CCS Exam Study Guide 2024: ICD-10-CM Coding and CPT Guidelines, Exams of Medicine

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A separate procedure is coded per CPT guidelines: a. Is considered to be an integral part of a larger service b. Is coded when it is performed as a part of another larger procedure c. Is never coded under any circumstances d. both a and b above - The answer is a. Because a separate procedure is considered a part of, and integral to, another, larger procedure, it is not coded when performed as part of the more extensive procedure. See Surgery Guidelines. It may, however, be coded when it is not performed as part of another, large service. The Black Triangle symbol before a code in the CPT manuals means? a. The code is exempt from bundling requirements. b. The code has been revised in some way. c. The code is exempt from unbundling requirements. d. The code can be used as an add-on code, never reported alone or first. - The answer is b. The code description has been revised. You will see this throughout the book. Which is true of the CPT codes? a. They describe both physician and non physician services

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b. They are numeric. c. Only physicians can report them. d. All of the above are correct. - The answer is a. They describe both physician and non-physician services. Category I are numeric ranging from 00100-99499 and correspond to a procedure or service. Category II and III CPT codes are alphanumeric with a T or F at the end. CPT has been developed and maintained by a. AMA b. CMS c. The Cooperating Parties d. WHO - The answer is a. American Medical Association. CPT codes were first published in 1996 and are developed, maintained and copyrighted by the AMA. This group performs the daily operations for CMS. a. OIG b. PRO c. FI (and carriers) d. WHO - The answer is c. FI and carriers. A fiscal intermediary is a private company contracted by Medicare to pay bills like hospital expenses for Medicare Part A and Part B.

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When using the ICD-10-CM a. Always use the index when coding b. Check the tabular before assigning a code c. It is perfectly appropriate to memorize codes d. b and c are correct - The answer is b. ALWAYS check the tabular before assigning a code. ICD-10-CM codes are composed of 3-7 alpha and numeric digit codes, when using them: a. Code to the greatest detail b. It's appropriate to code the 3 digit code when the category is further defined c. Code to the 4th digit when you don't have the information in your notes d. b and c is correct - The answer is a. Code to the greatest detail. When Acute and Chronic Conditions are noted: a. Always code the Chronic condition first b. Always coed the Acute condition first c. Code both and sequence the acute (sub-acute) code first

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d. b and c are correct - The answer is d. B and C are correct A 60 year old female comes to the clinic with shortness of breath. The doctor orders a chest x-ray, frontal and lateral. a. 71020x2, R06. b. 71035x2, R06. c. 71015, R06. d. 71020, R06. d. 71020, R06.02 - The answer is d. 71020, radiologic examination, chest, 2 views, frontal and lateral. R06.02, shortness of breath. A patient presents for an MRI of the pelvis with contrast materials. a. 72125 b. 72198 c. 72196 d. 72159 - The answer is c. 72196, Magnetic resonance imaging, pelvis; with contract materials Code an endoscopic catheterization of the biliary ductal system for the professional radiology component only.

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a. 74330-TC b. 74330- c. 74328- b. 74300-26 - The answer is c. 74328-26 interpretation of , Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation. Marcy is a 29 year old pregnant female in for a follow-up ultrasound with image documentation of the uterus. a. 76856 b. 74740 c. 76816 d. 74710 - The answer is c. 76816, Ultrasound, pregnant uterus, real time with image documentation, follow-up. Code a complex brachytherapy isodose calculation for a patient with prostate cancer: a. 77318, C b. 77317-22, C62. c. 77772, C d. 77300, C52 - The answer is a. 77318, Brachytherapy isodose plan complex. C61, Malignant neoplasm of the prostate.

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This patient received a prescription for a therapeutic radiology for a cancerous neoplasm of the adrenal gland. What code would you use for complex treatment planning? a. 60520 b. 77307 c. 77401 d.77263 - The answer is d. 77263, keyword; therapeutic radiology treatment planning, complex. Because of frequent headaches, this 50 year old females doctor ordered a CT scan of her head, without contrast materials. a. 70450 b. 70460 c. 70470 d. 70496 - The answer is a. 70450, Computed tomography, head and brain; without contrast material. A patient presents to the laboratory in the clinic for the following tests: TSH, comprehensive metabolic panel, and an automated hemogram with manual differential WBC count(CBC). How would you code this lab? a. 84445, 80551, 85025 b. 84443

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c. 80050 d. 84443, 80053, 85027, 85007 - The answer is c. 80050, general health panel, includes DBD, comprehensive metabolic profile, CBC automated and appropriate manual differential WBC count TSH. An 81 year old female patient presented to the laboratory for a lipid panel that includes measurement of total serum cholesterol, lipoprotein(direct measurement, HDL) and triglycerides. a. 80061 b. 80061- c. 82465, 83718, 84478 d. 82465-52, 83718, 84478 - The answer is a. 80061, lipid panel includes cholesterol, serum, total lipoprotein, direct measurement, high density cholesterol. Thomas has end stage renal failure and comes to the clinic lab today for his monthly urinalysis(qualitative, microscopic only). a. 81015, N b. 81001, N17. c. 81015, N18. d. 81003, N18.6 - The answer is c. 81015, Urinalysis, microscopic only, N18.6, end stage renal disease.

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This 34 year old female had been suffering from chronic fatigue. Her physician has ordered a TSH test. a. 80418, R53. b. 80438, R53. c. 84146, R53. d. 84443, R53.82 - The answer is d. 84443, Thyroid simulating hormone(TSH), R53.82, chronic fatigue syndrome. Surgical pathology , gross examination, or microscopic examination is most often required when a sample of an organ, tissue, or body fluid id taken from the body.. What codes would you use to report biopsy of the colon, hematoma, pancreas, and a tumor of the testis? a. 88307, 88304, 88309 b. 88305, 88304, 88307 c. 88305, 88302, 88307, 88309 d. 88305, 88304, 88307, 88309 - The answer is d. 88305, 88304, 88307, 88309, surgical pathology code location from which biopsy was taken. This patient presents to the clinic lab for a prothrombin time measurement because of long-term use of Coumadin

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a. 85210, Z79. b. 85210, Z79. c. 85610, Z79. d. 85230, Z79.2 - The answer is c. 85610, Prothrombin time Z79.01 encounter for long term(current) use of anticoagulants. The 62 year old female who suffers from treatment- resistant schizophrenia comes into the lab today to have a quantitative drug assay performed for the anti- psychotic medication clozapine, a regular white blood cell and absolute neutrophil count due to concern with agranulocytosis. a. 80159 b. 80159, 85048 c. 80159, 85048, 85004 d. 80159, 85025 - The answer is b. 80159: Clozapine; therapeutic drug assay for Clozapine. In CPT, 85048 is listed as: Blood count; leukocyte(WBC) automated. The CBC, 85058, and adding code 85004 would be unnecessary. The 67 year old female suffers from Chronic liver disease and needs a hepatic function panel performed every six months. Tests include total bilirubin(82274), direct bilirubin(82248), total protein (84155), alanine

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aminotransferases (ALT and SGPT)(84460), aspartate aminotransferases (AST and SGOT)(84450) and what other lab tests? a. 82040, 84075 b. 80061, 83718 c. 82040, 82247 d. 84295, 84450 - The answer is a. 82040, Albumin: serum, plasma or whole blood. 84075, phosphatase, alkaline. The patient presented to the laboratory at the clinic for the following blood tests ordered by her physician: albumin (serum), bilirubin(total), and Urea nitrogen(BUN) (quantitative) a. 82044, 82248, 84520 b. 82040, 82252, 84525 c. 82040, 82247, 84520 d. 82044, 82247, 84540 - The answer is c. 82040, Albumin: serum, plasma or whole blood, 82247, Bilirubin, total, 84520, Urea nitrogen(BUN): quantitative. This male is status post kidney transplant and comes into the clinic for a follow up creatinine clearance. a. 82540, Z94. b. 82575, Z94.

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c. 82565, N d. 82570, N18.6 - The answer is b. 82575, Creatinine; clearance, Z94.0 kidney replaced by transplant. An elderly man comes in for his flu (split virus, IM) and pneumonia (23-valent, IM) vaccines. Code only the immunization administration and diagnoses for the vaccines. a. 90658, 90632, Z23, Z b. 90471, 90658, 90472, 90732, Z23, Z c. 90471x2, 90658, 90632, Z d. 90471, 90472, Z23, Z23 - The answer is d. 90471, 1st administration. 90472, 2nd administration, Z23, need for influenza, Z23, need for pneumococcal vaccine. Code for a tetravalent, preservative free, flu vaccine for a three-year old girl, injected intramuscularly. a. 90686 b. 90686, 90471 c. 90687, 90460 d. 90688, 90460 - The answer is b. 90868: Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use. Quadrivalent (aka tetravalent) means the vaccine is a mixture of four flu-types. A "split virus" is

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chemically disrupted using a non ionic surfactant, which is futher purified. Bivalent is two and trivalent is three. Report the vaccine admin codes 90471-74 in addition to cods 90476-90749. The established patient is seen for a comprehensive eye exam (not E & M), fundus photography and the application of corneal bandage lenses for Keratoconus. Code for this encounter. a. 99215, 92250, 92082 b. 92004, 92250, 92072 c. 92014, 92250, 92071 d. 92014, 92250, 92072 - The answer is d. 92014 comprehensive eye exam. 99250 Fundus photography. Note: for keratoconus. 92072 Fitting of contact lens for management of keratoconus, initial fitting. The patient, a 55 year old male. This was a follow up for POAG. The patient had IOP of 22 OD and 24 OS, The Optometrist added TImolol Maleate to the patient's Xalatan prescription. The OD performed a Comprehensive Eye Exam, which included ExtraOcular Motility(EOM) Confrontation Fields and a Dilated Fundus Exam, No ROS was taken. The provider performed a refraction exam and GDX of the retina of both eyes. a. 99215, 92132

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b. 92004, 92250, 92015 c. 92014, 92134, 92015 d. 92014, 92134 - The answer is c. Key hints here: 55 year old is not a Medicare patient, POAG is Primary Angel Glaucoma, IOP is Intraocular Pressure the Comprehensive eye exam is a 92014 code and not an E & M code. Clues are the two included tests (EOM and CF) and the no ROS was done (not need for 92xxx codes) GDX HRT and OCT are all diagnostic tests coded as Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) 9213X, 92134 is the correct code. Code 92015 for the refraction services. Determination of refractive state. This 70 year old male is taken to the emergency room with severe chest pain. The physician provided an expanded problem-focused history and examination. While the physician is examining the patient, his pressures drop and he goes into cardiac arrest. Cardiopulmonary resuscitation is given to the patient, and his pressure returns to normal; he is transferred to the intensive care unit in critical condition. Code the cardiopulmonary resuscitation and the diagnosis. The medical decision making was of low complexity. a. 99282, 92950, I46. b. 99283, 92970, I46. c. 92950, I46.

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d. 92960, I46.9 - The answer is c. 92950, Cardiopulmonary resuscitation (eg, in cardiac arrest) I46.9 cardiac arrest, cause unspecified. How does CPT Professional Edition define a new patient? a. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 2 years. b. A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belong to the same group practice, within the past 3 years. c. A new patient is one who has received professional services from the physician or another physician of the dame specialty within the last 2 years for the same problem. d. A new patient is one who has received hospital services but has never been seen in the clinic by the reporting physician. - The answer is b. A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. James, a 35 year old new patient, received 45 minutes of counseling and risk factor reduction intervention services

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from Dr. Kelly. Dr Kelley talked to James about how to avoid sports injuries. Currently, James does not have any symptoms or injuries and wants to maintain this status. This was the only service rendered. How would you report this service? a. 99213 b. 99203 c. 99385 d. 99403 - The answer is d. Counseling and/or risk factor reduction intervention services are provided to patients with symptoms or established illness. 45 minutes. Andrea, a 52 year old patient, had a hysterectomy on Monday morning. That afternoon, after returning to her hospital room, she suffered a cardiac arrest. A cardiologist responded to the call and delivered one hour and 35 minutes of critical care. During this time the cardiologist ordered a single view chest x-ray and provided ventilation management. How should you report the cardiologist's services? a. 99291, 99292 b. 99291, 99292, 71010, 94002 c. 71010, 94002, 99231 d. 99291, 99292, 99292-52 - The answer is a. The guidelines for critical care have a list of services that are included with critical care when performed by the

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physician providing the critical care and these services should not be reported separately. Brandon was seen in Dr. Shaw's office after falling off his bunk bed. Brandon's mother reported that Brandon and his sister were jumping on the beds when she heard a "thud". Brandon complained of knee pain and had trouble walking. Shaw ordered a knee x-ray that was done at the imaging center across the street. The x-ray showed no fracture or dislocations. Shaw had seen Brandon for his school physical six months ago. Today, Shaw documented a detailed examination and decision-making of moderate complexity. He also instructed Brandon's mother that if Brandon had any additional pain or trouble walking he should see an orthopedic specialist. How should Dr. Shaw report her services from today's visit? a. 99204 b. 99394, 99214 c. 99214 d. 99203 - The answer is c. This is an established patient visit and meets two of the three key components for a 99214 level visit. Adam, a 48 year old patient, presented to Dr. Crampton's office with complaints of fever, malaise, chills, chest pain and a severe cough. Crampton took a history, did an exam and ordered a chest x-ray. After reviewing the x-

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ray, Crampton admitted Adam to the hospital for treatment of pneumonia. After his regular office hours, Crampton visited Adam in the hospital where he dictated a comprehensive history, comprehensive exam, and decision-making of moderate complexity. How would you report Dr. Crampton's services? a. 99214 b. 99222 c. 99204, 99222- d. 99223, 99214-21 - The answer is b. The subcategory guidelines for Initial Hospital Care state, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service all evaluation and management services provided by that physician in conjunction with the admission are considered part of the initial hospital services are reported with the initial hospital care code only. The office visit is a bundled service. Which below are not included with subsequent intensive care codes 99478-99480? a. Cardiac and respiratory monitoring b. Vital sign monitoring c. Enteral nutritional adjustments d. None of the answers are correct - The answer is d. These services are all included. Exceptions and inclusions

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in the guidelines should be highlighted or added to the margins for quick reference. Larry is being managed for his warfarin therapy on an outpatient basis. Dr. Nancy continues to review Larry's INR tests, gives patient instructions dosage adjustment as needed, and ordered additional test. How would you report the initial 90 days of therapy including 8 INR measurements? a. 99363 b. 99363, 99471 c. 99214 d. This service is bundled with evaluation and management services - The answer is a. This question deals with outpatient anticoagulant management. The code 99363 gives specific parameters for reporting. Dr. Jane admitted a 67 year old woman to the coronary care unit for an acute myocardial infarction. The admission included a comprehensive history, comprehensive examination, and high complexity decision-making. Jane visited the patient on days 2 and 3 and documented (each day) an expanded problem focused examination and decision-making of moderate complexity. On day four, Jane moved the patient to the medical floor and documented a problem focused examination and straight forward decision-making. Day 5,

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Jane discharged the patient to home. The discharge took over an hour. How would you report the services from day on to day five? a. 99213, 99232, 99231, 99239x b. 99221, 99222, 99223, 99238 c. 99231, 99232, 99355, 99217 d. 99223, 99232, 99232, 99231, 99239 - The answer is d. Day one admission or initial hospital care is 99223. Days two and three are subsequent hospital care services at 99232 and you should report them separately. Day four is subsequent hospital care at level 99231. Day five is the discharge service, which is based on time and code 99239 is reported for services of more than 30 minutes, regardless of the actual time. Report this code only once. The provider performed a 120 minute E & M service of a critically ill neonate plus selective head hypothermia reported as two days. a. 99291, 99184 b. 9929x4, 99184 c. 99291x2, 99184x d. 99291, 99292x2, 99184 - The answer is d. 99291, 99292x2; for 120 minutes. 99184 combines total and selective hypothermia in a critically ill neonate per day. Quantity is 2 days.

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Mr. Johnson, a 38 year old established patient is being seen for management of his hypertension, diabetes, and weight control. On his last visit, he was told he had a diabetic foot ulcer and needed to be hospitalized for this condition. He decided to get a second opinion and went to see Dr. Myers. This was the first time Myers had seen Johnson. Myers documented a comprehensive history, comprehensive examination, and decision-making of high complexity. He concurred with hospitalization for the foot ulcer and sent a report back to Johnson's primary care doctor. How would you report Dr. Myers visit? a. 99245 b. 99205 c. 99215 d. 99255 - The answer is b. This is a new patient visit not a consultation. "A consultation initiated by a patient and/or family, and not requested by a physician or other appropriate source, is not reported using the consultation cods but may be reporting using the office visit, home service, or domiciliary/rest home care codes". Report a consultation code only when a request is made by another physician or appropriate source, an opinion is rendered, and a written report is sent back to the "requestor". In this case the patient initiated the visit. Code for the supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger,

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includes two-way communication with transport team before transport, at the referring facility and during the transport including data interpretation and report; first 30 minutes: a. 99485 b. 99486 c. 99487 d. 99489 - The answer is a. 99485. On E & M codes be sure to circle and highlight location, type(critically ill, pediatric) limiting phrases (before transport) and time. Lucas, a 3 year old new patient is seen for a well-child exam. The doctor documents an age appropriate history, examination, anticipatory guidelines, risk factor reduction intervention and indicates Lucus immunizations are up to date. How would you report this service? a. 99392 b. 99213-25, 99385 c. 99203 d. 99382 - The answer is d. 99382, keywords, age 1-4. Preventive medicine services are based on new vs. established patient and age. An anesthesiologist provides general anesthesia for a 72 year old patient with mild systemic disease who is

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undergoing a ventral hernia repair. How would you report the anesthesia service? a. 00834-P2, 99100 b. 00832-P2, 99100 c. 49560, 00834, 91000-P2 d. 00832 - The answer is b. You should report the anesthesia services with modifier -P2 for mild systemic disease and qualifying circumstances due to the patient's age. Dr. Member performed a transesophageal echocardiography for a congenital cardiac condition on a 16 year old patient. Prior to the probe placement, moderate conscious sedation was administered. The probe was placed, images acquired, interpretation and reports were completed in the provider's office. This procedure lasted 45 minutes. What codes capture the services performed by Dr. Member? a. 93315, 99144, 99145 b. 00320, 99144, 99145 c. 93315 d. 93315-P1 - The answer is c. Refer to appendix G in the CPT edition. This appendix lists the codes that include moderate conscious sedation along with guidelines to assist with reporting these services. Additionally, code

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99315 has a bulls-eye symbol that indicates moderate conscious sedation is included with the service. Katherine is a 77 year old patient with a severe hypertensive disease. She underwent a cataract surgery to both eyes under general anesthesia. Dr. Sharon, the anesthesiologist, performed the anesthesia. Prior to induction of anesthesia Sharon completed a preoperative visit and documented a detailed history, detailed examination, and low complexity decision-making on this new patient. How would you report Dr. Sharon's services? a. 99203, 00142-P2, 99100 b. 66820, 00144 c. 0140-P1, 99116-59 d. 00142-P3, 99100 - The answer is d. According to the anesthesia guidelines in the CPT, the preoperative visit is bundled or included in the anesthesia services. A surgeon performed a cervical approach esophagoplasty with repair of a tracheosophageal fistula under general anesthesia. The surgeon performed both the procedure and the anesthesia. How would you report these services? a. 00500, 43305 b. 43305-47 c. 00500-47

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d. both a and c - The answer is b. According to the anesthesia guidelines; To report regional or general anesthesia provided by a physician also performing the services for which the anesthesia is being provided, see modifier -47. Which service is not included with anesthesia services? a. Swan-Ganz monitoring b. Administration of blood c. Blood pressure d. mass spectrometry - The answer is a. Swan-Ganz monitoring A patient was placed under general anesthesia for a simple incision and removal of a foreign body from the subcutaneous tissue. This procedure usually requires local anesthesia. Due to unusual circumstances, which required general anesthesia, what modifier would best describe this situation? a. 47 b. 22 c. 23 d. P6 - The answer is c. Modifier -23

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Erin, a 45 year old, asymptomatic female comes in for her annual bilateral screening mammography. Her physician ordered a computer aided detection along with the mammography. The procedure was performed in a hospital. How would you report the professional services for this study? a. 77057-26, 77067-26 b. 77056-26, 70051-26-59 c. 77059-26, 77057-51 d. 77057, 77067-51 - The answer is a. Report a screening mammography with 77057 and the computer aided detection with 77067-26. A patient presents to a freestanding radiology center and had ultrasonic guidance needle placement with imaging supervision and interpretation of two separate lesions in the left breast. The procedure required several passes to complete. How would you report the imaging procedure? a. 76930x2 b. 76941 c. 76942x2-LT d. 76942-LT - The answer is c. The code 76942 is the correct code to report this procedure according to the CPT. Code 76942 should be reported per distinct lesion that requires separate needle placement. therefore if