CCA Exam Elaborations 2023/2024
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery
suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow
instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased
prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following
instrument removal, a catheter is inserted and left in place. Which of the following code sets will be
reported for this service?
a. 600.20, 53852
b. 600.20, 52601
c. 600.00, 53852
d. 222.2, 53850 Answer - Correct Answer: A
When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical
resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20
(AHIMA 2012a, 697).
An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs
are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in
the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress
syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be
correct?
a. V30.01, 765.03, 765.24
b. 765.03, 769
,c. V30.01, 765.03, 765.24, 769
d. V30.01, 769 Answer - Correct Answer: C
The codes for prematurity 765.03 and code 765.24 for weeks of gestation meet reporting guidelines as
additional diagnoses. A birth code of V30.01 is reported as the principal diagnosis (CMS 2010c, Section I,
C, 15b; AHA 2006, 190). See instructional note under 765.0x to "Use Additional Code" for weeks of
gestation. A code is also needed for the respiratory distress syndrome, 769 (AHIMA 2012a, 676)
Identify the CPT procedure code(s) for an automated CBC with automated differential.
a. 85027
b. 85025
c. 85041
d. 85007, 85025 Answer - Correct Answer: B
Index Blood Cell Count, hemogram, added indices, resulting in code range 85025-85027. The codes for
reporting CBCs (complete blood counts) are very specific and should be carefully reviewed. The
appropriate code for a CBC with automated white blood cell differential is 85025 (AHIMA 2012a, 628).
Identify the CPT procedure code(s) and correct modifier for a thyroid stimulating hormone (TSH) when
medical necessity is not met and the patient signs a required waiver of liability signifying the patient will
be responsible for payment if the test is not covered by Medicare. Another name for waiver of liability is
Advance Beneficiary Notice (ABN).
a. 84443-GA
b. 80418-GA
,c. 84443-GY
d. 80418-GY Answer - Correct Answer: A
Index Thyroid simulating hormone, 80418, 80438-80440, 84443. Code 84443 is the correct code for a
TSH while the rest of the codes are panels including several tests. Modifier -GA is listed in the front cover
of the CPT Professional Edition and signifies the patient was given a notice of non-coverage also known
as waiver of liability or ABN (AMA 2012b, 427; CMS 2010d; CMS 2010e).
The patient presented through the ED with severe abdominal pain, amenorrhea. Serum human chorionic
gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient
diagnosed with tubal pregnancy. A unilateral salpingectomy with removal of tubal pregnancy was
performed. Which of the following is the correct code assignment?
a. 633.80, 66.62
b. 633.10, 66.62
c. 633.10, 66.4
d. 633.10, 66.02 Answer - Correct Answer: B
The ectopic pregnancy was documented as tubal. The salpingectomy was "with removal of tubal
pregnancy." The procedure performed was a salpingectomy, not a salpingostomy (AHIMA 2012a, 679).
Identify the CPT procedure code(s) for ultrasound, pregnant uterus, fetal and maternal evaluation,
second trimester, single gestation.
a. 76700
b. 76805
, c. 76801
d. 76813 Answer - Correct Answer: B
Index Ultrasound, pregnant uterus, resulting in code range 76801-76817. Review of the available codes
indicates that code 76805 is the appropriate code (AHIMA 2012a, 625).
Identify the CPT procedure code(s) for a SPECT bone scan.
a. 78710
b. 78803
c. 78607
d. 78320 Answer - Correct Answer: D
Index Bone, nuclear medicine, SPECT, resulting in code 78320. The acronym SPECT stand for single
photon emission computed tomography and is a more sophisticated form of CT scanning. Unlike basic x-
ray CT scanning, SPECT involves injected radionuclides and is considered a form of nuclear medicine. It is
being supplanted to some extent now by PET (positron emission tomography) scanning, which is capable
of better resolution and sensitivity (AHIMA 2012a, 625).
Select the appropriate CPT code(s) to report a therapeutic subcutaneous injection of rabies immune
globulin performed under direct physician supervision.
a. 96372
b. 90471
c. 90375, 96372
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery
suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow
instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased
prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following
instrument removal, a catheter is inserted and left in place. Which of the following code sets will be
reported for this service?
a. 600.20, 53852
b. 600.20, 52601
c. 600.00, 53852
d. 222.2, 53850 Answer - Correct Answer: A
When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical
resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20
(AHIMA 2012a, 697).
An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs
are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in
the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress
syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be
correct?
a. V30.01, 765.03, 765.24
b. 765.03, 769
,c. V30.01, 765.03, 765.24, 769
d. V30.01, 769 Answer - Correct Answer: C
The codes for prematurity 765.03 and code 765.24 for weeks of gestation meet reporting guidelines as
additional diagnoses. A birth code of V30.01 is reported as the principal diagnosis (CMS 2010c, Section I,
C, 15b; AHA 2006, 190). See instructional note under 765.0x to "Use Additional Code" for weeks of
gestation. A code is also needed for the respiratory distress syndrome, 769 (AHIMA 2012a, 676)
Identify the CPT procedure code(s) for an automated CBC with automated differential.
a. 85027
b. 85025
c. 85041
d. 85007, 85025 Answer - Correct Answer: B
Index Blood Cell Count, hemogram, added indices, resulting in code range 85025-85027. The codes for
reporting CBCs (complete blood counts) are very specific and should be carefully reviewed. The
appropriate code for a CBC with automated white blood cell differential is 85025 (AHIMA 2012a, 628).
Identify the CPT procedure code(s) and correct modifier for a thyroid stimulating hormone (TSH) when
medical necessity is not met and the patient signs a required waiver of liability signifying the patient will
be responsible for payment if the test is not covered by Medicare. Another name for waiver of liability is
Advance Beneficiary Notice (ABN).
a. 84443-GA
b. 80418-GA
,c. 84443-GY
d. 80418-GY Answer - Correct Answer: A
Index Thyroid simulating hormone, 80418, 80438-80440, 84443. Code 84443 is the correct code for a
TSH while the rest of the codes are panels including several tests. Modifier -GA is listed in the front cover
of the CPT Professional Edition and signifies the patient was given a notice of non-coverage also known
as waiver of liability or ABN (AMA 2012b, 427; CMS 2010d; CMS 2010e).
The patient presented through the ED with severe abdominal pain, amenorrhea. Serum human chorionic
gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient
diagnosed with tubal pregnancy. A unilateral salpingectomy with removal of tubal pregnancy was
performed. Which of the following is the correct code assignment?
a. 633.80, 66.62
b. 633.10, 66.62
c. 633.10, 66.4
d. 633.10, 66.02 Answer - Correct Answer: B
The ectopic pregnancy was documented as tubal. The salpingectomy was "with removal of tubal
pregnancy." The procedure performed was a salpingectomy, not a salpingostomy (AHIMA 2012a, 679).
Identify the CPT procedure code(s) for ultrasound, pregnant uterus, fetal and maternal evaluation,
second trimester, single gestation.
a. 76700
b. 76805
, c. 76801
d. 76813 Answer - Correct Answer: B
Index Ultrasound, pregnant uterus, resulting in code range 76801-76817. Review of the available codes
indicates that code 76805 is the appropriate code (AHIMA 2012a, 625).
Identify the CPT procedure code(s) for a SPECT bone scan.
a. 78710
b. 78803
c. 78607
d. 78320 Answer - Correct Answer: D
Index Bone, nuclear medicine, SPECT, resulting in code 78320. The acronym SPECT stand for single
photon emission computed tomography and is a more sophisticated form of CT scanning. Unlike basic x-
ray CT scanning, SPECT involves injected radionuclides and is considered a form of nuclear medicine. It is
being supplanted to some extent now by PET (positron emission tomography) scanning, which is capable
of better resolution and sensitivity (AHIMA 2012a, 625).
Select the appropriate CPT code(s) to report a therapeutic subcutaneous injection of rabies immune
globulin performed under direct physician supervision.
a. 96372
b. 90471
c. 90375, 96372
