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質問 # 116
A 52-year-old male patient with known AIDS saw his orthopedic physician today for severe pain in the right knee. The physician documents that his knee pain is due to a flare up of posttraumatic osteoarthritis and he gives him a cortisone injection in the right knee joint. The osteoarthritis is not related to AIDS.
What ICD-10-CM codes are reported for this encounter?
- A. B20, M17.31
- B. M17.11, B20
- C. M17.31, B20
- D. Z21, M08.861
正解：A
解説：
In this encounter, the correct coding order follows ICD-10-CM guidelines for coding multiple conditions when AIDS (B20) is documented, as it takes precedence. The patient's diagnosis of AIDS, documented with code B20, is reported as the primary diagnosis since it is a chronic condition. The M17.31 code is used to document unilateral primary osteoarthritis of the right knee, unrelated to AIDS but causing the patient's knee pain.
Explanation of each answer choice:
A: B20, M17.31: Correctly lists AIDS (B20) as the primary diagnosis and osteoarthritis of the right knee (M17.31) as the secondary diagnosis.
B: Z21, M08.861: Z21 represents asymptomatic HIV, not AIDS, which is incorrect here, and M08.861 is the code for juvenile idiopathic arthritis, not relevant in this case.
C: M17.11, B20: Incorrect as M17.11 is for unilateral primary osteoarthritis of the right knee, not left, and does not prioritize B20 as required.
D: M17.31, B20: Incorrect because it does not list B20 as the primary diagnosis, which is necessary per coding guidelines when AIDS is documented.
Thus, the correct answer is A. B20, M17.31.
質問 # 117
A patient underwent a cystourethroscopy with a pyeloscopy using lithotripsy to break up the ureteral calculus.
An indwelling stent was also inserted during the same operative session on the same side. This service was performed in the outpatient hospital surgery center.
What CPT coding reported?
- A. 0
- B. 52352, 52332-51
- C. 52325, 52332-51
- D. 52353, 52332-51
正解：A
解説：
* Cystourethroscopy: This is a procedure that involves the use of a cystoscope to look inside the urethra and bladder.
* Pyeloscopy: Involves the examination of the upper urinary tract, typically done through the cystoscope.
* Lithotripsy: A procedure that uses shock waves or a laser to break up stones in the kidney, bladder, or ureter.
* Indwelling stent insertion: A procedure to place a stent in the ureter to help urine flow from the kidney to the bladder.
* 52356: Cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization and/or ureteral stent placement).
The code 52356 includes all components mentioned: cystourethroscopy, pyeloscopy, lithotripsy, and stent insertion performed in the same operative session.
References:
* AMA's CPT Professional Edition (current year)
* ICD-10-CM (current year), HCPCS Level II (current year)
質問 # 118
Dr. Burns sees newborn baby James at the birthing center on the same day after the cesarean delivery. Dr.
Burns examined baby James, the maternal and newborn history, ordered appropriate blood test tests and hearing screening. He met with the family at the end of the exam.
How would Dr. Bums report his services?
- A. 0
- B. 1
- C. 2
- D. 3
正解：A
解説：
Dr. Burns is providing initial hospital or birthing center care for the evaluation and management of a normal newborn infant. CPT code 99460 is used to report initial hospital or birthing center care, per day, for evaluation and management of a normal newborn infant. This includes a comprehensive history, examination, and medical decision-making. The description of the service provided fits this CPT code accurately.
References: CPT Professional Edition (current year), AMA.
質問 # 119
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis Procedure: Cholecystectomy Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT coding is reported for this case?
- A. 47605, 74300-26
- B. 47563, 74300-26
- C. 47562, 74300-26
- D. 47600, 74300-26
正解：B
解説：
* 47563: Laparoscopic cholecystectomy with cholangiography is coded as 47563. The report details the laparoscopic removal of the gallbladder with intraoperative cholangiography.
* 74300-26: The radiological supervision and interpretation for the cholangiography is coded as 74300 with modifier -26 (Professional Component) since the interpretation was done by the physician.
References:
* CPT Professional Edition, AMA
質問 # 120
Where is a Warthin's tumor found?
- A. Salivary gland
- B. Back of eye
- C. Ovary
- D. Bone
正解：A
質問 # 121
A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：A
質問 # 122
A surgeon removes the right and left fallopian tubes and the left ovary via an abdominal incision. How is this reported?
- A. 58700-50
- B. 0
- C. 58720-50
- D. 1
正解：D
解説：
* Bilateral salpingo-oophorectomy: This involves the removal of both fallopian tubes and ovaries.
* Right and left fallopian tubes: Both fallopian tubes are removed.
* Left ovary: Only the left ovary is removed.
* Abdominal incision: The procedure is performed via an abdominal approach.
* 58720: Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure).
The procedure involves the removal of both fallopian tubes and one ovary, making 58720 the appropriate code.
References:
* AMA's CPT Professional Edition (current year)
* ICD-10-CM (current year), HCPCS Level II (current year)
質問 # 123
The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
質問 # 124
A 55-year-old patient with suspected liver cancer was seen by the physician to obtain a biopsy. The special biopsy needle was placed using ultrasonic guidance. The physician obtained a small tissue sample from the liver, which was then sent to pathology.
What CPTcodes are reported?
- A. 47000, 76942-26
- B. 47100, 77012-26
- C. 47000, 10005
- D. 47000, 77002-26
正解：A
解説：
* Procedure: The physician performed a liver biopsy using ultrasonic guidance.
* CPTCodes:
* 47000: This code is for the liver biopsy.
* 76942-26: This code is for ultrasonic guidance for needle placement, with modifier -26 indicating the professional component.
* Code Selection Justification: The CPTcode 47000 specifically captures the liver biopsy, and 76942-
26 accurately represents the ultrasonic guidance utilized during the procedure.
References:
* AMA CPTProfessional Edition (current year)
* ICD-10-CM (current year)
* HCPCS Level II (current year)
質問 # 125
View MR 099401
MR 099401
Established Patient Office Visit
Chief Complaint: Patient presents with bilateral thyroid nodules.
History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can "feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.
Review of Systems:
Constitutional: Negative for chills, fever, and unexpected weight change.
HENT: Negative for hearing loss, trouble swallowing and voice change.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting Endocrine: Negative for cold Intolerance and heat intolerance.
Physical Exam:
Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97% Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65") General Appearance: Alert, cooperative, in no acute distress Head: Normocephalic, without obvious abnormality, atraumatic Throat: No oral lesions, no thrush, oral mucosa moist Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD Lungs: Clear to auscultation, respirations regular, even, and unlabored Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click Lymph nodes: No palpable adenopathy ASSESSMENT/PLAN:
1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
What E/M code is reported for this encounter?
- A. 0
- B. 1
- C. 2
- D. 3
正解：D
質問 # 126
Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.
What diagnosis coding is reported for the second colonoscopy?
- A. Z86.010, K63.5
- B. Z09, Z86.010
- C. K63.5
- D. Z09, K63.5
正解：D
質問 # 127
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
- A. J9312 x 80, 00163 x 2
- B. J9312, Q0163
- C. J9312 x 80, J1200 x 2
- D. J9312, J1200
正解：A
質問 # 128
The CPT code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.
What is the full description of CPT code 69644?
- A. Without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
- B. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction with intact or reconstructed canal wall, with ossicular chain reconstruction
- C. Tympanoplasty with mastoidectomy (including canalplasty. middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction
- D. With intact or reconstructed canal wall with ossicular chain reconstruction
正解：C
質問 # 129
The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.
What CPT and ICD-10CM codes are reported?
- A. 46250, K64.0, K64.9
- B. 46250, 46945, K64.0, K64.4
- C. 46320, 46945, K64.0, K64.9
- D. 46255, K64.0, K64.4
正解：D
解説：
CPT code 46255 describes the excision of both internal and external hemorrhoids, which matches the procedure described. The ICD-10-CM codes K64.0 (First degree hemorrhoids) and K64.4 (Residual hemorrhoids) describe the conditions treated.
References:
* AMA's CPT Professional Edition (current year), Code 46255
* ICD-10-CM (current year), Codes K64.0, K64.4
質問 # 130
A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesia. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots.
Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT coding is reported for this procedure?
- A. 22857 x 2
- B. 0
- C. 1
- D. 22857, 22860
正解：A
解説：
This scenario describes an anterior discectomy and arthroplasty at two levels (L3-L4 and L5-S1) using artificial discs. CPT code 22857 describes total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar. Since the procedure was performed at two levels, the code should be reported twice.
References:
* AMA's CPT Professional Edition (current year), Code 22857
質問 # 131
The pulmonologist performs a bronchoscopy with fluoroscopic guidance. The scope is introduced into the right nostril and advanced to the vocal cords and into the trachea. The scope is advanced to the right upper lobe and a lung nodule is noted. An endobronchial biopsy is performed.
What CPT code is reported for the procedure?
- A. 0
- B. 1
- C. 2
- D. 3
正解：D
質問 # 132
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