COC 2023 FINAL EXAM STUDY QUESTIONS AND ANSWERS LATEST UPDATE

COC 2023 FINAL EXAM STUDY QUESTIONS AND ANSWERS LATEST UPDATE 14 year-old status post injury over one year ago to her left wrist presented with recurrent wrist pain. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. There was found to be mild synovitis in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. Using outside in technique, a PDS suture was placed across the TFCC and into the capsule. There was synovitis within the midcarpal joint, but there was no articular injury. All instruments were removed and the wounds were closed with interrupted nylon sutures. What CPT ® code is reported? - answer29846-LT 44-year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. The intraoperative mounting parameters, deformity parameters, and initial strut settings are inserted into the computer prior to Jim's discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) should be reported? - answer20697 56 year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages? - answer17311, 17312, 1731566 year-old male with a history of anemia presents for a liver core biopsy to evaluate for possible cirrhosis. The patient was brought to the CAT scan suite in which limited CT images of the upper abdomen were performed for biopsy needle placement. The appropriate site for the liver core biopsy was chosen. The patient's skin was then marked with the computer coordinates. An 18-gauge needle was advanced into the appropriate site and a sample was obtained. What CPT ® codes are reported for the facility? - answer47000, 77012 A must include cholesterol, serum total (82465), Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), and Triglycerides (84478) - answerLipid Panel (80061)A patient presents to the hospital-based outpatient surgery department for a left knee medial meniscus repair. She had recurrent locking, swelling and catching of the knee. A diagnostic arthroscopy was performed. Under direct visualization, a medial portal was established and debridement of the posterior horn of the medial meniscus was performed. A shaver was then introduced to trim the meniscus back to a stable rim. The remainder of the knee was probed. The scope was then withdrawn and the wound was closed with #4-0 Vicryl. The discharge diagnosis was a bucket-handle tear of the medial meniscus. The patient tolerated the procedure well. What are the correct procedure and diagnosis codes for this encounter? - answer29881, S83.212A A 12 year-old child presents to the ED with an acute exacerbation of asthma. The patient is wheezing and is having difficulty breathing. She is not responding to the therapy. The physician documents as the final diagnosis asthma with status asthmaticus. What ICD-10-CM code(s) is/are reported? - answerJ45.902 A 12 year-old's diabetes mellitus is well controlled with oral antidiabetic medications . The patient has no complications. Applying the coding concept from ICD-10-CM guidelines I.C.4.a.l, I.C.4.a.2, and I.C.4.a.3, what ICD-10-CM code(s) is/are reported? - answerE11.9, Z79.84 A 13 year-old is seen in the emergency department with a sudden onset of nausea, fever and diarrhea. A stool culture indicated Salmonella bacterium. The patient stated that she had been at a family reunion and recalls eating some salad, ice-cream and chicken. Diagnosis made was salmonella gastroenteritis. Report the diagnosis code(s) for the visit. - answerA02.0 A 14-year-old male is brought to the ER by his parents after hitting his left knee on the base when sliding into base at a baseball game in a public park. After X-rays were obtained, it revealed a sprain to the knee. The patient was instructed to keep his leg elevated and keep weight off of it as much as possible for the next two weeks. What diagnosis codes are reported for this encounter? - answerS83.92XA, W21.89XA, Y92.830, Y93.64 A 15 year old female undergoing treatment for Hodgkin's lymphoma presents to the behavioral health clinic to be evaluated for increasing acute panic attacks during her cancer treatments. The psychologist spent 1 hour and 15 minutes face-to-face with the patient. The patient was diagnosed with adjustment disorder with anxiety and a treatment plan was initiated. She will be seen for a reassessment in 30 days. What are the correct CPT ® and ICD-10-CM codes to report this service? - answer96150 x 5, F43.22, C81.90A 15 year-old has been taken to surgery for crushing his index and middle fingers, injuring his digital nerves of the left hand. The physician located the damaged nerves in both fingers and sutures them to restore sensory function. What CPT® and ICD-10-CM codes are reported? - answer64831-LT, 64832-LT, S64.491A, S64.493A A 16 year-old male is brought to the ED by his mother. He was riding his bicycle in the park when he fell off the bike. The patient's right arm is painful to touch, discolored, and swollen. The X-ray shows a closed fracture of the ulna. What ICD-10-CM codes are reported? - answerS52.201A, V18.0XXA, Y92.830 A 19 year-old female is seen in the hospital-based outpatient department for surgical implantation of birth control. Once prepped and draped, the surgeon makes a small incision in the skin on the inside of the patient's left upper arm. Using a trocar, six 3.0 cm Norplant II (Levonorgestrel) capsules are implanted subdermally. After all capsules were placed, the incision was closed with a simple repair. What are the correct procedure and diagnosis codes for this encounter? - answer11981, J7306, Z30.017 A 2 month-old is seeing his pediatrician for a routine health check examination. The physician notices a diaper rash and prescribes an ointment to treat it. What ICD-10-CM code(s) is/are reported? - answerZ00.121, L22 A 2 year-old girl is brought to the ED. She is pulling on her ears. After examination, the ED physician determines the patient has acute serousotitis media in both ears. What diagnosis is reported? - answerH65.03 A 21 year-old male is brought into the ED by his father who states that his son is dizzy and has anxiety. The ED provider runs a drug screen test and the test comes back positive for marijuana use. The final diagnosis is documented as marijuana abuse with anxiety disorder. What ICD-10-CM code is reported? - answerF12.180 A 22 year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.l.d.l.b, what ICD-10-CM codes are reported (in the correct sequencing)? - answerA41.9, R65.20, Nl7.9A 22 year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened by a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and closed with sutures. What CPT ® code is reported? - answer20680-F4 A 22 year-old female suffered a 10-cm laceration on her cheek, a 4-cm laceration on her chin, and a 9-cm laceration on the dorsum of her right hand when she slipped on loose pavement while riding her bicycle. All lacerations were contaminated with dirt and gravel and required cleansing with debridement and copious saline irrigation before layered closure. How should this be coded? - answer13132, 13133 x 4 A 22 year-old is in an outpatient facility for an inguinal hernia repair. Just before surgery, the surgeon discovers the patient is positive for MRSA and the surgery is canceled. Which ICD-10-CM code(s) should be reported for the outpatient service? - answerK40.90, A49.02, Z53.09 A 22 year-old is taken to the ED by her husband. She is in her 16th week of pregnancy and is experiencing dizziness and swelling in the hands and feet. The ED physician performs a detailed history and examination. Final assessment is mild preeclampsia with edema. She is instructed to follow-up with her OB physician tomorrow. What diagnosis and CPT codes are reported for this mid-level visit? - answer99283, O14.02, Z3A.16 A 24 year-old woman developed a keloid scar as a result of a third degree burn on the left upper arm. What ICD-10-CM code(s) is/are reported? - answerL91.0, T22.332S A 25 year-old female presents to the same day surgery unit for the removal of a dislodged plastic biliary stent. The esophagogastroduodenoscope was inserted in the posterior oropharynx. The previously placed stent, which is now dislodged was identified in the upper duodenum and was removed with a polypectomy snare. What CPT® code is reported for the procedure? - answer43247 A 26 year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia washarvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high-speed drill, a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT ® code is reported? - answer69631-LT A 26 year-old male patient with left lower-lobe bronchial cancer has an obstructed bronchus in the left lower lobe of the lung. Airway is viewed using a flexible bronchoscope introduced through the oral airway, following administration of conscious sedation. Fluoroscopic guidance assists in identifying the obstruction. A laser probe is introduced through the scope to eradicate and relieve the tumor obstruction. What CPT ® and ICD-10-CM codes are reported? - answer31641, C34.32 A 26 year-old patient presents with headache, neck pain, and fever, and is concerned he may have meningitis. The patient was placed in the sitting position and given 0.5 mg Ativan IV. His back was prepped and a 20- gauge needle punctured the spine between L4-L5 with the return of clear fluid. The cerebrospinal fluid was reviewed and showed no sign of meningitis. What CPT® code is reported? - answer62270 A 26-year-old male is diagnosed with recurrent acute sinusitis of the ethmoid sinuses per CT scan. He reports to the ASC for endoscopy. After anesthesia is administered, the patient undergoes a nasal/sinus endoscopy that involves the removal of the anterior and the posterior ethmoids on the right and left sides. What CPT" and ICD-10-CM codes are reported? - answer31255-50, J0l.21 A 27 year-old female in her 15th week of pregnancy is in outpatient surgery for a vaginal cervical cerclage. The patient's diagnosis is an incompetent cervix. The patient tolerated the procedure well and fetal heart tones were beating at 142 beats per minute. What diagnosis and procedure codes are reported for this encounter? - answer59320, O34.32, Z3A.15 A 27 year-old female presents to the hospital outpatient surgery department. PREOPERATIVE DIAGNOSIS: Chronic pelvic pain with mild endometriosis and right ovarian cyst POSTOPERATIVE DIAGNOSIS: Same OPERATION PERFORMED: Laparoscopy with ovarian cyst aspiration and endometrial cauterization ANESTHESIA: General FINDINGS: The uterus and tubes are normal in appearance. The left ovary was normal in appearance; however, the right ovary was swollen and contained a cyst measuring approximately 3 cm. Serous fluid was aspirated from the cyst. In the posterior cul-de-sac toward the left uterosacral ligament close to its attachment to theuterus, a fleshy area consistent with endometriosis was evident. This area was cauterized and there were no other areas consistent with endometriosis and no pelvic adhesions were noted. The abdomen and appendix were also normal in appearance. INDICATIONS: Chronic pelvic pain PROCEDURE: The patient was taken to the operating room and IV infusion was performed. She was placed on the operating table in the dorsal supine position. Following induction of general endotracheal anesthesia, she was placed in the dorsal lithotomy position. Her abdomen and perineum were prepped and draped in the usual sterile fashion for the laparoscopy. The cervix was visualized with a weighted speculum and a manipulator was placed. The speculum was removed and a picture of the laparoscopic portion of the procedure was taken. A 1cm long vertical incision was made at the umbilicus. A Veress needle was introduced into the abdominal cavity. The umbilical site and a suprapubic site were injected with 25 percent Marcaine with Epinephrine prior to the incision. The abdomen was insufflated with CO2 gas. The Veress needle was removed and a 10 mm trocar was placed in the umbilical incision without difficulty. The scope was placed through the sleeve and under direct visualization, a second puncture site was made with a 5 mm trocar. It was approximately 3 cm from the pubic symphysis in the midline. The pelvis was noted to be as previously described. The ovarian cyst was aspirated and approximately 20 cc of serous fluid was obtained. The area of fleshy appearing endometriosis along the right uterosacral ligament was cauterized.Hemostasis was assured. The CO2 gases were allowed to escape and both trocar sleeves were removed with direct visualization and hemostasis noted. Each site then closed using 4-0 Vicryl in a subcuticular fashion. Sterile dressings were applied. - answer49322, 58662, N83.201, N80.8 A 27 year-old is being examined for stomach pain in the outpatient hospital department. After adequate anesthesia, the patient was placed in the left lateral position. The endoscope was placed in the oropharynx and visualization of the larynx and laryngeal structures was good. They appeared normal. The esophagus was readily intubated and the proximal, mid, and distal esophageal mucosal appeared essentially unremarkable. With the stomach, there were patches of erythema in the antrum and body. These were photographed and biopsied. In the more proximal body, there was subtle edema and this was photographed. Careful inspection of the stomach was made in forward and retroflexed views, looking at cardia, fundus, annulus, body, antrum, and pylorus. The duodenal bulb and second portion of the duodenum appeared entirely normal. I await the biopsies with interest. The diagnosis is gastritis, rule out eosinophilic gastritis. Provide the procedure code and diagnosis code for this encounter. - answer43239, K29.70 A 27 year-old was admitted to the outpatient surgery center at the local hospital for surgical repair of the left elbow. The surgeon performed a left elbow arthroplasty with a fascial graft for the patient's systemic sclerosis. What are the correct procedure and diagnosis for this? - answer24360-LT, M34.9A 27-year-old woman in the first trimester of her first pregnancy had a transabdominal ultrasound with real-time image documentation for fetal and maternal evaluation in the hospital. The ultrasound revealed that the woman was pregnant with twins. What CPT® and ICD-10-CM codes are reported by the facility? - answer76801, 76802, Z34.01, Z3A.00 A 28 year-old male was rushed to the ED after being found unconscious. Information from family members indicated the patient had left a suicide note and taken a large amount of LSD (a hallucinogenic). What ICD-10-CM codes are reported? - answerT40.8X2A, R40.20 A 28 year-old with a deviated nasal septum, chronic turbinate hypertrophy, chronic tonsillitis and tonsillar hypertrophy undergoes a tonsillectomy, septoplasty and submucous resection of the turbinates in the hospital outpatient center. Once intubated, the tonsils were removed gently by the usual technique with dissection, followed by suction cauterization of larger vessels. The septum was approached through a left hemitransfixion incision. Elevation of mucoperichondrium and detachment of the cartilage from the bony septum was performed. A cartilaginous spur was shaved off and a bony spur of the maxillary crest was removed with a chisel. Alignment of the caudal system was secured with sutures. The inferior turbinates were injected with Xylocaine. The hemitransfixion incision was closed. I divided the turbinate in the longitudinal fashion and removed the anterior 30 percent of the lateral mucosal and turbinate bone on each side. Bipolar cauterization and silver nitrate was used to achieve hemostasis and then dressing with ventilation tubes for a nasal dressing. Provide the procedure code and diagnosis code for this encounter. - answer42826, 30520, 30130-50, J34.2, J34.3, J35.01 A 28 year-old woman was diagnosed with cancer and will be starting radiation and chemotherapy treatment. Before she starts treatment, she has cryopreservation and storage of her mature oocytes performed for having children in the future. What CPT ® codes are used for this procedure? - answer89337, 89346 A 29 year-old female presents to the hospital outpatient surgery center for diagnostic study for infertility. Under general anesthesia she is placed in lithotomy and prepped and draped in the usual fashion. A speculum is inserted into the vagina, and the cervix is dilated. A catheter is inserted into each fallopian tube and saline is injected. Dye is then injected under fluoroscopic guidance. Dye is shown escaping from fallopian tubes, so the tubes are patent. Following this a D&C is performed. What are the CPT and ICD-10-CM codes? - answer58345, 74742, 58120, N97.9 A 31 year-old female undergoes surgery in the ASC for carpal tunnel syndrome, right wrist. UnderBier block anesthesia, preparation was done with Betadine scrub solution and sterile draping was done. Curvilinear incision was made based on the lunar side of the longitudinal wrist crease and carried up to the proximal flexor wrist crease. This was carried through subcutaneous tissue and range retractors were inserted. The median nerve was visualized at the proximal edge of the transverse carpal ligament. The nerve was protected and using curved dissecting scissors, the transverse carpal ligament was sectioned under direct vision. The nerve was quite compressed. After the ligament had been sectioned, the wound was closed with interrupted sutures and sterile dressings were applied. The patient tolerated the procedure well and circulation to the extremity was intact. Provide the procedure code and diagnosis code for this encounter. - answer64721, G56.01 A 31 year-old in her 22nd week of pregnancy is in observation for abnormal glucose tolerance. Her glucose level was brought under control while in observation. Report the diagnosis code(s). - answerO99.810, Z3A.22 A 32 year-old female had a mastectomy for breast cancer. The mastectomy completely removed the breast cancer with no further treatment. On a follow-up visit to her oncologist, it is determined the cancer has metastasized to the right lung. The patient is now undergoing a lung resection for the lung cancer. Applying the coding concept from ICD-10-CM guidelines I.C.2.b. and I.C.2.d., what ICD-10-CM codes are reported for the lung resection? - answerC78.01, Z85.3 A 32 year-old male is in a diagnostic center for an ultrasound of his neck due to difficulty swallowing. The patient's father had esophageal cancer. What is/are the appropriate code(s) to report for the diagnostic service? - answerR13.10, Z80.0 A 32 year-old male was seen in the ASC for removal of two lipomas. One was located on his back and the other was located on the right forearm. Both involved subcutaneous tissue. What ICD-10-CM code(s) is/are reported? - answerD17.21, D17.1 A 32 year-old sees her obstetrician about a lump in the lower outer quadrant of the right breast. Her mother and aunt both have a history of breast cancer. What diagnosis code(s) should be reported? - answerN63.13, Z80.3 A 32 year-old who is 21 weeks pregnant (antepartum) presents with vaginal bleeding. She is admitted to the observation unit to rule out a spontaneous abortion. What ICD-10-CM code(s)is/are reported? - answerO46.92, Z3A.21 A 33 year-old is in the local hospital's surgery department for a scheduled surgery of internal hemorrhoids. Once prepped and draped, the surgeon explores the anal canal and locates the internal hemorrhoid columns. Liquid sclerosing solution is then injected into the submucosa of the rectal wall under the hemorrhoidal column. What CPT® code is reported for the procedure? - answer46500 A 35 year-old female presents to the hospital outpatient surgery for elective sterilization via hysteroscopy. Under general anesthesia the patient is prepped and draped in the lithotomy position. The fallopian tubes are successfully cannulated and occlusion is accomplished by placement of permanent implants. Report the CPT ® and ICD-10-CM codes. - answer58565, Z30.2 A 35 year-old woman is experiencing dizziness with nausea and vomiting. The provider documents auditory vertigo of both ears, possible Meniere's disease. What ICD-10-CM code(s) is/are reported? - answerH81.313 A 35-year-old male in the ED with a spontaneous pneumothorax secondary to pneumonia due to Pneumocystitis carinii and AIDS. A thoracentesis with placement of a chest tube using fluoroscopic guidance is performed. What CPT® and ICD-10-CM codes are reported by the facility? - answer32555, B20, B59, J93.12 A 36 year-old patient who with chalazion lesions in the upper eyelid of his right eye undergoes excision in the ambulatory surgery center. Following prepping and draping, the physician uses topical eye drops and local injection to provide anesthesia to the eyelid area. Then the physician uses a chalazion clamp and exposes the posterior surface of the eyelid. She then incises both lesions and explores the eyelid with a curette. After the incisions are drained, the wounds are cauterized and the clamp is released. The patient tolerated the procedure well. What CPT ® and ICD-10-CM codes are reported by the facility? - answer67801-E3, H00.11 A 37 year-old female is seen in the outpatient surgery department of the hospital. The scheduled procedure is laser ablation of cervical dysplasia CIN-III. IV sedation is administered and the patient was taken to the operating room where she was placed in the dorsolithotomy position. After a vaginal speculum was placed, the surgeon proceeded with the colposcopy. No abnormalities were noted at the time of the colposcopy. To ablate the cervix, 100 watts with a 2mm laser beam were used. The endocervix was buttonholed. The patient tolerated the procedure well and was in stable condition when she was sent to recovery and released the same day. What are the CPT ® and ICD-10-CM codes reported? - answer57513, D06.9 A 37 year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5- S1, the physician uses the transforaminal approach. With fluoroscopic guidance, the spinal needle is inserted, and the patient experienced paresthesia in her left lower extremities. The anesthetic drug is injected into the epidural space. Report the CPT® code(s). - answer64483 A 37 year-old male is diagnosed with cholelithiasis, choledocholithiasis and acute and chronic cholecystitis. What ICD-10-CM code(s) is/are reported? - answerK80.66 A 37 year-old pregnant female returns to the United States from her Peace Corps travels in Southeast Asia. Due to her occupation she has not been able to see a physician for prenatal care until now. She is approximately 20 weeks gestation and presents to her OB/GYN outpatient clinic for care. Upon examination, a fetal heartbeat is not heard. An ultrasound is performed and it is determined she has a hydatidiform mole pregnancy. It is decided to treat her molar pregnancy with a hysterotomy due to previous cesarean sections. Her provider performs a hysterotomy to remove the mole from her uterus. At the request of the patient a tubal ligation is performed as well. What are the CPT ® and ICD-10-CM codes? - answer59100, 58611, O01.9 A 37 year-old woman presents with abdominal pain, bleeding unrelated to menses and an abnormal pap showing LGSIL (low grade squamous intraepithelial lesion). Treatment is hysteroscopy with thermoablation of the endometrium and cryocautery of the cervix. This is performed without difficulty. What are the CPT ® and ICD-10-CM codes reported for this procedure? - answer58563, 57511, R87.612 A 39 year-old patient underwent a left femoral hernia repair. The postoperative diagnosis was recurrent left femoral hernia. What is the diagnosis code for this encounter? - answerK41.91 A 4 year-old male is brought to the hospital by his mother. Today he is going to have surgery to repair his Cheiloschisis. Assign the correct code for his condition. - answerQ36.9A 40 year-old patient has a history of difficulty swallowing for the past several months. He is sent to the hospital for an esophageal manometry study. Report this service for the facility. - answer91010 A 40 year-old woman presents with vaginal bleeding for several weeks unrelated to her menstrual cycle. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter? - answerN93.9 A 41 year-old female has carpal tunnel syndrome in her left hand. The patient underwent release of the carpal ligament with internal neurolysis. An incision was made directly over the carpal ligament through the skin to the carpal ligament. Under direct vision the carpal ligament was divided and under microscopic vision internal neurolysis was performed on the median nerve. What CPT® code is reported? - answer64721 A 42 year-old with chronic right trochanteric bursitis is scheduled to receive an injection at the Pain Clinic. A 22-gauge spinal needle is introduced into the trochanteric bursa, and a total volume of 8 cc of normal saline and 40 mg of Kenalog was injected. What CPT ® codes should be reported? - answer20610-RT, J3301 x 4 A 43-year-old steps on a piece of glass and cuts the bottom of her left foot. There are no pieces of glass in the foot when the patient is examined in the emergency department. Select the ICD-10-CM code(s) for the injury (do not report external cause codes). - answerS91.312A A 44 year-old with ampulla cancer of the pancreas underwent a Port-A-Cath insertion, left cephalic vein approach, in the hospital outpatient surgery department. The right chest was prepped and draped in the usual fashion. A 4-cm incision was made over the delta pectoral groove on the right side. This continued down through subcutaneous tissue to the cephalic vein. The cephalic vein was tied distally and controlled proximally. A venotomy was performed. The catheter tip was inserted and passed to the superior vena cava right atrial junction. The port was attached to the catheter and sutured in place at the 3 o'clock and 9 o'clock positions with interrupted 2-0 Proline. Flow of the catheter was checked and it was excellent and heparinized. The subcutaneous tissue was then closed with running 3-0 Vicryl and the skin closed with running 4-0 Vicryl. The patient tolerated the procedure well and was sent to recovery in stable condition. What CPT ® and ICD-10-CM codes are reported? - answer36571, C25.3A 45 year-old female with malignant Mullerian duct cancer is receiving her first treatment of chemotherapy. What diagnosis codes are reported? - answerZ51.11, C57.7 A 45 year-old female with ovarian cancer visits her oncologist to receive an injection of Procrit. The Procrit has been prescribed to her for treatment of her anemia resulting from antineoplastic chemotherapy treatment. Applying the coding concept from ICD-10-CM guideline I.C.2.c.2., what ICD-10-CM codes should be reported? - answerD64.81, C56.9, T45.1XSA A 45 year-old mother of three children is having surgery to correct an anterior vaginal wall prolapse with an incomplete uterine prolapse. What ICD-10-CM code is reported? - answerN81.2 A 45 year-old-male patient developed an ulcer on his upper back. He has had diabetes for several years and is on insulin. The provider determines that the ulcer is due to his diabetes. What ICD-10-CM codes are reported? - answerE11.622, L98.429, Z79.4 A 46 year-old patient was admitted to the outpatient surgery for a left malignant parotid gland tumor. After induction of endotracheal anesthesia, the left face was prepped and draped. A preauricular curvilinear incision was made which extended horizontally into the neck toward the mid jawbone. The entire parotid gland was removed, and pathology notified that the edges were clear. The facial nerve was dissected during the procedure to free up the parotid gland. After removal the facial nerve was repaired by connecting the ends of the nerve with sutures. Report the CPT® and ICD-10-CM codes for this procedure. - answer42420-LT, 64864, C07 A 47 year-old male was treated in the ED after being involved in a fight at a local pub. The patient sustained two lacerations, one to the left cheek and one to the left forearm. Abrasions were also on the left cheek. What ICD-10-CM codes are reported? - answerS01.412A, S51.812A, Y04.0XXA, Y92.29 A 47 year-old male was treated in the emergency room after being involved in a fight at a local mall. The patient suffered two lacerations. One was to his right cheek and the other was to his left forearm. What are the correct diagnosis codes for this encounter? - answerS01.411A, S51.812A, Y04.0XXA, Y92.59 A 47-year-old patient visited the outpatient clinic in a teaching hospital for a biopsy of a suspicious forearm lesion that needed to be biopsied. The physician removed the lesion thatmeasured 3.0 cm with margins . The physician sent the lesion to pathology and the pathology report indicated the lesion was malignant. Provide the correct CPT® code(s). - answer11603 A 49 year-old presents to the hospital-based clinic with an abscess of the right thumb. The physician incises the abscess and purulent sanguineous fluid is drained. The wound is packed with iodoform packing. What CPT ® code is reported? - answer26010-F5 A 50 year-old female patient was seen on June 2 for a one-week history of gastroenteritis with nausea, diarrhea and vomiting. She returned to the hospital outpatient clinic on June 3 for scheduled hydration therapy. She received five hours of IV hydration therapy. Report the CPT ® and ICD-10-CM codes. - answer96360, 96361 x 4, K52.9 A 50 year-old presents to the ASC for an elective repair of a reducible recurrent inguinal hernia. The usual surgical preparation and positioning has occurred. Prior to the administration of general anesthesia, the patient complains of chest pain with the cardiac monitor reflecting S-T segment changes. Due to the possibility of an evolving cardiac event, the procedure is canceled. Provide the procedure code for this encounter. - answer49520-73 A 52-year-old patient develops an ulcer on the big toe of his right foot. The patient has type 2 diabetes controlled with oral hypoglycemic medication. Select the diagnosis code(s) - answerEll.621, L97.519, Z79.84 A 53 year-old woman with scarring of the right cornea has significant corneal thinning with a high risk of perforation and underwent reconstruction of the ocular surface. The eye is incised and an operating microscope is used with sponges and forceps to debride necrotic corneal epithelium. Preserved human amniotic membrane is first removed from the storage medium and transplanted by trimming the membrane to fit the thinning area of the cornea then sutured. This process was repeated three times until the area of thinning is flushed with surrounding normal-thickness cornea. All the knots are buried and a bandage contact lens is placed with topical antibioticsteroid ointment. What CPT ® code is reported? - answer65780 A 54 year-old patient with primary right lung cancer is receiving his first radiation treatment at the hospital oncology clinic. What ICD-10-CM codes are reported? - answerZ51.0, C34.91A 55 year-old female (non-Medicare) is having a diagnostic mammogram performed on her left breast because a screening mammogram detected density in the breast. What CPT ® and ICD-10-CM codes are reported for the facility? - answer77065-LT, R92.2 A 55 year-old female is admitted to the hospital observation for management of her type 2 diabetes mellitus. Her Hemoglobin A1C was 10.5 on admission. During the stay, a lab result showed an elevated creatinine level of 12.1 mg/dl. She was seen by her nephrologist to evaluate her Stage 3 chronic kidney disease. Assign the diagnoses code(s) for the hospital. - answerE11.22, N18.3 A 55 year-old female with right hydronephrosis presents for a cystourethroscopy with a retrograde pyelogram. What is the correct diagnosis code? - answerN13.30 A 56 year-old female fell while ice-skating. Another skater skated over her hand causing a 15-cm laceration to her right hand. She was admitted to the outpatient hospital surgery department for surgical repair of the laceration. The physician had to use an operating microscope to repair the median, ulnar and radial nerves. The laceration provided access to the nerves for repair and it was closed with an intermediate repair. How should the facility's services be reported? - answer64835, 64836, 64837, 69990 A 56 year-old male presents to the ER in acute respiratory distress syndrome. The clinical staff performs 30 minutes of critical care and the physician performs an endotracheal intubation which is not included in the critical care time. What CPT ® and ICD-10-CM codes are reported? - answer99291-25, 31500, J80 A 56 year-old male was admitted to Observation from his physician office for chest pain at 3 PM and the ED physician ordered a chest X-ray (71045), EKG (93005), and blood work (80053, 80061, 84484). The patient stayed in observation for 12 hours. The next day a repeat chest X-ray (71045) and EKG (93005) and blood work (84484) were performed. Report the facility services for Day 2. - answer71045, 93005, 84484 A 56 year-old patient with multiple sclerosis receives continuous infusion therapy of a therapeutic medication over a three-hour period in the hospital's outpatient clinic. The patient has a venous access device in place. What is the correct way to report these services? - answer96365, 96366 x 2, G35A 56-year-old former ski professional just went downhill skiing for the first time this season at a mountain resort and fell and now is complaining of right shoulder pain. A rotator cuff injury is suspected. His orthopedist sends him to the hospital for an MRI with contrast (Gadolinium (1.4 mg) (iron-based contrast). The MRI confirms a torn rotator cuff capsule. What CPT® and ICD-10-CM codes are reported by the facility? - answer73222. A9579 x 2, S43.421A, V00.321A, Y93.23, Y92.828 A 57 year-old male with adenoma of the prostate is in the ambulatory surgery department of the hospital for treatment. After prepping and draping the area, the urologist inserts an endoscope into the penile urethra, dilating the structure in order to allow passage of the endoscope. The diseased benign prostate is destroyed with radiant energy after a radio frequency stylet is inserted. Electrocoagulation was used to control bleeding and the endoscope was removed and a catheter was placed. The patient tolerated the procedure well and was sent to recovery. What CPT and ICD-10-CM codes are reported? - answer53852, D29.1 A 6 month-old patient is seen at the clinic for a routine well-child visit and vaccinations. During the examination the provider finds that the child has a fever and a diagnosis of acute otitis media in the right ear is documented. Vaccinations are not given at this time. What ICD-10-CM code(s) is/are reported? - answerZ00.121, H66.91, Z28.01 A 6 year-old patient has an open wound on his right forearm from a raccoon bite. The animal tested positive for rabies. He is brought into the urgent care department for treatment. The physician counsels with the parents on the treatment protocol for rabies. The patient is given Rabies immune globulin (RIg) IM. He is scheduled to return for further treatment in 5 days. What CPT ® codes are reported? - answer90375, 96372 A 60 year-old male presents to the outpatient surgery center for a colonoscopy due to a recent episode of bleeding from the rectum. The scope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice and ileocecal valve. An area of bleeding was identified at the rectosigmoid junction, which was controlled using electrocautery. Report the CPT® code(s) for the procedure? - answer45382 A 62 year-old woman with a history of urinary incontinence and incomplete bladder emptying presents for sling urethropexy and repair of a cystocele. The sling urethropexy is performed using prosthetic mesh. The anterior repair is also performed without difficulty and both repairs aremade vaginally. What are the CPT ®/HCPCS codes reported for this service? - answer57288, 57240, C1771 A 63 year-old man sustained a gunshot wound through the right maxillary sinus penetrating through the right neck. CT scan revealed no hard evidence of arterial injury but a bullet was directly in line with the internal jugular vein. He was sent to the operating room for neck exploration to rule out vascular injury and injury to the aerodigestive tract. A sternocleidomastoid incision was performed and carried down through the platysma muscle. There was no penetration of the internal jugular vein, but a foreign body was identified resting on the internal jugular vein at approximately the level of the angle of the mandible and removed. The parotid gland was noted to have a blast injury near the tail. This was not surgically repaired or resected. Once all bleeding was controlled, a 10 French round drain was placed in the wound. The wound was copiously irrigated. The platysma muscle was closed as well as the skin with subcuticular closure. What CPT ® code is reported? - answer20100 A 65 year-old female comes to the hospital outpatient surgery department for a surgical repair for stress incontinence. PREOPERATIVE DIAGNOSIS: 1) Stress incontinence POSTOPERATIVE DIAGNOSIS: 1) Stress incontinence OPERATION: 1) Transobturator tape operation PROCEDURE: The patient was placed in the supine position. General anesthesia was induced. Position was changed to the lithotomy position. The patient was cleaned and draped in the usual manner. A Foley catheter was inserted into the bladder. The bladder was drained. Indigo carmine was insufflated and the catheter was clamped. Both the labia minora were sutured to the labia majora. Two incisions were applied on each side at the level of the clitoris between the labia majora and the thigh and 0.25% Marcaine was insufflated into the anterior vaginal wall. A vertical incision was made about 2 cm below the urethra, and the vaginal mucosa was separated from the urethra and the bladder. A tunnel was dissected between the vaginal opening toward the vulvar incision. An attempt was made to insert the needle for carrying the transobturator tape mesh. The needle could not reach to the incision, so a piece of mesh was cut, about 10 cm in length, and placed in front of the urethra, tacked on each side into the paraurethral space, reaching up to the obturator foramen. The vaginal mucosa was closed using 2-0 Vicryl continuous locking stitches. The vaginal mucosa was closed using 2-0 Vicryl continuous locking stitches. Complete hemostasis was obtained. Estimated blood loss was 150 ml. The vagina was packed. Postoperative recovery of the patient was uneventful. What are the CPT® and ICD-10-CM codes? - answer57288, N39.3 A 65 year-old male with a history of chronic glaucoma has progressive optic nerve damage and elevated intraocular pressure. A clear corneal incision is made and viscoelastic material is injected into the anterior chamber over the lens to increase and maintain anterior chamber depth. The endoscope is inserted through the temporal incision to view the nasal ciliary processes, which are coagulated with the endpoint of shrinkage and whitening. The endoscope is moved in an arc,allowing treatment of the processes over an arc of 180° and a second corneal incision is made 90°away and 180° of ciliary processes are destroyed with laser therapy (cyclophotocoagulation). The surgeon has completed coagulation of 270° of angle. The eye is reformed with balanced salt solution. Wounds are checked for leakage and sutures are placed to seal the wound. What CPT code is reported? - answer66711 A 65 year-old Medicare patient presented to the ER after a fall off a sidewalk in the city park. He had been taking his daily exercise run. He hit his head, and there is moderate bruising of the right temple. He also has a laceration of the knee which required intermediate suturing. The laceration was 5 cm. The patient was evaluated for head injury and a CT without contrast (70450) was taken of the head. He was then kept for two hours before being released. The facility ED E/M for the head injury was moderate (Level 3). Report the facility services. The repair is status indicator T. - answer99283-25, 12032, 70450 A 65 year-old Medicare patient with known right upper lobe lung cancer is seen in the ED with shortness of breath. After examination, the physician determines that the patient has pleural effusion after a chest X-ray is performed (71045). The facility ED services are moderate based on the facility E/M list (level 3). The physician then performed a thoracentesis with imaging guidance (32555). Report the facility services and diagnosis codes. - answer99283-25, 32555, 71045, C34.11, J91.8 A 65-year-old Medicare patient presented to the outpatient surgery department of the hospital to undergo a thyroidectomy, including substernal thyroid via a cervical approach for removal benign neoplasm of a thyroid gland. What CPT® and ICD-10-CM codes are reported? - answer60271, D34 A 66 year-old sustained a left proximal humerus fracture. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The fracture site was identified, fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stablecondition. No immediate complications. What CPT ® code is reported? - answer23616-LT A 66 year-old woman had breast cancer removed three years ago via a right partial mastectomy. She presented to her provider with lumps in her right axilla. The surgeon performs an incisional deep biopsy of the axillary lymph nodes bilaterally. What CPT ® and ICD-10-CM codes are reported? - answer38525-50, R59.0, Z85.3 A 67-year-old female with known osteoporosis with a recent fall. Probable vertebral fracture and patient needs a DXA scan of the vertebrae for fracture assessment. What CPT® and ICD-10-CM codes are reported by the facility? - answer77086, M81.0, W19.XXXA A 68 year-old male with glaucoma experiences a sudden but painless lossof vision in his right eye due to blockage of a blood vessel in the retina. The eye surgeon decides to perform an anterior chamber paracentesis. He places anesthetic drops in the patients' right eye to numb the eye during the procedure. The surgeon inserts a needle through the cornea into the anterior chamber of the eye and withdraws a small amount of aqueous fluid, which helps to reduce the pressure in the eye. Assign the CPT ® code for this procedure. - answer65800 A 68-year-old female with a 12 cm complex mass in the right adnexa found on routine exam, confirmed with ultra sound, is sent to the hospital for a pelvic MRA with contrast (Gadolinium 1.5 mL) (iron-based magnetic resonance contrast). What CPT® and ICD-10-CM codes are reported by the facility for this Medicare patient? - answerC8918, A9579 x 2, N94.9