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Gastrointestinal Coding and Diagnosis, Exams of Nursing

Walden UniversityNursing

A coding and diagnosis reference for various gastrointestinal conditions and procedures. It includes a series of questions and answers related to the appropriate icd-10-cm and cpt codes for different scenarios involving the digestive system, such as crohn's disease, ulcerative colitis, gallbladder removal, endoscopic procedures, and more. A wide range of gastrointestinal topics and could be useful for healthcare professionals, medical coders, and students studying gastroenterology or medical coding. The level of detail and technical nature of the content suggests it is likely intended for an audience with some prior knowledge or training in medical coding and terminology.

Typology: Exams

2024/2025

Available from 10/23/2024

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AAPC CPC Examination with Answers
Chapter 11 Edition.
1. D - Is the Correct..A screening colonoscopy is performed on a 50
year-old patient with a family history of colon cancer. Multiple
polyps were found during the procedure. Two polyps in the
transverse colon were removed with hot forceps cautery. Three
polyps in the ascending colon were removed via snare. Portions of
all polyp tissues were to be sent to pathology. What are the
correct CPT® and ICD-10-CM codes for this patient encounter?
A) 48584 x2, 45385 x3, K63.5
B) 45384, 45385-59, K63.5, Z12.11, Z80.0
C) 45384 x2, 45385 x3, Z80.0, K63.5, Z12.11
D) 45384, 45385-59, Z12.11, D12.3, D12.2, Z80.0
2. B - Is the Correct..A 33 year-old male patient presents to the
endoscopy suite to determine if he has an ulcer. The physician
performs a diagnostic scope through the esophagus, stomach and
into the duodenum and jejunum. During the scope the patient has
a severe drop in blood pressure and the physician discontinues
the procedure, but not before observing and diagnosing a
bleeding ulcer on the stomach lining as well a perforated ulcer in
the jejunum. A repeat examination is planned.
3. What CPT® and ICD-10-CM codes are reported?
A) 43235-52, K25.4, K28.5
B) 43235-53, K25.4, K28.5
C) 43200-52, K25.5, K28.5
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AAPC CPC Examination with Answers

Chapter 11 Edition.

  1. D - Is the Correct..A screening colonoscopy is performed on a 50 year-old patient with a family history of colon cancer. Multiple polyps were found during the procedure. Two polyps in the transverse colon were removed with hot forceps cautery. Three polyps in the ascending colon were removed via snare. Portions of all polyp tissues were to be sent to pathology. What are the correct CPT® and ICD- 10 - CM codes for this patient encounter? A) 48584 x2, 45385 x3, K63. B) 45384, 45385-59, K63.5, Z12.11, Z80. C) 45384 x2, 45385 x3, Z80.0, K63.5, Z12. D) 45384, 45385-59, Z12.11, D12.3, D12.2, Z80.
  2. B - Is the Correct..A 33 year-old male patient presents to the endoscopy suite to determine if he has an ulcer. The physician performs a diagnostic scope through the esophagus, stomach and into the duodenum and jejunum. During the scope the patient has a severe drop in blood pressure and the physician discontinues the procedure, but not before observing and diagnosing a bleeding ulcer on the stomach lining as well a perforated ulcer in the jejunum. A repeat examination is planned.
  3. What CPT® and ICD- 10 - CM codes are reported? A) 43235 - 52, K25.4, K28. B) 43235 - 53, K25.4, K28. C) 43200 - 52, K25.5, K28.

D) 43235 - 53, K25.4, K28.

  1. A - Is the Correct..A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon (25mm). What CPT® code(s) is/are reported? A) 43220 B) 43450 - 53, 43220 C) 43450, 43220 D) 43220, 434 50 - 52
  2. D - Is the Correct..How do you report a screening colonoscopy performed on a 65 year-old Medicare patient with a family history of colon cancer? The physician was able to pass the scope to the cecum. What CPT® and ICD- 10 - CM codes are reported? A) 45330, Z13.818, Z80. B) 45378, Z12.11, Z85. C) G0104, Z13.818, Z85. D) G0105, Z12.11, Z80.
  3. A - Is the Correct..A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion along with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service? A) 40510 B) 11442, 12011- 51

A) Crohn's disease of the small intestine is reported first with intestinal obstruction reported as a secondary diagnosis. B) Intestinal obstruction is reported first with Crohn's disease of the small intestine is reported as a secondary. C) One combination code is reported to indicate Crohn's disease of the small intestine with intestinal obstruction. D) Crohn's disease of the small intestine is reported as regional enteritis of the small intestines.

  1. C - Is the Correct..A patient is seen in the gastroenterologist's clinic for a diagnostic colonoscopy. When performing the service, the physician notes suspicious looking polyps and removes three using a snare technique to send to pathology for further testing. What is/are the correct CPT® code(s) to report? A) 45378, 45385- 51 B) 45380 C) 45385 D) 45378, 45380- 51
  2. C - Is the Correct..What ICD- 10 - CM code(s) is reported for ulcerative colitis with rectal bleeding? A) K51. B) K52.9, K62. C) K51. D) K51.
  1. D - Is the Correct..What is the CPT® code for removal of a foreign body from the esophagus via the thoracic area? A) 43215 B) 43020 C) 43500 D) 43045
  2. B - Is the Correct..Where is the vermilion border located? A) Underneath the tongue B) Upper and lower lips C) Stomach lining D) In the esophagus
  3. C - Is the Correct..What ICD- 10 - CM code is reported for internal hemorrhoids? A) K64. B) K64. C) K64. D) K64.
  4. C - Is the Correct..A 56 year-old patient complains of occasional rectal bleeding. His physician decides to perform a rigid proctosigmoidoscopy. During the procedure, two polyps are found in the rectum. The polyps are removed by a snare. What CPT® and ICD- 10 - CM codes are reported? A) 45309, 45309, K63. B) 45385, K63. C) 45315, K62.
  1. C - Is the Correct..A 28 year-old female had symptoms of RLQ abdominal pain, fever and vomiting. She was diagnosed with acute appendicitis. The surgeon makes an abdominal incision to remove the appendix. The appendix was not ruptured. The incision is closed. What are the correct CPT® and ICD- 10 - CM codes for this encounter? A) 44950, R10.31, R50.9, R11.10, K35. B) 44970, K35. C) 44950, K35. D) 44970, K
  2. C - Is the Correct..A 20 year-old patient presented to the hospital for a sigmoidoscopy due to a history of bloody stools for three weeks' duration. The patient was prepped for the sigmoidoscopy and the sigmoidoscope was passed without difficulty to about 40 cm. The entire mucosal lining was erythematosus. There was no friability of the overlying mucosa and no bleeding noted. No pseudo polyps were identified. Biopsies were taken at about 30 cm; these were thought to be representative of the mucosa in general. The scope was retracted; no other abnormalities were seen. What CPT® and ICD- 10 - CM codes are reported? A) 45330, 45331, K62. B) 45333, Z12.11, K62. C) 45331, K92. D) 45305, K92.
  1. A - Is the Correct..A 45 year-old patient with liver cancer is scheduled for a liver transplant. The patient's brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient.
  2. What CPT® codes are reported? A) 47140, 47146, 47147, 47135 B) 47141, 47146, 47135 C) 47140, 47147, 47146, 47399 D) 47141, 47146, 47399
  3. A - Is the Correct..Operative Report
  4. Indications: This is a third follow-up EGD dilation on this 40 year-old patient for a pyloric channel ulcer which has been slow to heal with resulting pyloric stricture. This is a repeat evaluation and dilation.
  5. Medications: Intravenous Versed 2 mg. Posterior pharyngeal Cetacaine spray.
  6. Procedure: With the patient in the left lateral decubitus position, the Olympus GIFXQ10 was inserted into the proximal esophagus and advanced to the Z-line. The esophageal mucosa was unremarkable. Stomach was entered revealing normal gastric mucosa. Mild erythema was seen in the antrum. The pyloric channel was again widened. The ulcer, as previously seen, was well healed with a scar. The pyloric stricture was still present. With some probing, the 11 mm endoscope could be introduced

jejunum anastomosis by the Puestow-type operation. What are the correct CPT® and ICD- 10 - CM codes for the encounter? A) 48520, K85. B) 48548, K86. C) 48520, K86. D) 48548, K85.

  1. D - Is the Correct..Procedure: Colectomy with a take-down of splenic flexure.
  2. The patient was taken to the operating room, placed in the dorsal lithotomy position, and then prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascitic fluid was removed and hand-held retractors were used to assist in surgical exposure.
  3. The malignant intra-abdominal tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the malignant tumor mass and the transverse colon were unsuccessful as it appeared the tumor

mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen.

  1. Given the mass could not be resected without removal of bowel, attention was directed to mobilization of the splenic flexure. Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexure were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated
  2. D - Is the Correct..A patient suffering from cirrhosis of the liver from alcohol abuse presents with a history of coffee ground emesis (bleeding). The surgeon diagnoses the patient with esophageal gastric varices. Two days later, in the hospital GI lab, the surgeon ligates the varices with bands via an UGI endoscopy. What CPT® and ICD- 10 - CM codes are reported? A) 43400, I85.11, F10.10, K74. B) 43235, I83.008, F10.20, K70. C) 43205, K74.60, I85.01, F10. D) 43244, K70.30, I85.11, F10.
  3. C - Is the Correct..Bile empties into the duodenum through what structure?

A) 47605, K81.

B) 47570, K81.

C) 47562, K81.

D) 47600, K81.

  1. B - Is the Correct..A 12 year-old patient had an adenoidectomy in 2013 and a second adenoidectomy this year. What CPT® code(s) is/are reported for the second adenoidectomy performed this year? A) 42826 B) 42836 C) 42831, 42836 D) 42831
  2. D - Is the Correct..What CPT® code(s) is/are reported when a physician makes two separate incisions to perform a laparoscopic appendectomy and laparoscopic cholecystectomy? A) 47562 B) 44960, 47562 C) 47562, 44970- 51 D) 47562, 44970- 59
  3. B - Is the Correct..What CPT® and ICD- 10 - CM codes are reported for a gastric restriction by placing a gastric band via laparoscopic surgery for an adult patient diagnosed as morbidly obese having a BMI of 43, type 2 uncontrolled diabetes and elevated blood sugar readings daily? A) 43644, E66.9, Z68.41, E10.

B) 43770, E66.01, Z68.41, E11.

C) 43842, E66.01, Z68.41, E11.

D) 43771, E66.01, Z68.41, E10.

  1. C - Is the Correct..What CPT® code(s) is/are reported for an endoscopic direct placement of a percutaneous gastrostomy tube for a patient who previously underwent a partial esophagectomy? A) 49440, 43116- 51 B) 43246, 43116- 51 C) 43246 D) 49440
  2. D - Is the Correct..What ICD- 10 - CM code is reported for acute gastritis with bleeding? A) K29. B) K29. C) K29. D) K29.
  3. D - Is the Correct..What CPT® and ICD- 10 - CM codes represent the creation of an opening into the stomach to insert a temporary feeding tube for nutritional support in an adult patient with proximal esophageal carcinoma due to alcohol dependence? A gastric tube was not created. A) 43653, C15.9, F10. B) 43870, C15.8, F10. C) 43831, D49.0, F10. D) 43830, C15.3, F10.
  1. C - Is the Correct..When reporting an encounter for screening of malignant neoplasms of the intestinal tract, what does the 5th character indicate? A) History of malignancy in the intestinal tract. B) Laterality of the intestinal tract. C) Anatomic location being screened in the intestinal tract. D) Screening codes for malignant neoplasms of the intestinal tract are only reported with four characters.
  2. B - Is the Correct..What is the term that describes the removal of a portion or all of the stomach? A) Gastrotomy B) Gastrectomy C) Gastrostomy D) Gastric bypass
  3. CPT® code: 45330
  4. ICD- 10 - CM code: K62.89 - Is the Correct..CASE 10
  5. Extent of Examination: Proximal sigmoid colon. Reason(s) for Examination: Proctitis. Postoperative assessment: Proctitis.
  6. Description of Procedure: Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to sigmoidoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Patient was re-examined and no interval changes were noted from the preoperative history & physical. After being placed on the table, patient identification was verified prior to the procedure. Immediately prior to sedation for endoscopy the

patient's ASA classification was Class 2: Mild systemic disease. Monitored anesthesia care (MAC) was administered by the anesthesia team. The quality of the prep was adequate. Prior to the exam, a digital exam was performed and it was unremarkable.

  1. The procedure was performed with the patient in the left lateral decubitus position. The sigmoidscope was inserted to the proximal sigmoid colon. In the rectum, a retroflex was performed. The withdrawal time from the proximal sigmoid colon was 8 minutes. The patient tolerated the procedure well.
  2. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. IV moderate sedation was administered under direct supervision of the physician. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols.
  3. Findings: In the rectum, mild segmental inflammation with erythema was seen. There was no mucosal bleeding.
  4. What are the CPT® and ICD- 10 - CM codes for this service?
  5. CPT® code:
  6. ICD- 10 - CM code:
  7. CPT® code: 45378
  8. ICD- 10 - CM codes: Z85.048, K52.9 - Is the Correct..CASE 9
  9. Extent of Examination: Terminal ileum. Reason(s) for Examination: Hx of rectal cancer s/p Low Anterior Resection (LAR) and colonic J pouch for closure of loop ileostomy. Description of Procedure: Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to colonoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored

was administered by the anesthesia team. The bowel was prepared with GoLYTELY prep. The quality of the prep is based on the Ottawa bowel preparation quality scale. Total score: Right: 1 + Middle: 1 + Left: 1 + Fluid: 0 = 3/14. Prior to the exam, a digital exam was performed; hemorrhoids were noted.

  1. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted in the anus and advanced to the terminal ileum. The cecum was identified by the following: the ileocecal valve and the appendiceal orifice. In the rectum, a retroflex was performed. The patient tolerated the procedure well. There were no complications.
  2. Findings: In the rectum, a few medium-size uncomplicated internal hemorrhoids were seen. The internal hemorrhoids were not bleeding. There was no evidence of inflammation, friability, granularity, or bleeding. Biopsy were taken. In the ascending colon and cecum there was mild granularity and red spots that were nonspecific and possibly due to air insufflation. No friability, ulcerations or bleeding. Biopsy taken. The remainder of the colon was normal. The terminal ileum was normal.
  3. What are the CPT® and ICD- 10 - CM codes for this service?
  4. CPT code:
  5. ICD- 10 - CM codes (2):
  6. CPT® code: 43235
  7. ICD- 10 - CM code: K21.9 - Is the Correct..CASE 7
  8. Extent of Examination: Upper gastrointestinal endoscopy. Reason(s) for Examination: Gastroesophageal Reflux Disease (GERD). Description of Procedure: Informed consent was obtained

with the benefits, risks, including the risk of perforation and alternatives to upper GI endoscopy were explained. The patient agreed to proceed. No contraindications were noted on physical exam. Anesthesia was administered by the ICU staff. (See anesthesiologist report) Monitored anesthesia care (MAC) was administered by anesthesia team. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted through the mouth to the second part of the duodenum. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols.

  1. Findings: The esophagus was examined and no abnormalities were seen. The gastroesophageal junction (upper level of gastric folds) was located 40cm from the incisors. The stomach was examined and no abnormalities were seen. The small bowel was examined and no abnormalities were seen.
  2. What are the CPT® and ICD- 10 - CM codes for this service?
  3. CPT® code:
  4. ICD- 10 - CM code:
  5. CPT® code: 43644
  6. ICD- 10 - CM codes: E66.01, I10, Z68.43 - Is the Correct..CASE 6
  7. Preoperative Diagnosis: Severe obesity. Hypertension. BMI
  8. Postoperative Diagnosis: Severe obesity. Hypertension. BMI