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質問 # 50
View MR 006399
MR 006399
Operative Report
Preoperative Diagnosis: Chronic otitis media in the right ear
Postoperative Diagnosis: Chronic otitis media in the right ear
Procedure: Eustachian tube inflation
Anesthesia: General
Blood Loss: Minimal
Findings: Serous mucoid fluid
Complications: None
Indications: The patient is a 2-year-old who presented to the office with chronic otitis media refractory to medical management. The treatment will be eustachian tube inflation to remove the fluid. Risks, benefits, and alternatives were reviewed with the family, which include general anesthetic, bleeding, infection, tympanic membrane perforation, routine tubes, and need for additional surgery. The family understood these risks and signed the appropriate consent form.
Procedure in Detail: After the patient was properly identified, he was brought into the operating room and placed supine. The patient was prepped and draped in the usual fashion. General anesthesia was administered via inhalation mask, and after adequate sedation was achieved, a medium-sized speculum was placed in the right ear and cerumen was removed atraumatically using instrument with operative microscope. The tube is dilated, an incision is made to the tympanum and thick mucoid fluid was suctioned. The patient was awakened after having tolerated the procedure well and taken to the recovery room in stable condition.
What CPT coding is reported for this case?
- A. 69420-RT
- B. 69433-RT
- C. 69436-RT
- D. 69421-RT
正解：D
質問 # 51
View MR 099405
MR 099405
CC: Shortness of breath
HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.
Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.
ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.
PMH: Asthma
SH: Lives with both parents.
FH: Family hx of asthma, paternal side
ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child's family and no changes reported.
PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.
Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.
Lymph nodes: normal.
Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.
Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.
GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly Skin: normal warm and dry. Pink well perfused Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.
Assessment: Asthma, acute exacerbation
Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.
What E/M code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：C
質問 # 52
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image Reason: Screen Bilateral digital mammography with computer-aided detection (CAD) No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT coding is reported for this case?
- A. 77066-50, Z12.31, Z80.3
- B. 77066, Z80.3, Z12.31
- C. 77067-50, Z80.3, Z12.31
- D. 77067, Z12.31, Z80.3
正解：D
質問 # 53
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT coding is reported for this case?
- A. 14001, 11606-51, 12034-51
- B. 14001, 11606-51
- C. 0
- D. 1
正解：C
質問 # 54
A patient suffers a ruptured infrarenal abdominal aortic aneurysm requiring emergent endovascular repair. An aorto-aortic tube endograft is positioned in the aorta and a balloon dilation is performed at the proximal and distal seal zones of the endograft. The balloon angioplasty is performed for endoleak treatment.
What CPT code does the vascular surgeon use to report the procedure?
- A. 0
- B. 1
- C. 2
- D. 3
正解：D
質問 # 55
Eric is buying his first life insurance policy from XYZ Life Insurance Company. The company requires Eric have a physical exam prior to issuance of the policy. Eric sees his primary care provider who completes the required documentation and forms provided by the insurance company.
How does the primary care provider report his services?
- A. 0
- B. 1
- C. 2
- D. 3
正解：B
質問 # 56
View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See Nurses Notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Have been reviewed-tachycardic.
Eyes: Pupils equal, round and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardia. Heart sounds normal. Pulses normal.
E D. Course: Insulin IV drip per protocol, at 10 units/hr.
Zofran 8 mg 01:33 Jul 13 2008 IVP.
Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.
Total critical care time: 45 min.
Disposition: Admitted to Intensive Care Unit. Condition: stable.
Admit decision based on need for monitoring and IV hydration and medications.
CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.
What E/M code is reported for this encounter?
- A. 0
- B. 99291, 99292
- C. 1
- D. 2
正解：C
質問 # 57
A 5-year-old is brought to the QuickCare in the ED to repair two lacerations: a 3 cm laceration on her right arm and 2 cm laceration on her nose. Her arm is repaired with a simple one-layer closure with sutures. Her nose is repaired with a simple repair using tissue adhesive, 2-cyanoacrylate.
How are the repairs reported?
- A. 12032, 12041-59
- B. 12002, 12011-59
- C. 0
- D. 1
正解：C
質問 # 58
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 CPT codes are reported?
- A. 47000, 10005
- B. 47100, 77012-26
- C. 47000, 76942-26
- D. 47000, 77002-26
正解：C
質問 # 59
A business requires drug testing for cocaine and methamphetamines prior to hiring a job candidate. A single analysis with direct optical observation is performed, followed by a confirmation for cocaine.
Which codes are used for reporting the testing and confirmation?
- A. 80305 x 2, 80353
- B. 80306, 80375
- C. 80306 x 2, 80353
- D. 80305, 80353
正解：D
質問 # 60
A 35-year-old female has cancer in her left breast. The surgeon performs a mastectomy, removing the breast tissue, skin, pectoral muscles, and surrounding tissue, including the axillary and internal mammary lymph nodes.
Which mastectomy code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
正解：B
質問 # 61
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. 1
- D. 58720-50
正解：B
質問 # 62
This 27-year-old male has morbid obesity with a BMI of 45 due to a high calorie diet. He has decided to have an open Roux-en-Y gastric bypass. The patient is brought to the operating room and placed in supine position. A midline abdominal incision is made. The stomach is mobilized, and the proximal stomach is divided and stapled creating a small proximal pouch in continuity with the esophagus. A short limb of the proximal bowel of 155 cm is divided. It is brought up and anastomosed to the gastric pouch. The other end of the divided bowel is connected back into the distal small bowel to the short limb's gastric anastomosis to restore intestinal continuity. The abdominal incision is closed.
What are the procedure and diagnosis codes for this encounter?
- A. 43644, E66.01, Z68.43
- B. 43645, E66.8, Z68.42
- C. 43847, E66.9, Z68.42
- D. 43847, E66.01, Z68.42
正解：D
質問 # 63
A Medicare patient that is on dialysis for ESRD is seen by the nurse for a Hep B vaccination. This patient is given a dialysis patient dosage as part of a three-dose schedule. The nurse administers the Hep B vaccine in the right deltoid. The physician reviews the chart and signs off on the nurse's note.
What procedure and diagnosis codes are reported for the scheduled vaccine injection for this Medicare patient?
- A. 99211-25, G0010, 90740, B19.10, N18.6, Z99.2
- B. 90471, 90746, Z23, B19.10, N18.6, Z99.2
- C. 90471, 90746, Z23, N18.6, Z99.2
- D. G0010, 90740, Z23, N18.6, Z99.2
正解：D
質問 # 64
A physician prescribes carbamazepine to treat a patient with epileptic seizures. After six months, the physician performs a therapeutic drug test to monitor the total level of the drug in the patient.
What CPT and ICD-10-CM coding is used for the six month-evaluation?
- A. 80156, G40.909
- B. 80157, G40.909
- C. 80157, R56.9
- D. 80156, R56.9
正解：A
質問 # 65
According to the Repair (Closure) CPT guidelines, what type of repair is reported when a single layer closure includes copious irrigation and extensive cleaning to remove particulate matter?
- A. Complex repair
- B. Simple repair
- C. Simple repair plus a code for irrigation
- D. Intermediate repair
正解：D
質問 # 66
Patient has undergone open surgery for a left total knee arthroplasty. While in the recovery room, he continued to have severe postoperative pain. The surgeon ordered a femoral block for postoperative pain. The anesthesiologist evaluated the patient and performed a left femoral block, which provided significant post-operative pain relief.
What CPT coding is reported?
- A. 01402, 64447-59-LT
- B. 01404, 64450, 01996
- C. 01380, 64447-59-LT
- D. 01402, 64448-59-LT, 01996
正解：D
質問 # 67
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.
What CPT coding is reported for this case?
- A. 0
- B. 1
- C. 2
- D. 3
正解：A
質問 # 68
A 42-year-old with chronic left trochanteric bursitis is scheduled to receive an injection at the Pain Clinic. A 22-gauge spinal needle is introduced into the trochanteric bursa under ultrasonic guidance, and a total volume of 8 cc of normal saline and 40 mg of Kenalog was injected.
What CPT code should be reported for the surgical procedure?
- A. 20610-LT, 76942
- B. 20611-LT, 76942
- C. 20611-LT
- D. 20610-LT
正解：C
質問 # 69
Which one of the following is a commercial or private payer?
- A. Medicaid
- B. Medicare
- C. Veterans Health Administration (VHA)
- D. Blue Cross Blue Shield
正解：D
質問 # 70
Which statement regarding lesion excision is TRUE?
- A. Lesion excision codes include removal of a lesion, with margins, and intermediate closure when performed
- B. Lesion excision codes include removal of a lesion with margins, and complex closure when performed
- C. Lesion excision codes are selected by measuring the greatest clinical diameter of a lesion excluding the margins required to complete the excision
- D. Lesion excision codes include removal of a lesion, with margins, and simple (nonlayered) closure when performed
正解：D
質問 # 71
An interventional radiologist performs an abdominal paracentesis in his office utilizing ultrasonic imaging guidance to remove excess fluid. What CPT coding is reported?
- A. 49082, 76942
- B. 49082, 76942-26
- C. 49083, 76942-26
- D. 0
正解：D
質問 # 72
A patient suffering from idiopathic dystonia is seen today and receives the following Botulinum injections: three muscle injections in both upper extremities and seven injections in six paraspinal muscles.
How are these injections reported according to the CPT guidelines?
- A. 64642, 64643, 64647
- B. 64642 x 3, 64642 x 3, 64647 x 7
- C. 64644, 64647 x 7
- D. 64642-50, 64643-50, 64647
正解：A
質問 # 73
A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.
What CPT coding is reported?
- A. 0
- B. 36253, 75625-26
- C. 1
- D. 36252, 75625-26
正解：A
質問 # 74
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