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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q105-Q110):
NEW QUESTION # 105
A 69-year-old patient with a medical history of diabetes is evaluated in the emergency room for a urinary tract infection. After performing a medically appropriate history and exam, the physician prescribes 100 mg of Macrobid every 12 hours and admits the patient to observation status to monitor for sepsis. After seeing an improvement in symptoms, the physician discharges the patient the following day. What CPT and ICD-IO-CM code(s) should be reported for the entirety of the patient's stay?
- A. 99222, 99238, N39.O
- B. 99221, 99238, N39.O, Ell.9
- C. 99284, 99238, Ell.69, N39.O
- D. 99234, N39.O, 397.89
Answer: B
Explanation:
When a patient is admitted into observation status from the emergency room, only the observation code is reported for that day. When observation extends past the initial date of service, the initial treatment would be reported with CPT codes 99221-99223. In this scenario, the appropriate level of service would be 99221, based on the moderate level of decision-making.
which can be ascertained by the number and complexity of problems addressed and the risk of complications and/or morbidity or mortality of patient management. Discharge from observation on a separate date is reported with CPT codes 99238-99239.
Because the diabetes is documented and is a coexisting chronic condition during the time of the encounter, it should follow the reason for admission. Due to a lack of specificity in the diabetes diagnosis, a causal relationship with a UTI is not presumed, and Ell.69 should not be coded.
NEW QUESTION # 106
A new, 29-year-old female patient is seen for a preventative visit and receives counseling that totals 30 minutes about contraceptive management. How would the provider code the CPT code(s) for this visit?
- A. 99385, 99203-25
- B. 99385, 99402-25
- C. 0
- D. 99385, 99417, 99417
Answer: C
Explanation:
If 99402 is part of a more complex service, it would not be separately identifiable, thus eliminating answer A Because 99385 includes counseling/anticipatory guidance/risk factor reduction interventions, the additional 30 minutes that the provider spent discussing contraceptives would not be considered a significant, separately identifiable E/M service, eliminating answer B. Last, because time is not a factor when selecting a preventative service,
99417 reflected in answer C, indicating a prolonged outpatient E/M service totaling 30 minutes would not apply.
NEW QUESTION # 107
A patient presents to physical therapy status post repair of a complete rotator cuff tear in the right shoulder due to a fall. After applying ice to the shoulder for 8 minutes, the physical therapist performs a soft-tissue massage to the infraspinatus muscle that lasts 23 minutes. Just prior to discharge, the therapist spends 20 minutes instructing the patient on isokinetic exercises to help improve range of motion. Which CPT and ICD-IO-CM code(s) should be used to accurately describe encounter?
- A. 97010, 97140x2, 97530, M75.121
- B. 97010, 97140, 97530, S46.011A,W19XXXA
- C. 97110, 97010, S46.011D, W19,XXXD
- D. 97110, 97140, 97010, Z48.89, S46.091A, W19XXXA
Answer: C
Explanation:
Although CPT code 97530 does describe therapeutic activities, the focus is directed at improving functional performance, whereas the correct CPT code 97110 works to develop range of motion. The CPT code for a soft tissue massage (or manual therapy 97140) is based on 15-minute increments, however, anything over 8 minutes prior to or after can be counted as a unit. Based on this, the 23 minutes spent can be counted as two units. Sequencing is based on highest RVU.
Coding crosswalk for a rotator cuff tear is classified as a muscle strain, so answer B, which specifies
"other injury," can be eliminated. Because the patient is in the recovery period of the injury, the seventh character would not be considered active but subsequent.
NEW QUESTION # 108
A 45-year-old female patient with urinary incontinence is treated by means of a Burch procedure. The patient is morbidly obese. What CPT and ICD-IO-CM codes should be reported by the surgeon?
- A. 51840, R32
- B. 51840, R32, E66.8
- C. 51841, R32
- D. 51841, R32, E66.8
Answer: D
Explanation:
When choosing betvteen CPT 51840 and 51841, consider that obesity reduces the operative field, increases surgical time, and poses difficulties in surgical technique. It is therefore considered one of several complicating factors to this surgery because it has an abdominal approach.
Additionally, although the obesity is not the reason for the surgical encounter, it nevertheless should be coded due to the impact it has on the procedure.
NEW QUESTION # 109
Which term describes a procedure in which real-time moving images of an organ are displayed on a screen so that a physician can examine its function and/or structure?
- A. Fluoroscopy
- B. Tomography
- C. Magnetic resonance imaging
- D. Computed tomography
Answer: A
Explanation:
Magnetic resonance imaging (MRI) uses magnets, radio waves, and a computer to display detailed pictures of the inside of the body. Tomography uses waves of energy to create three- dimensional, computer-generated images of any internal structure. Computed tomography is cross- sectional images of the body obtained by a narrow beam of x-rays that quickly rotates around the body.
NEW QUESTION # 110
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