follicle containing the egg.
What is the correct CPT code for this procedure?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
NEW QUESTION # 43
A 35-year-old female has cancer in her left breast. The surgeon performs a mastectomy, removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes.
Which mastectomy code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
Explanation:
For a mastectomy that involves removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes, the appropriate CPT code is:
* 19306: Mastectomy, radical, including pectoral muscles, axillary lymph nodes.
This code captures the extent of the surgery, including the removal of the breast tissue, skin, pectoral muscles, and lymph nodes.
References:
* CPT Professional Edition (current year)
* Surgery guidelines for mastectomy procedures
NEW QUESTION # 44
View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See Nurses Notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Have been reviewed-tachycardic.
Eyes: Pupils equal, round and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardia. Heart sounds normal. Pulses normal.
E D. Course: Insulin IV drip per protocol, at 10 units/hr.
Zofran 8 mg 01:33 Jul 13 2008 IVP.
Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.
Total critical care time: 45 min.
Disposition: Admitted to Intensive Care Unit. Condition: stable.
Admit decision based on need for monitoring and IV hydration and medications.
CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.
What E/M code is reported for this encounter?
- A. 99291, 99292
- B. 0
- C. 1
- D. 2
Answer: C
NEW QUESTION # 45
Where is a Warthin's tumor found?
- A. Back of eye
- B. Salivary gland
- C. Ovary
- D. Bone
Answer: B
NEW QUESTION # 46
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.
What CPT coding is reported for this case?
- A. 29827, 29824-51, 29826-51, 29805-59
- B. 29827, 29828-51, 29824-51, 29826
- C. 29827, 29824-51, 29826-51
- D. 29827, 29828-51, 29824-51, 29826, 29805-59
Answer: B
NEW QUESTION # 47
A Medicare patient is scheduled for a screening colonoscopy.
What code is reported for Medicare?
- A. G0121
- B. G0105
- C. 0
- D. G0106
Answer: B
NEW QUESTION # 48
A patient with a history of chronic venous embolism in the inferior vena cava has a radiographic study to visualize any abnormalities. In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the inferior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician.
What codes are reported for this procedure?
- A. 36010, 75827-26
- B. 36010, 75825-26
- C. 36000, 75825-26
- D. 36000, 75827-26
Answer: B
NEW QUESTION # 49
A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
NEW QUESTION # 50
A 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws were placed at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.
Select the procedure codes for this scenario.
- A. 63017, 63048, 22612, 22808, 22842 x 3
- B. 63047, 63048, 22612, 22614 x 3, 22842
- C. 63005 x 2, 22612, 22614 x 3, 22842
- D. 63042, 63043, 22808, 22841 x 3
Answer: B
NEW QUESTION # 51
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT coding is reported for this case?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: B
NEW QUESTION # 52
The outermost protective layer of skin is called the:
- A. Subcutaneous tissue
- B. Dermis
- C. Epidermis
- D. Hypodermis
Answer: C
Explanation:
The outermost protective layer of the skin is called the epidermis. It serves as a barrier to protect the body against environmental elements, pathogens, and helps to retain moisture. The epidermis itself is composed of several sub-layers, with the stratum corneum being the outermost layer.References: ICD-10-CM (current year), Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99).
NEW QUESTION # 53
The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger's lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
- A. Percutaneous
- B. Cannot determine based on the documentation
- C. Laparoscopic
- D. Open
Answer: D
NEW QUESTION # 54
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