ICD-9-CM chapters are arranged according to body system and etiology.
In ICD-9-CM, E and V codes are located in supplementary classifications.
When coding the diagnosis “Anterior wall myocardial infarction,” the coder should locate the main term infarction first.
ICD-9-CM chapters contain groups of three-digit disease categories.
M codes classify neoplasm morphology.
When coding for a carcinoma, the coder should use the M codes for third-party reimbursement.
Fracture of lower limb (820-829) is an example of an ICD-9-CM category code.
An experienced coder may code directly from the ICD-9-CM Index to Diseases
ICD-9-CM is a closed classification system.
Nonessential modifiers in the ICD-9-CM Index to Diseases qualify the main term by listing alternative sites, etiology, or clinical status.
History of cardiovascular disease. Assign the ICD-9-CM code(s).
Asymmetry of face. Assign the ICD-9-CM code(s).
Dacryocystitis. Assign the ICD-9-CM code(s).
Discharge, ear, cerebrospinal fluid. Assign the ICD-9-CM code(s).
Periodontal pockets. Assign the ICD-9-CM code(s)
Acute pneumonia. Assign the ICD-9-CM code(s).
Arterial hypotension. Assign the ICD-9-CM code(s).
ICD-9-CM Appendix E contains which of the following?
List of Three-Digit Categories
The diagnostic terminology Status cardiac pacemaker would be assigned a(n) _____ code.
Which is the last section of the ICD-9-CM Index to Diseases?
Alphabetic Index to External Causes of Injury
When coding a diagnosis using a three-volume set of ICD-9-CM, the coder should refer to which volume first?
Volume 2
Onycholysis is reported with ICD-9-CM code _____
Which of the following is reported to state cancer registries?
M codes
Locate the main term for the diagnosis “acute bronchial pneumonia with influenza” in the ICD-9-CM Index to Diseases. Which of the following is a nonessential modifier?
The Classification of Drugs by AHFS List is found in Appendix _
Chronic Rheumatic Heart Disease (393-398) is an example of an ICD-9-CM _
The AHFS List can be referenced in the ICD-9-CM Table of Drugs and Chemicals by locating the main term _____.
The Glossary of Mental Disorders is found in _
A morphology code contains the letter M followed by _____ digit(s) before the slash
The ICD-9-CM Alphabetic Index to External Causes of Illness and Injury is located in the ____
Index to Diseases
When coding the procedure “open reduction of closed radial fracture,” which is the main term?
To code the diagnosis “allergic rash due to penicillin,” the coder would need to assign a(n) _
Table of Drugs and Chemicals code
Square brackets are used in the ICD-9-CM and ICD-10-CM Index to Diseases to enclose abbreviations, synonyms, alternative wording, or explanatory phrases.
The word and is interpreted as “and/or.”
When coding, sequence the underlying condition first before the manifestation code.
Tables appear in the ICD-9-CM and ICD-10-CM Index to Diseases and Index to Procedures
Eponyms are found only in the ICD-9-CM and ICD-10-CM Index to Diseases
The colon is used after an incomplete term.
The instruction see condition is found in the ICD-9-CM and ICD-10-CM disease index
The phrase due to is used in the ICD-9-CM Index to Procedures and Tabular List of Procedures and ICD-10-CM Index to Diseases and Injuries.
Parentheses are used in the ICD-9-CM and ICD-10-CM Index to Diseases to identify manifestation codes
Eponyms are diseases or syndromes that are named for people.
Calcification of lens. Assign the ICD-9-CM code(s)
Chronic crepitant synovitis of wrist. Assign the ICD-9-CM code(s).
Phobic disorders. Assign ICD-9-CM fourth listed second qualifier.
Gelastic epilepsy. Assign the ICD-9-CM code(s).
Smallpox. Assign ICD-9-CM first qualifier code.
Benign neoplasm of skin. Assign ICD-9-CM second first qualifier code.
Diabetes mellitus uncontrolled with gangrene. Assign the ICD-9-CM code(s).
ICD-9-CM code 473.8 Other Chronic Sinusitis is an example of the use of
Which are used in the ICD-9-CM alphabetic indexes to enclose italicized codes, which signify the use of more than one code to describe a diagnosis or procedure?
Slanted brackets
An abbreviation used in the ICD-9-CM and ICD-10-CM indexes and tabular lists to save space is
Which punctuation is used to identify manifestation codes in the ICD-9-CM Index to Diseases?
Slanted brackets
Which is a mandatory instruction?
In the ICD-9-CM, which code is an “other” and “other specified” code?
Which ICD-9-CM code is an “unspecified” code?
Which is an example of punctuation used in ICD-9-CM and ICD-10-CM?
Which is equivalent to “unspecified” and “unqualified”?
Which statement regarding the phrase due to is correct?
Due to indicates the presence of a cause-and-effect relationship between two conditions.
Millin-Read operation is an example of a(n)
Barlow syndrome is an example of a(n) _
Which statement regarding etiology/manifestation codes is correct?
The etiology code is always sequenced first.
The ICD-9-CM Index to Diseases entry for “amyloid neuritis” lists two codes, 277.39 [357.4]. How is code 357.4 reported?
357.4 is reported second.
In the ICD-9-CM Index to Procedures entry “Venotomy, Abdominal,” the word Abdominal is a
If the phrase omit code is found after the main term or subterm, do not assign a code to the operative approach.
ICD-9-CM diagnosis codes have been adopted under HIPAA for all health care settings.
The condition or nature of a late effect should be reported as the secondary code
When coding both an acute and chronic condition, sequence the acute condition first.
When a late effect is coded, the late effect code is sequenced first.
Procedure codes should always be assigned for an operative approach.
ICD-9-CM procedure codes have been adopted for inpatient procedures by hospitals
ICD-9-CM procedure codes consist of alphanumeric codes.
A colonoscopy is an example of an open procedure.
When a “code first” note is present and an underlying condition is documented in the patient record, the underlying condition is reported first.
Removal of frontal lobe neoplasm; pathology results not reported. Assign ICD-9-CM code(s).
Sunburn on nose, 2nd degree. Assign ICD-9-CM code(s).
Sudden change of air pressure in aircraft, causing aeroneurosis, or aviator’s disease. Assign ICD-9-CM code(s).
E 902. 1
Kayser-Fleischer ring. Assign ICD-9-CM code(s)
Confusional arousals. Assign ICD-9-CM code(s).
Elevated fasting glucose. Assign ICD-9-CM code(s).
Died without medical attention (cause unknown). Assign ICD-9-CM code(s).
Displacement of cardiac pacemaker electrode. Report code _
Acute gangrenous appendicitis. Postoperative complication paralytic ileus. Appendectomy. Report codes _____.
540.9, 997.4, 47.09
Given the diagnosis “metastatic carcinoma from breast to lung,” breast would be coded as
malignant primary
Uremia; malignant hypertension. Report code(s) _
586, 401.0
Gram-negative septicemia due to bacteroides. Report code
A patient suffered a fracture of the radius and ulna due to a fall on ice a year ago. The patient presents today with pain due to nonunion of the fracture. Which should be coded as a late effect?
Five-hour-old infant, premature at 30 weeks, spontaneous birth, is transferred to general hospital for treatment in the neonatal intensive care unit. Final diagnosis: male newborn, suspected respiratory distress syndrome due to prematurity. Report codes _____ for the general hospital inpatient stay.
769, 765.10, 765.25
A malignant neoplasm that is localized, circumscribed, encapsulated, and noninvasive but has not spread to deeper or adjacent tissues or organs is _____.
in situ
A 16-year-old male patient suffered a missile (open) fracture of tibial shaft, upper section. Report code(
Peritonitis due to catheter inserted into abdomen for ambulatory peritoneal dialysis. Removal of catheter. Report codes ____
996.68, 567.89, 97.82
A 19-year-old patient was treated as an inpatient for “fever of unknown origin.” Report code(s)
Which of the following diagnostic statements is an example of a late effect?
Traumatic arthritis of the knee
Suspected myocardial infarction, ruled out. Report code(s
Hemiplegia secondary to cerebral artery thrombosis 1 year ago. Report code(s
Yung Lee was diagnosed with angina; permanent cardiac pacemaker inserted 1 year ago, functioning well. Report codes __
413.9, V45.01
A radiology center is directed by a radiologist.
An ambulatory patient may also be referred to as an outpatient
A rehabilitation facility provides occupational, physical, and speech therapy to patients
Reporting qualified diagnoses on the CMS-1500 claim is allowed.
Ambulatory patients typically have a hospital length of stay of 1 day
Intravenous administration of fluids, electrolytes, and other additives is called hydration therapy
A patient receiving services in a day treatment program may come to the facility for up to three days per week.
A patient is being treated in an outpatient setting. During a routine exam, if a diagnosis or condition is documented, it should be reported as an additional code.
An ambulatory care center that is established remotely from a hospital is referred to as a satellite clinic.
The Uniform Ambulatory Care Data Set (UACDS) was established by the federal government as a standard data set for ambulatory care facility records.
Patient treated presented with abdominal pain; scheduled for x-ray to rule out a gastric ulcer. Assign ICD-9-CM disease code(s).
Urinary tract infection due to E. coli. Assign ICD-9-CM disease code(s).
Patient treated in the office for type 2 diabetes mellitus and possible pneumonia. Urinalysis revealed presence of ketone bodies. Patient is referred for outpatient chest x-ray. Assign ICD-9-CM disease code(s).
Outpatient cataract extraction for left toxic cataract. Caused by unknown liquid substance. Assign ICD-9-CM disease code(s).
Recheck in rheumatologist’s office for acrosclerotic scleroderma. Assign ICD-9-CM diagnosis code.
Patient presents with shortness of breath and difficulty breathing. Chest x-ray revealed areas of opacity. Sputum culture was negative. Patient was diagnosed with viral pneumonia. Assign ICD-9-CM disease code(s).
Follow-up office visit for patient discharged from hospital with final diagnoses of peripheral vascular disease, chronic pyelonephritis, and essential hypertension. Assign ICD-9-CM disease code(s).
Hemiplegia resulting from a cerebrovascular accident that occurred 1 year ago is coded as _
Annual physical examination is coded as __
Physiatrists, psychiatrists, neurologists, neurosurgeons, and physical and occupational therapists are all part of the staff at a(n) ____
Pain Management Care
An elderly male patient suffered a cerebrovascular accident. What type of medical specialist would he go to?
Cardiovascular medicine
Diabetic cataract is coded as _
A patient is being treated for primary retinal cysts. How is this coded as?
Facial laceration is coded as _
Intensive case management is associated with _____ care
mental health
HIV positive is coded as
Which of the following allows patients to receive care in 1 day without the need for inpatient hospitalization?
Ambulatory care
Point of first contact is a phrase most closely associated with _
Primary Care
Anoxic brain damage due to a previous accidental overdose of Nembutal (1 year ago) is coded as _
348.1,909.0,E 929.2
Urinary tract infection due to E. coli is coded as __
599.0, 041.49
Which of the following typically provides preventive medicine services such as well-child clinics?
Public health department
Which of the following are reimbursed under Medicare?
Speech Therapy
DME MACs have the authority and responsibility to establish local policies.
When multiple modifiers are added to a code, the most specific modifier is listed first.
Submission of an HCPCS level II code guarantees health insurance coverage
When a radiology procedure is canceled, report a code to describe the extent of the procedure performed.
The dash that precedes a modifier should be reported.
Addition, endoskeletal system, below knee, alignable system. Assign HCPCS code(s).
Smoking cessation gum. Assign HCPCS code(s).
Enteral nutrition infusion pump, with alarm. Assign HCPCS code(s).
Compression burn garment, bodysuit (head to foot), custom fabricated. Assign HCPCS code(s)
Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg. Assign HCPCS code(s)
Positioning seat for persons with special orthopedic needs. Assign HCPCS code(s).
Radiopharmaceutical, diagnostic, not otherwise classified. Assign HCPCS code(s).
Culture, bacterial, urine, quantitative, sensitivity study. Assign HCPCS code(s).
Contact lens, gas permeable, bifocal, one lens. Assign HCPCS code(s
Adhesive remover, wipes, any type, each. Assign HCPCS code(s).
Additive for enteral formula (e.g. fiber). Assign HCPCS code(s).
Assistive listening device, alerting, any type. Assign HCPCS code(s).
Injection, ziprasidone mesylate, 20 mg. Assign HCPCS code(s).
J3486 X 2
Catheter, hemodialysis/peritoneal, long term. Assign HCPCS code(s)
Stoma cap. Assign HCPCS code(s).
What services are included under Transportation Services of HCPCS level II codes?
The Transportation Services Including Ambulance section of HCPCS level ll includes codes for ancillary transportation-related fee, ground and air ambulance, and nonemergency transportation ( e.g., automobile, bus, taxi, and wheelchair van
What should a coder do if she cannot find a code for the procedure or service that needs to be reported?
If MAC does not provide special instructions for reporting these services in HCPCS, report them with the proper “unlisted procedure”code from CPT> Remember to submit documentation explaining the procedure or service when using the “unlisted procedure”
An HCPCS level II code begins with the letter “K.” This signifies that the Medicare administrative contractor responsible for processing the claim is a _
An outpatient received hyperbaric oxygen therapy, 60 minutes. Report code(s) _
C1300, C1300
he Administrative, Miscellaneous, and Investigational section of HCPCS level II includes codes for all of the following EXCEPT _
ancillary transportation-related fees
A patient is prescribed orthopedic shoes. A code to reflect the shoes would be found under the _____ section.
A patient was administered butorphanol tartrate (trade name Stadol NS), nasal spray, 25 mg. Report code
A patient who is severely diabetic received a below-knee test socket. The code assigned would be found under the _____ section.
Prosthetic Procedure
Which of the following modifiers may be added to a code for CPT radiology services?
A patient was supplied with a water pressure mattress. Report code ___
Codes for outpatient PPS would include which of the following
What are used to report product-specific HCPCS codes to obtain reimbursement for biologicals, devices, drugs, and other items associated with implantable device technologies?
C codes
Match each description with a category code listed below.
Question Selected Match
identifies services that would not ordinarily be assigned a CPT code
C. Q
reported to Medicare administrative contractors for outpatient department procedures
B. C
identifies professional health care procedures and services that do not have codes identified in CPT
D. G
developed by BCBSA and HIAA when no HCPCS level II national codes exist to report drugs, services, and supplies but codes are needed for claims processing
A. S
reported to MACs when existing permanent national codes do not include codes needed to implement a medical review coverage policy
E. K
CPT Category I codes are organized according to five sections
CPT does not support electronic data interchange.
The descriptions of all codes listed for a specific procedure must be carefully reviewed before a final code is selected.
Use of CPT is mandated for reporting Medicare Part B physician services.
The National Correct Coding Initiative was implemented by the American Medical Association.
Patient seen for trimming of three nondystrophic nails, becomes extremely anxious, physician chooses to administer anesthetic to make patient more at ease. Assign code with appropriate modifier.
Surgeon repaired reducible umbilical hernia on infant weighing less that 4 kg. Assign code with appropriate modifier.
Transcriptionist developed pain in right and left wrists. PCP diagnosed carpal tunnel syndrome. Corticosteroids were injected. Assign code with appropriate modifier.
Dermatologist performs shaving of dermal lesion, 1.5 cm on arm of patient; at same time, a 2.3 lesion was removed from the patient’s eyelid. Assign code with appropriate modifier
On-call radiologist is called to the ED to review the four x-ray views of a skull taken by radiology technician. Assign code with appropriate modifier.
Excision of rectal tumor, transanal endoscopic microsurgical (TEMS) approach. Surgeon supplied regional anesthesia. Assign code with appropriate modifier.
During an emergency cesarean section of quadruplets, on-call physician requires another physician to assist in the delivery. Assign code with appropriate modifier.
While on vacation, a patient is rushed to surgery for laparoscopic treatment of ectopic pregnancy, she will see her regular OB/GYN when she returns home for aftercare. Assign code with appropriate modifier.
Postsurgical patient presents to surgeon’s office for a follow-up visit; nurse reports elevated blood pressure and a prescription for hypertension is provided, resulting in a level 3 E/M examination. Assign code with appropriate modifier.
Surgeon in hospital setting documents multiple codes for a procedure. What modifier would the coder use to alert third-party payers that more than the allowable modifier(s) are added to a procedure or service code? Assign appropriate claim form and modifier.
PCP sends patient out of office for a heavy metal screening to be performed at an outside clinical laboratory. Assign code with appropriate modifier.
Patient sent to laboratory for general health panel blood draw. Sample was inadvertently dropped and the patient was asked to return that afternoon to give another sample. Assign code with appropriate modifier.
Surgeon performs emergency laparoscopic cholecystectomy on a 550-pound patient. Complicated and extensive measures were necessary to complete the procedure. Assign code with appropriate modifier.
Patient with a fractured cervical vertebra undergoes a surgical fusion. One surgeon harvests a section of bone from the hip; second surgeon performs the procedure. Assign code with appropriate modifier
New patient visit to discuss new diagnosis of diabetes mellitus, level 3 E/M with 45 minutes used explaining proper procedures for management of disease. Assign code with appropriate modifier.
Describe the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003
Which required that new,revised and deleted CPT codes be implemented each january 1. In the past, 90-day grace period had been allowed so provider’s and health care facilities had time to update billing system and coders had an opporunity to undergo training regarding new,revised and deletated codes.
Describe the outcome of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
HIPAA named CPT and HCPCS level II as the procedure code sets for physicians services, Physical and occupational therapy services radiological procedures clinical laboratory tests other medical diagniostic. HIPAA also named ICD-9-CM code set
A patient underwent a total thyroxine lab test that was sent to an outside laboratory. Report code
A patient fractured his left leg. An assistant surgeon participated in the open reduction and internal fixation of the tibial fracture, proximal end. Record code
The symbol that indicates that a procedure includes conscious sedation is a ___
A patient presented to the physician’s office for removal of five plantar warts on his feet. During the procedure, the patient became extremely anxious, and the procedure was discontinued. Record code __
A pregnant woman underwent a complete Doppler echocardiogram for evaluation of her fetus. Record code _____.
A patient underwent posterior osteotomy of the spine, three thoracic vertebral segments. Record code(s) _____.
22212, 22216, 22216
A patient underwent a costochondral cartilage graft procedure. She also underwent a nasal septal cartilage graft procedure during the same operative session. Record code(s) __
A patient underwent total gastrectomy with intestinal pouch, by two surgeons. Record code ___
When a procedure was repeated because of special circumstances involving the original service and the same physician performed the repeat procedure, modifier _____ should be recorded.
Revised guidelines and notes are identified by a ___
Notes located beneath headings and/or subheadings apply to all codes in the categories or subcategories.
Physician standby services involve a physician spending a prolonged period of time without patient contact, waiting for an event to occur that will require the physician’s services.
The fact that a patient is located in a critical care unit means that she is receiving critical care.
Unit/floor time is the amount of time the provider spends at the patient’s bedside and in management of the patient’s care on the unit or floor.
When codes for specialty services are reported, a separate evaluation and management service from the CPT E/M section is reported on the same date.
Observation care discharge, day management. Assign code(s).
Physician direction of emergency medical systems (EMS) emergency care, advanced life support. Assign code(s).
Office or other outpatient visit, for established patient, presenting problem(s) are minimal. Assign code(s).
Physician standby service, 15 minutes. Assign code(s).
Initial observation care per day, comprehensive history, comprehensive examination, and medical decision making of moderate complexity. Assign code(s).
Critical care for the critically ill or critically injured patient, 1 hour, 30 minutes. Assign code(s)
99291 X 1 AND 99292 X 1
Emergency department visit that requires an expanded problem-focused history, expanded problem-focused examination, and medical decision making of moderate complexity. Assign code(s).
Work-related or medical disability examination by other than the treating physician. Assign code(s).
Medical team conference, patient and/or family not present, 30 minutes or more participation by nonphysician qualified health care professional. Assign code(s).
Home visit of new patient which requires comprehensive history, comprehensive examination, and medical decision making of high complexity. Assign code(s).
How are critical care codes selected?
Critical care service codes are selected according to the total duration of time the provider spent delivering the services to the patient, even if the time spent was not continuous.
List some examples of critical care areas.
coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit or emergency care facility
The physician spent 30 minutes providing telephone services to a distraught patient who had been seen in the office two weeks ago. The patient was calm by the end of the call, and the physician scheduled an appointment to see the patient the next day. Which is reported?
No code is reported.
A limited examination of the affected body part or organ system and other symptomatic or related organ systems is a(n) _____ examination.
expanded problem-focused
A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status is _____.
Dr. Lee saw Kenya Yatani in her office for the first time for treatment of a mild sprain. A problem-focused history and exam were performed, and medical decision making was straightforward. Report code __
A physician returns a call to a patient who needs clarification about instructions for taking a medication prescribed during an office visit ten days ago. Medical discussion was 8 minutes in duration, and the physician confirmed that the patient would be seen in the office in 2 weeks. Report code __
CPT recognizes _____ types of presenting problems.
When selecting an E/M code, it is important to review patient record documentation to consider up to _____ components
Which of the following refers to type of service?
Critical care
Evaluation and management code selection is based on _____ key components
Dr. Lewis treated an established patient in the office who complained of a 3-month history of fatigue and weight loss. Comprehensive history and exam were performed; medical decision making was of high complexity. Report code ____
Question Selected Match
consists of chief complaint and brief history of present illness or problem
E. problem-focused history
chronological description of patient’s present condition from time of onset to present
A. history of present illness
chief complaint, extended history of present illness, review of systems directly related to the problem identified in the HPI in addition to a review of all additional body systems, and complete past/family/social history
D. comprehensive history
chief complaint, brief history of present illness, and problem pertinent system review
B. expanded problem-focused history
description of medical condition stated in the patient’s own words
C. chief complaint
Match each code with a service listed below.
Question Selected Match
E. psychotherapy with patient; session was 30 minutes
A. sleep study with ECG and oxygen monitoring; technologist in attendance
B. patient who saw physician for third opinion regarding ulcer treatment
C. examination of a patient applying for basic life insurance
D. unlisted E/M service
The code that describes the anesthesia service for the procedure that has the highest basic unit value is reported first.
Notes located beneath headings apply to all codes in the heading.
Placing an airway tube is included as part of the anesthesia service.
An anesthesiologist is a physician who, after medical school, completes a one-year internship and three-year residency in anesthesia.
The postanesthesia evaluation should be coded separately.
Anesthesia for electroconvulsive therapy. Assign code(s)
Physiological support for harvesting of organ(s) from brain-dead patient. Assign code(s).
Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider), prone position. Assign code(s).
Anesthesia for repair of ruptured Achilles tendon, with or without graft on patient with controlled diabetes. Assign code(s).
Anesthesia for urgent hysterectomy following delivery. Assign code(s).
Anesthesia for procedures in lumbar region, diagnostic or therapeutic lumbar puncture. Assign code(s)
Anesthesia for procedures involving plastic repair of cleft lip on 6-month-old child. Assign code(s).
Anesthesia for diagnostic arteriography/venography on patient with history of severe coronary artery disease. Assign code(s).
Anesthesia for procedures on eye, corneal transplant on 82-year-old patient. Assign code(s).
Anesthesia for open or surgical arthroscopic procedures of the elbow, repair of nonunion or malunion of humerus. Assign code(s)
What services are bundled in the anesthesia code section?
Draping,Postioning,Prepping, and transporting the patient.
Inserting nasogastric or orogastric tubes
Inserting peripheral IV lines for fluid and medication administration
Interpreting laboratory results
Interpreting monitored functions
Placing airway tubes for airway management
Positioning eternal devices
Stimulating nerves to determine level of paralysis or localization of nerve
What is a peripheral nerve block?
Injection of local anesthetic in the vicinity of a peripheral nerve to anesthetize that nerve’s aea of innervation
An anesthesiologist provided general anesthesia monitored to a normal healthy patient who underwent diagnostic arthroscopy on the right knee. Report code __
Topical application of a local anesthetic cream is an example of __
surface anesthesia
Ron McAllister underwent extracorporeal shock wave lithotripsy. He suffers from controlled hypertension. Using the Anesthesia section, report code __
Review of a patient record reveals the following: The anesthesia code has a basic unit value of 5, and the physical status modifier -P2 has a relative value of 0. Anesthesia time is 30 minutes. A conversion factor of $17.04 is assigned to Alabama. Payment for anesthesia services is calculated as __
A healthy 10-month-old patient received general anesthesia services from an anesthesiologist for low abdominal hernia repair. Report code(s) __
A patient undergoes a surgical procedure that requires 60 minutes of anesthesia time. The patient received _____ unit(s) of anesthesia time.
A 32-year-old patient with type 1 diabetes mellitus underwent biopsy of the liver for which an anesthesiologist provided anesthesia services. Report code __
Which modifier should be assigned to indicate the patient’s condition at the time anesthesia was administered?
A CRNA provided general anesthesia services to a 5-year-old normal healthy patient who underwent third-degree burn debridement of the chest, 5 percent of total body surface area. Report code __
Jane Smith underwent amniocentesis. She has petit mal epilepsy. Using the Anesthesia section, apply code _____.
Match each meaning with a modifier listed below.
Question Selected Match
reduced services
D. -52
multiple procedures
C. -51
discontinued procedure
B. -53
multiple modifiers
E. -99
bilateral procedures
A. -50
Match each description with a physical status modifier listed below.
Question Selected Match
patient with mild systemic disease
C. -P2
normal healthy patient
E. -P1
declared brain-dead patient
A. -P6
moribund patient
B. -P5
patient with severe systemic disease
D. -P3
The global surgical package definition prevents Medicare payments for services that are more or less comprehensive than intended.
Supplies and materials provided by the physician over and above those usually included with the office visit or other services rendered may be listed separately.
The Centers for Medicare and Medicaid Services established a national definition for a global surgical package.
When surgical destruction is part of a surgical procedure, different methods of destruction are not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition.
A 1.5-cm malignant lesion was excised from the patient’s chin, and the excised diameter was 2.9 sq cm. An adjacent tissue transfer procedure from the right cheek (4 sq cm) to the chin defect was also performed. Report codes 11642 and 14040
False.Do not report code 11642 with code 14040. Instead, report only code 14040 because notes located in this subsection of CPT state that the excision of a lesion is included when a repair by adjacent tissue transfer or tissue rearrangement is performed.
Chemical exfoliation for acne (e.g., acne paste, acid). Assign code(s).
Incision and drainage of a pilonidal cyst, complicated. Assign code(s).
Repair of brow ptosis. Assign code(s).
Mammaplasty, augmentation, with prosthetic implant. Assign code(s).
Excision, sacral pressure ulcer, with skin flap closure, with ostectomy. Assign code(s).
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs, excised diameter 2.1 to 3.0 cm, complicated. Assign code(s).
Placement of percutaneous localization clip during a percutaneous needle core right breast biopsy using stereotactic imaging guidance. Assign code(s).
Tattooing, intradermal introduction of insoluable opaque pigments to correct color defects of skin, including micropigmentation, 6.0 sq cm or less. Assign code(s).
Trimming of nondystrophic nails, any number. Assign code(s).
Electrolysis epilation, each 30 minutes. Assign code(s).
When should modifier -58 be assigned?
58 modifier is assigne when staged or related procedure or service by the same physician or other qualified health care professional during postoperative period.
What should the coder report when coding wound repairs?
calculate the size of the wound in centimeters regardless the shape
add together the lenghts of all wound for the multiple repair of wounds in the same anatomic area and report just one code
report the code for the most complicated repair first
when physician locates a foreign body and removes it , report a code for its removal
Add on codes do not requires modifier -51
A large basal cell carcinoma on a patient’s forehead is removed using Mohs’ chemosurgery. The first stage involves removing all visible tumor and preparing six specimens using mapping, color coding, and microscopic examination. Report code(s) ___
17311, 17315
How is the Surgery section organized?
Body system
Replacement of breast tissue expander with breast prosthesis (permanent). Report code __
The patient undergoes breast biopsy following a complaint of a lump in the left breast. The entire lump is excised and, upon pathologic examination, it is determined that the lump is benign. No further surgery is necessary. Report code _
Information applicable to a particular CPT section is located in the _
A patient had avulsion of four nail plates. Report code(s) __
11730, 11732, 11732, 11732
A surgeon performed bilateral breast biopsies; the left breast mass was completely removed, but only a portion of the right breast was removed due to its large size. Frozen section revealed the right breast mass to be malignant; a modified radical mastectomy was performed during the same operative session. Report code(s) ____
19307-RT, 19120-51, LT
Excision of two 1-cm benign skin lesions of the face. Report code(s) _
Adjacent tissue transfer (1 sq cm) of skin defect of the chin, which was the result of an excision of benign skin lesion (1 cm) of the chin (performed during the same operative procedure). Report code(s) __
A patient had intermediate closures of a 1-cm laceration of the neck and a 6-cm laceration of the foot. Report code ____
Question Selected Match
D. application of extreme cold, such as liquid nitrogen, to destroy abnormal tissue
E. surgical closure of a wound
C. use of chemicals to destroy diseased tissue
B. surgical rebuilding of a body part, such as a knee joint
A. moving healthy tissue from one site to another to replace diseased tissue
Question Selected Match
transplantation of tissue from the same individual
B. autograft
transplantation of tissue from someone of the same species
E. allograft
transplantation of tissue from a different species
C. xenograft
supplied by laboratories
D. tissue-cultured autografts
bioengineered artificial skin
A. acellular dermal replacement
LeFort procedures are performed to treat ankle fractures.
Code 29280 is reported when an initial strapping of the hand is done at the same time as the suture of a laceration.
When coding an initial fracture treatment, do not assign a separate code for the cast application.
Keller, McBride, and Mitchell are types of procedures performed to surgically correct bunions.
A compound fracture is a type of closed fracture
Arthrotomy of the temporomandibular joint, bilateral. Assign code(s).
Arthroscopy of the left ankle with ankle arthrodesis. Assign code(s).
Removal of lung, total pneumonectomy, extrapleural with empyemectomy. Assign code(s)
Pneumonolysis, extraperiosteal, including filling or packing procedures. Assign code(s).
Windowing of cast on right lower leg. Assign code(s).
Insertion of indwelling tunneled pleural catheter with cuff, imaging guidance performed. Assign code(s).
Arytenoidectomy or arytenoidopexy, external approach. Assign code(s).
Surgical repair of nasal vestibular stenosis. Assign code(s).
Tenotomy, shoulder area, multiple tendons through same incision. Assign code(s).
What is the difference between a direct and indirect laryngoscopy?
Direct laryngoscopy is the insertion of a flexible or rigid fiberoptic scope or a rigid laryngoscope to visualize throat structures.
Indirect laryngoscopy is the insertion of a small hand mirror in the patient’s mouth at the back of the throat while the physician wears headgear that contains a mirror and light source, allowing the physician to visualize the patient’s throat
List examples of internal fixation devices.
Pins,screws,and/or plates are inserted through or within the fracture area to stablize and immobilize the injury.
A 33-year-old female underwent incision and drainage of infected bursa, right wrist. Report code
A patient sustained a fracture of his left ankle four weeks ago. The short-leg cast that was applied at that time has broken down, and during this encounter, the physician removed the old cast and applied a replacement cast for the remaining three weeks of healing time. Report code(s)
Which term describes the attempted reduction or restoration of a fracture or dislocation with application of manually applied forces?
Biopsy of mediastinal space performed via thoracoscopy. Report code(s) _
Treatment of metacarpal fracture of one bone of the hand with manipulation of the site and application of cast. Report code(s) _
Arthrodesis of two interphalangeal joints. Report code(s)
26860, 26861
Mr. Chung underwent open reduction with internal fixation of shaft fractures of the right tibia and fibula on June 20. Late during that same evening, the patient’s wound site became inflamed and showed signs of infection. Upon his return to the operating room, the site was reopened, a severe reaction to the metal was noted, and the metal rod was removed. The patient did not have the internal fixation device replaced, but a cast was applied to the leg. Report code(s) __
27758-RT, 20680-78-RT
Surgical treatment was rendered to a patient who sustained a fracture of the right humeral shaft. The orthopedic surgeon performed open treatment of the fracture using an intramedullary implant and locking screws. Following the procedure, a cast was applied. Report code(s) _
A patient underwent closed reduction of a closed fracture of the right clavicle as the result of an automobile accident. Report code __
Bilateral sinus endoscopy performed with partial resection of ethmoid. Report code __
Match each CPT code to the correct heading below.
Question Selected Match
H. wound exploration
E. introduction or removal
B. Excision
F. introduction or removal
A. Grafts
D. incision
C. Replantation
G. Grafts
Match each procedure to the correct CPT code below.
Question Selected Match
Patient had fluid aspiration of the knee.
D. 20610
Patient received an injection in the sinus tract for pain.
E. 20500
Patient had a deep abscess, and the doctor made an incision to drain the abscess.
C. 20005
A child fell on some old wood, and his mother thought he got a large chunk lodged in his leg. The ER doctor did an exploration of the leg and found nothing.
A. 20103
Patient received a graft of a nasal septum.
F. 20912
Patient received a replantation of her arm after a complete traumatic amputation during a car accident.
B. 20802
Stromal stem cells produce blood, fat, and bone
The majority of cardiac tumors are benign.
There are two types of bone marrow and three types of stem cells
Notes located beneath headings and subheadings in a CPT section apply to all codes throughout the section
There are six areas of lymph nodes in the human body
Insertion of cannulas for prolonged extracorporeal circulation membrane oxygenation (ECMO). Assign code(s)
Resection, diaphragm, with complex repair (e.g., prosthetic material, local muscle flap). Assign code(s).
Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass. Assign code(s).
Transfusion, intrauterine, fetal with radiological supervision and interpretation. Assign code(s).
Upgrade of implanted pacemaker, conversion of single-chamber system to dual-chamber system. Assign code(s).
Repair of double outlet right ventricle with intraventricular tunnel repair. Assign code(s)
Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft. Assign code(s).
Norwood procedure. Assign code(s).
Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure). Assign code(s).
Selective catheter placement, arterial system, initial third order or more selective thoracic or brachiocephalic branch, within a vascular family. Assign code(s).
CPT code 38724 is reported to reflect a modified radical neck dissection, which preserves what type of structures?
in a modified radical neck dissection Which preserves of one or more nonlymphatic structures (SAN, IJV, SCM)
CPT codes 38562-38564 describe the limited excision of lymph nodes for what purpose?
38562-38564 describe the limited excision of lymph nodes for cancer-staging, Which is the determination that cancer has or has not spread anatomically from its point of origin.
A patient presents with tricuspid valve regurgitation and undergoes repair of the valve, which requires use of a ring. Report code
Ligation and stripping of bilateral short saphenous veins and ligation of long saphenous veins from the saphenofemoral junction to the knee of the left leg. Report code(s) __
37718-50, 37722-LT
Liza Mills was diagnosed at birth with atresia of her tricuspid valve. Liza is now 3 years old, and today she underwent tricuspid valve repair, which involved closure of the atrial septal defect and anastomosis of the vena cava to the pulmonary artery. Report code ___
Vein graft repair of blood vessel, right arm. Report code
Charles Joseph, a 2-day-old infant weighing just 3 kg, underwent a blood transfusion. Report code ___
A patient underwent bone marrow aspiration only. Report code __
Cutdown of vein for venipuncture, 55-year-old male patient. Report code __
A patient underwent coronary artery bypass graft, three venous vessels. This is a repeat CABG because the patient previously underwent CABG surgery five years ago during which two coronary venous grafts were performed. Report code(s) __
33512, 33530
Repositioning of implanted transvenous pacemaker electrode was performed on May 6. Pacemaker was originally implanted on April 2. Report code(s) __
Allogenic stem cell transplant. Report code _
Match each procedure with a CPT code below.
Question Selected Match
Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s) by thoracotomy
D. 33243
Patient comes in for a repair of atrial septal defect with cardiopulmonary bypass with patch
F. 33641
Valvotomy pulmonary value, closed heart transventricular
A. 33470
Patient comes in to have a repair of a congenital arteriovenous fistula of the neck
C. 35180
A patient fell and ruptured his spleen. The provider did a total splenectomy
B. 38100
Patient comes in for a coronary artery bypass, using a single arterial graft
E. 33533
Match each procedure or device with its abbreviation below.
Question Selected Match
percutaneous myocardial revascularization
coronary artery bypass graft
percutaneous transmyocardial laser revascularization
percutaneous transluminal angioplasty
ventricular device
pacing cardioverter-defibrillator
For the correct reporting of a complete tonsillectomy performed on a 10-year-old patient, modifier -50 is added to CPT code 42820.
An extracorporeal shock wave lithotripsy is a procedure that requires a surgical incision.
The visual examination of the entire colon is called a colonoscopy.
The human body has two urethras
The protrusion of a portion of the intestine is termed a hernia.
Endoscopic retrograde cholangiopancreatography (ERCP), with sphincterotomy/papillotomy with radiological supervision and interpretation. Assign code(s
Plastic repair of cleft lip/nasal deformity, primary bilateral 1 of 2 stages. Assign code(s)
Complete esophagogastric fundoplasty via laparotomy. Assign code(s).
Removal of embedded foreign body from dentoalveolar structures, bone. Assign code(s).
Biopsy, abdominal or retroperitoneal mass, percutaneous needle. Assign code(s).
Cricopharyngeal myotomy. Assign code(s).
Percutaneous cholecystostomy with radiological supervision and interpretation. Assign code(s)
Hepatectomy, resection of liver, partial lobectomy. Assign code(s).
Upper gastrointestinal endoscopy with directed submucosal injection(s), any substance. Assign code(s)
Repair recurrent inguinal hernia, any age, incarcerated or strangulated. Assign code(s).
What procedure involves passing an endoscope through the esophagus and other structures to the pancreas, after which dye is injected to visualize biliary ducts?
Endoscopic retrograde cholangiopancreatography (ERCP)
A patient undergoes placement of a ureteral stent done during a cystourethroscopy. The code assigned is 50605. An audit of the record and assigned code identifies this as an incorrect code assignment. What is the correct CPT code for this procedure?
A 75-year-old male has been diagnosed with rectal prolapse. The Thiersch procedure is performed to correct this problem. Report code _
Total colectomy done under laparoscopic approach with ileostomy. Report code _
A 50-year-old male patient undergoes a screening sigmoidoscopy and colonoscopy during the same operative session. Report code(s) __
A 55-year-old female presents to the same-day surgical unit for a sigmoidoscopy. The physician inserts a flexible scope into the patient’s rectum and determines that the rectum is clear of any polyps. The scope is advanced to the sigmoid colon, and a total of three polyps are found. Using the snare technique, the polyps are removed. The flexible scope is withdrawn. Report code(s) _
A patient presents to the ambulatory surgical unit for a colonoscopy due to her history of colon cancer. The patient has performed the full prep for this procedure. The procedure is started. Once the splenic flexure is reached, a large obstruction of the area prevents the scope from passing any farther. The colonoscopy is discontinued after viewing only the sigmoid portion of the colon. Report code ___
A 65-year-old male patient undergoes transurethral resection of the prostate gland with vasectomy and meatotomy. Report code(s) __
Carol Maddox is diagnosed with a large bladder stone that measures 4 cm. A procedure is performed to crush the stone and remove the fragments. Report code(s)
Laser surgery to remove a molluscum contagiosum lesion of the anus. Report code _
Repair of acute diaphragmatic hernia in a 25-year-old patient who was injured during a motor vehicle crash (MVC). Report code __
Radiofrequency thermotherapy to treat benign prostate hypertrophy (BPH). Report code _

Match each procedure with its CPT code below.

Question Selected Match
Female patient underwent total urethrectomy, including cystostomy.

Male patient underwent total urethrectomy, including cystostomy.

Patient underwent urethroplasty, second stage, to form urethra.

Patient underwent excision of urethral polyp, distal urethra.

Patient underwent one-stage urethroplasty.

Patient underwent urethroplasty, first stage, to repair stricture.

Patient underwent initial dilation of urethral stricture by passage of urethral dilator, male.

Patient underwent excision of urethral caruncle.

Patient underwent subsequent dilation of urethral stricture by passage of sound or urethral dilator, male.

Patient underwent excision of bulbourethral gland.

Patient underwent initial dilation of urethral stricture by passage of filiform and follower, male.

Patient underwent initial dilation of female urethral, including suppository and instillation.


Match each description with a procedure listed below.

Question Selected Match
thin, telescope-like tube with a light and tiny camera attached is inserted into the bladder through the urethra

allows a doctor to look inside the entire large intestine

used to examine the anal canal

a very useful tool in the diagnosis and treatment of esophageal diseases

tubelike instrument with a light and a lens for viewing the rectum and sigmoid; may also have a tool to remove tissue to be checked under a microscope for signs of disease

an instrument that is used during an endoscopic procedure

cold biopsy forceps
examination of the esophagus and stomach

a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum


A varicocele is an abnormal dilation of the veins of the spermatic cord in the scrotum.
The carotid body is tissue that contains many lymphatic vessels, and it is located at the point where the carotid branches in the neck.
CPT codes for procedures on the pituitary and pineal glands are located in the Endocrine section.
The lacrimal apparatus is a mucous membrane that lines the underside of each eyelid and forms a protective covering over the exposed surface of the eyeball.
CPT code 58950 is assigned to report a resection of the female genital system due to malignancy.
Laminoplasty, cervical, with decompression of the spinal cord, two or more vertebral segments. Assign code(s).
Percutaneous core needle biopsy of thyroid. Assign code(s).
Three nerve grafts (includes obtaining graft), single strand, hand or foot more than 4 cm in length. Assign code(s).
Marsupialization of Bartholin’s gland cyst. Assign code(s).
Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation, arterial anastomosis, each. Assign code(s).
Repair of meningocele, less than 5-cm diameter in newborn less than 4 kilograms. Assign code(s).
Ablation, one or more renal tumor(s), percutaneous, bilateral, radiofrequency. Assign code(s)
Resection or excision of neoplastic, vascular, or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex, intradural, including dural repair, with or without graft. Assign code(s).
Injection procedure for corpora cavernosography with radiological supervision and interpretation. Assign code(s).
Ureterotomy for insertion of indwelling stent, all types. Assign code(s).
What is the abbreviation for transurethral resection of the prostate?
When a laminectomy is coded, the record is reviewed to determine what three components to ensure correct code assignment?
Anatomic site
Surgical approach
Type of procedure performed
A 75-year-old female diagnosed with a cataract in the right eye undergoes ECCE one-stage procedure to correct this problem. Report code(s) _
Carl is a 6-year-old male who is admitted to the ambulatory surgical unit of a local hospital on May 4 and who undergoes removal of bilateral ventilating tubes. Dr. White had inserted the tubes in November of the previous year. Dr. White removed them after administering general anesthesia to the patient. Report code(s) _____.
Reduction of two fetuses, with three fetuses left intact. Report code _
Ms. Gomez presents to the emergency department (ED) of her local hospital, complaining of body aches, fever, and headache. The ED physician performs a spinal puncture to rule out meningitis. Report code ____
A patient is diagnosed with a ventral hernia two months after having undergone a hysterectomy via abdominal approach. A hernia repair is done using tension-free mesh implantation technique. Report code(s) _
49560, 49568
Transabdominal biopsy, left adrenal gland, via open approach. Report code _
A patient diagnosed with an ectopic pregnancy undergoes laparoscopic treatment of this condition that also requires removal of the fallopian tube. Report code ___
Complete removal of thyroid gland with radical dissection due to thyroid cancer. Report code
A patient diagnosed with meningioma undergoes craniectomy to remove the tumor. Report code
Photocoagulation destruction of corneal lesion, right eye. Report code __
Match each procedure to its code below.
Question Selected Match
excision of carotid body tumor without excision of carotid artery
D. 60600
repair of laceration conjunctiva with or without non-perforating laceration sclera, direct closure
C. 65270
Eustachian tube inflation transversal with catheterization
E. 69400
destruction of lesion conjunctiva
G. 68135
subdural tap through fontanelle or suture infant unilateral subsequent taps
H. 61001
nerve block of facial nerve
F. 64402
twist drill hole for subdural or ventricular puncture
A. 61107
evisceration of ocular content without implant of the eye
B. 65091
Match each GYN or OB procedure with its code below.
Question Selected Match
vaginal delivery
B. 59400
tubal ligation performed after delivery
H. 58605
open lysis of fallopian or ovarian adhesions
A. 58740
pelvic exam under anesthesia
G. 57410
delivery after previous Cesarean section
F. 59610
loop or LEEP
E. 57522
C. 58943
delivery of the placenta
D. 59414
B-scan is a type of ultrasound display mode.
An ultrasound uses high-frequency sound waves to create echoes.
Radiology procedures include only two components: a technical component and a professional component.
M-mode is a display mode for an ophthalmic ultrasound
A cystography is done to view the gallbladder.
Radiation treatment delivery, single treatment area, single port or parallel opposed ports, single blocks or no blocks, 11-19 MeV. Assign code(s).
Epidurography, radiological supervision, and interpretation. Assign code(s).
Fluoroscopic guidance for needle placement. Assign code(s).
Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies). Assign code(s).
Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy). Assign code(s).
Therapeutic radiology simulation-aided field setting, three-dimensional. Assign code(s).
Ultrasound, retroperitoneal, real time, with image documentation, complete. Assign code(s).
Bone age studies. Assign code(s).
CT scan, head or brain, without contrast material, followed by contrast materials(s), and further sections. Assign code(s).
Vitamin B-12 absorption study (e.g., Schilling test), without intrinsic factor. Assign code(s)
What are the three components of radiology procedures?
Technical Component
Professional Component
Global service
Hyperthermia is performed before or after what other type of radiation therapy?
External Beam radiation therapy
Nuclear medicine scan, parathyroid gland. Report code _
CT scan of lumbar spine after administration of radiopaque liquid. Report code __
OB ultrasound of a patient in her second month; ultrasound confirmed twin pregnancy. Report code(s)
Two views of cervical spine. Report code
Chest x-ray, frontal, lateral, and oblique views. Report code(s) _
Bilateral screening mammography due to family history of breast cancer. Report code __
Transvaginal ultrasound of a 30-year-old female who is not pregnant. Report code(s) __
Epidurogram of cervical and thoracic regions under fluoroscopic guidance with image documentation and reporting. Report code(s) __
Bilateral examination of TMJ. Report code ___
MRI of abdomen after administration of contrast agent. Report code _
What does a roentgen identify?
Unit of exposure dose
SPECT imaging of liver to assess vascular flow. Report code __
Complete acute abdomen series with supine, erect, and decubitus views and single chest x-ray.
The contrast agent barium sulfate is used for radiology studies of the _____ body area
Application of seven interstitial ribbons in the patient’s abdominal cavity. Report code _
CPT code 36600 is assigned when a vein is punctured to collect a blood sample.
Arterial puncture is coded as 36400
A block is a thin slice of tissue prepared from a tissue section.
Modifier -91 is added to a CPT code when pathology services are repeated on the same date of service.
CPT laboratory codes include collection of the specimen.
Urine pregnancy test, by visual color comparison methods. Assign code(s).
Antibody screen, RBC. Assign code(s)
Assisted embryo hatching, microtechniques (any method). Assign code(s).
Fresh frozen plasma, thawing, each unit. Assign code(s).
Infectious agent antigen detection by immunofluorescent technique, Herpes simplex virus type 1. Assign code(s).
Lipoprotein, direct measurement, LDL cholesterol. Assign code(s).
Clotting factor X (Stuart-Prower). Assign code(s).
Blood occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations. Assign code(s).
Deoxyribonuclease acid (DNA) antibody native or double stranded. Assign code(s).
Tissue preparation for drug analysis. Assign code(s).
What cytology system is used to report cell shape from cervical or vaginal specimens?
The Bethesda system is a format for reporting cervical/vaginal cytology .
How many times is an ambulatory payment classification (APC) transfusion payment paid if three units of blood are transfused in one day?
A transfusion APC payment is paid just once per day regardless of the number of units.
ABO blood typing of whole blood unit that will be transfused. Report code ___
Complete autopsy of a 35-year-old man found dead in his car in the parking lot of a convenience store. Report code
Surgical pathology analysis level VI of esophageal tissue. Report code __
Blood testing for presence of varicella antibodies. Report code ____
A patient with a history of colorectal cancer underwent quantitative immunoassay of tumor antigen 242 to test for recurrence of colon cancer. Report code _
Culture of nail for presence of fungi. Report code _
KOH slide examination of hair sample for presence of scabies. Report code __
CPK isoenzymes testing of blood specimen. Report code __
Testing of a blood sample for bleeding time. Report code(s) _
A patient undergoes the following blood tests: carbon dioxide, CBC (automated), chloride, potassium, and sodium. Report code(s) _
80051, 85027
Pathology examination of tissue removed during a pancreas biopsy. Report code
Analysis of semen for presence and motility. Report code __
Patient undergoes a lipid panel. Because of an abnormally high triglyceride level, a repeat triglyceride is done as an individual test. Report code(s) _
80061, 84478
Blood testing for presence of Chlamydia immunoglobulins. Report code _
Testing of blood for presence of Bordetella antibody. Report code __
Match each surgical pathology to its level of pathological examination.
Question Selected Match
B. level III
lung, transbronchial
E. level IV
colon, colostomy stoma
D. level III
urinary bladder, TUR
L. level V
A. level II
cervix, conization
P. level V
G. level IV
lip biopsy
I. level IV
C. level I
J. level III
fetus with dissection
H. level VI
fallopian tube, sterilization
F. level II
skin tag
N. level III
bone resection
O. level VI
hernia sac, any location
K. level II
An intravenous push is a method for infusing medications for 30 minutes or more.
A duplex scan is a type of noninvasive diagnostic study.
Cardiac catheterization is a noninvasive diagnostic procedure.
Psychologists report E/M services with CPT Medicine section codes or E/M section codes.
Patient received a home visit from a registered nurse for mechanical ventilation care. Report code 99504.
Actinotherapy (ultraviolet light). Assign code(s).
Chemotherapy administration, intra-arterial infusion technique, up to 1 hour. Assign code(s).
Comprehensive computer-based motion analysis by videotaping and 3D kinematics with dynamic plantar pressure measurements during walking. Assign code(s).
Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient, 90 minutes. Assign code(s).
Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report, subsequent. Assign code(s).
Psychotherapy, 30 minutes face-to-face with the patient. Assign code(s).
Oscillating tracking test with recording. Assign code(s).
Temporary transcutaneous pacing. Assign code(s)
Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age. Assign code(s).
Esophagus, acid perfusion (Bernstein) test for esophagitis. Assign code(s).
A patient, Clarissa Edwards, had a cochlear implant inserted 8 months ago. Today Clarissa, who is 8 years old, requires reprogramming of this device. Report code
A patient diagnosed with asthma was provided with respiratory care about the correct usage of a bronchodilator. This service is provided in the patient’s home. Report code _
A 17-year-old patient received an IM injection of HPV vaccine type 11. Report code(s)
A 23-minute telephone assessment and management service was performed on a patient who had not been in the office for any services within 24 hours. How would the coder code this service. Report code _
CMT of cervical, thoracic, and lumbar regions. Report code
Ventilator management performed on May 6 and May 7. Report code(s)
94002, 94003
Fitting of single vision eyeglasses. Report code _
Which diagnostic test measures muscle function?
Air and bone tone audiometry testing. Report code
On September 8 and September 17, Wendy James received outpatient cardiac rehabilitation services provided by Dr. Scott. The services were performed with continuous ECG monitoring. Report code(s
93798, 93798
Match each CPT code to the correct subsection
Question Selected Match
90834 psychotherapy, 45 minutes
H. Psychiatry
96360 intravenous infusion hydration, initial 31 minutes to 1 hour
J. Hydration
92511 nasopharyngoscopy with endoscope
B. Special Otorhinolaryngologic Services
94004 vent management nursing facility, per day
N. Pulmonary
97810 acupuncture using one or more needles
I. Acupuncture
99144 moderate (conscious) sedation, age 5 years or older, first 30 minutes intraservice time
D. Moderate (Conscious) Sedation
95130 allergen immunotherapy, single stinging insect venom
E. Allergy and Clinical Immunology
90660 influenza virus vaccine, live
P. Vaccines/Toxoids
98967 telephone service 11-20 minutes
C. Telephone Service
92015 determination of refractive state
F. Ophthalmology
98962 education and training for patient self-management, 5-8 patients
O. Education and Training for Patient Self-Management
93000 ECG 12 leads with interpretation and report
L. Cardiography
97010 application of a modality to one or more areas, hot or cold packs
G. Physical Medicine and Rehabilitation
90296 diphtheria antitoxin
A. Immune Globulins
93880 duplex scan of extracranial arteries, complete bilateral study
M. Cerebrovascular Arterial Studies
90970 end-stage renal disease-related service (less than a full month) per day for patient 20 years of age or older
K. Dialysis
The coder is responsible for documenting and authenticating legible, complete, and timely patient records
Upcoding refers to reporting codes that are not supported by documentation in the record for the purpose of increasing reimbursement
HIPAA’s large code set collects data about the type of facility and the type of nursing unit.
Nurses and physicians use medical management software to create work schedules for the office staff.
In SNOMED CT, the abbreviation CT refers to current terminology
An alternative to traditional off-site storage that uses automated record and laser technology to create an image of patient data is called __________ imaging.
Optical disk imaging or document imaging
Medical assistants and insurance specialists collect data for reimbursement purposes using __________ software.
medical management
Professional organizations that certify coders (e.g., AAPC, AHIMA) require them to earn __________ credits every two years in order to remain certified.
Reports that are organized according to documentation source, each of which is located in a labeled section of the record, are located in a(n) __________ record.
Source-oriented record or sectionalized record
The public or private entity that processes or facilitates the processing of health information and claims from a nonstandard to a standard format is called a(n) __
clearinghouse or health care clearinghouse
Explain the difference between ICD-10-CM and ICD-10-PCS.
ICD-10-CM is going to be used for code and classify disease data from inpatient and outpatient record.
ICD-10-PCS is going to be used for code and classify procedure data from inpatient records only.
Name exemplary behaviors that students should exhibit during an internship
well groomed, professionally dressed, interested, react appropriately to criticism, work according to the schedule
List three coding systems used by a physician’s office.
Describe the three patient record formats
A Manual record is paper-based fomat
Autmated record uses computer technology
and Hybrid record consist of both paper-based and computer- generated documents
When a coder has a question about medical record documentation and needs clarification from the physician, what should the coder implement?
They should use physician query process to contact the responsible physician.
Medical management software is used to generate CMS-1500 claims that are printed and mailed to whom?
CMS-1500 claims are printed and mailed to Health care clearinghouses, third-party administrators, third-party payers for processing
The Health Insurance Portability and Accountability Act of 1996 legislation _
expanded continuity of health insurance coverage
Patient records that consist of handwritten progress notes and automated laboratory results are considered _____ records.
A physician query that is generated during an inpatient hospitalization is considered _
Automated case abstracting software is used by hospitals to _
collect data for statistical analysis
The provider documents patient care, treatment, response to care, and condition on discharge in the _
discharge summary
The process of converting patient records to an electronic image and saving them on storage media is called _
optical disk imaging
Which is an example of a third-party payer?
Blue Cross/Blue Shield
The CMS-1500 claim is submitted by _____ to third-party payers for processing.
physician offices
The HIPAA small code set collects information concerning __
race, ethnicity, type of facility, and type of unit
Which professional most frequently uses medical management software?
Medical Assistant
Match each illegal coding practice with the correct term listed below.
Question Selected Match
Reporting multiple CPT codes to increase reimbursement when a combination code should be reported
B. Unbundling
Reporting codes for associated signs and symptoms in addition to an established diagnosis
C. Overcoding
Routinely assigning lower-level CPT codes as a convenience instead of reviewing documentation and the coding manual to determine the proper code to be reported
E. Downcoding
Routinely assigning a 0 or 9 as the fourth- or fifth-digit position of an ICD-9-CM disease code instead of reviewing the coding manual to select the appropriate code number
A. Jamming
Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement
D. Upcoding
Match each statement of purpose with the reference/resource listed below.
Question Selected Match
Medicare regulations (Centers for Medicare and Medicaid Services)
C. Conditions of Participation and Conditions for Coverage
Software used by hospitals to help identify CPT/HCPCS coding errors
A. Outpatient Code Editor with APCs
Monthly newsletter published by AMA as an official coding resource
D. CPT Assistant and HCPCS Assistant
Quarterly newsletter published by AHA as an official coding resource
E. Coding Clinic for HCPCS Level II
“Code edits pairs” that cannot be reported on the same claim for payment
B. National Correct Coding Initiative
HAVEN software is used to input data resulting from a minimum data set (MDS)
Case mix is the physiologic complexity that comprises the extent and interactions of a patient’s diseases
A CMS-1500 claim can be submitted to report ambulance services.
RACs are not the same as Medicare’s Comprehensive Error Rate Testing (CERT) program.
A participating provider (PAR) is a member of a managed care plan.
The Recovery Audit Contractor program is not the same as Medicare’s ________________ __________ __________ __________ program, which was implemented in 2003.
The computer-to-computer transfer of data is called ____________ __________ ____________.
Workers’ compensation is a(n) __________ __________ insurance program.
A health savings account is also called a(n) __________ __________ __________ __________.
health saving security account
After the insurance claim was processed by Blue Cross/Blue Shield Association for services provided to Mrs. Wakefield on April 4, the office received a(n) ____________ __________.
Remittance advice
A triple option insurance plan is also called a(n) ____________ plan
cafeteria plan
A(n) __________ __________ __________ is a tax-exempt account offered by an employer for employees to pay health care bills.
Flexible spending account
A physician under contract to a managed care plan is called a(n) __________ provider.
TEFRA legislated implementation of the ____________ ______________ __________ __________, which uses diagnosis-related groups (DRGs) to reimburse short-term hospitals for inpatient stays.
hospital inpatient prospective payment system
HIPAA provisions were designed to improve the __________ and __________ of health coverage by limiting exclusions for preexisting medical conditions.
portability continuity
What were eliminated by Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003?
The elimination of carriers, fiscal intermediaries and durable medical equipment regional carriers and the creation of Medicare administrative contractors.
What is the abbreviation for the categories into which DRGs are organized?
DRGs are organized into MDCs (Major diagnostic categories)
What are the components of relative value units (RVUs)?
Physician work, practice expense, and malpractice expense
The HIPAA security rule was published in 2003, and it establishes standards and safeguards for what type of health information?
Electronic health information transmitted by a provider to a health plan
When referring to the False Claims Act (FCA), which statement is true?
The FCA does not penalize mistakes or errors
Which is known as a 401(k) plan for health care?
Consumer-directed health plan
What are the civil penalties if a person is found guilty of Medicare fraud?
$5,000 to $10,000 per claim, plus triple damages
A fee schedule is
a cost-based fee-for-service reimbursement methodology
Mr. French is a patient at a skilled nursing facility, and he has been a resident at the facility for the past 14 days. Today the nursing supervisor uses a software tool to capture data on Mr. French to answer the questions on the minimum data set (MDS). What is this software called?
When referring to Stark I and Stark II, which statement is true?
Stark I and Stark II regulate physician self-referral
How many categories of ground ambulance services were established by the Balanced Budget Act of 1997?
What is assigned to each CPT and HCPCS code when reported under the OPPS to identify the monetary payment for that code?
Status indicator
Match each third party or managed care group to its abbreviation below.
Question Selected Match
exclusive provider organization
point-of-service plan
State Children’s Health Insurance Program
individual practice association
physician-hospital organization
consumer-direct health plan
preferred provider organization
group practice without walls

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