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Various topics related to icd-10-cm and icd-10-pcs coding, including code assignment, coding guidelines, and coding scenarios. It provides information on the organizations responsible for updating the procedure classification, standard terminologies used for coding medical procedures and services, and the appropriate coding for various medical conditions and procedures. The document also discusses coding for myocardial infarction, stroke, alcohol abuse, chronic kidney disease, and other medical conditions. Additionally, it covers coding for surgical procedures, such as inguinal hernia repair and obstetric procedures. The document aims to enhance the understanding of icd-10-cm and icd-10-pcs coding principles and their application in healthcare settings.
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Identify the diagnosis code for carcinoma in situ of vocal cord. a. D02. b. C32. c. D49. d. D14.1 - a. D02. Rationale: Index Carcinoma, in situ. See also Neoplasm, by site, in situ Identify the diagnosis code(s) for melanoma of skin of right shoulder. a. D03.61, C43. b. C43. c. C43. d. D03.61 - b. C43. Rationale: Index Melanoma, skin, shoulder Which of the following organizations is responsible for updating the procedure classification of ICD- 10-PCS? a. Centers for Disease Control (CDC) b. Centers for Medicare and Medicaid Services (CMS) c. National Center for Health Statistics (NCHS) d. World Health Organization (WHO) - b. Centers for Medicare and Medicaid Services (CMS)
In ICD-10-CM, a condition that is produced by another illness or injury and remains after the acute phase of the illness or injury is referred to as a: a. Late effect b. Sequela c. Complication d. Comorbidity - b. Sequela Which character in an ICD-10-CM diagnosis code provides information regarding encounter of care? a. Fourth b. Fifth c. Sixth d. Seventh - d. Seventh Rationale: Seventh character provides information about encounter of care, such as initial encounter, subsequent encounter, or sequelae. What does the fourth character of an ICD-10-CM diagnosis code capture? a. Anatomic site b. Severity c. Etiology d. Supplemental information - c. Etiology ICD-10-CM codes must be a minimum length of how many characters? a. Three
b. Five c. Six d. Seven - a. Three Notes appearing under a three-character code apply to which of the following? a. Only to category codes that are exactly three-characters long b. To all codes within that category c. Only to one specific code d. To all codes within that chapter - b. To all codes within that category Which volume of ICD-10-CM contains the Tabular and Alphabetic Index of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. None of the above - d. None of the above Rationale: ICD-10-CM includes diagnoses only. In the development of the ICD-10 code sets, it was determined that creating a separate volume for procedures would be insufficient. Because of this, an entirely new procedure code system, ICD-10-PCS, was developed An exception to the Excludes 1 definition is the circumstance when the two conditions ________. a. Are unrelated to each other b. Are related to each other c. Will not be assigned as the principal diagnosis d. Are injuries with external cause codes - a. Are unrelated to each other
Rationale: Coding Guideline I.A.12.a explicitly states this exception Identify the correct diagnosis code(s) for adenoma of left adrenal cortex with Conn's syndrome. a. D35.02, E26. b. D35. c. E26. d. E26.01, D35.7 - a. D35.02, E26. Rationale: Index Adenoma, adrenal (cortical). Index Syndrome, Conn's. Conns Syndrome in tabular also indicates to code for adrenal adenoma. Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-10-PCS d. SNOMED CT - a. CPT Identify the appropriate ICD-10-CM diagnosis code for right cerebral contusion with 15-minute loss of consciousness, initial encounter for care. a. T14. b. S06.371A c. S06.311A d. S06.310A - c. S06.311A Rationale: Index Contusion, cerebral, right.
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report - d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? a. Simple b. Intermediate c. Complex d. Not specified - c. Complex A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage and products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis - a. Miscarriage Rationale: Guideline I.C.15.q.2 Retained Products of Conception following an abortion: Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion
are assigned the appropriate code from category O03, spontaneous abortion, or codes O07.4, Failed attempted termination of pregnancy without complication and Z33.2, Encounter for elective termination of pregnancy. An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coding professional proceed to code this case? a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. b. Code urinary tract infection with sepsis as the principal diagnosis. c. Query the physician to determine if the patient has sepsis due to the symptomatology. d. Query the physician to determine if the patient has septic shock so that this may be used as the principal diagnosis. - c. Query the physician to determine if the patient has sepsis due to the symptomatology. A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? a. Ataxia b. Fractured arm c. Metastatic carcinoma of the brain d. Carcinoma of the lung - c. Metastatic carcinoma of the brain Rationale: Guideline I.C.2.a: If treatment is direct at the malignancy, designate the malignancy as the principle diagnosis. The only exception to this guideline is if a patient admission or encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate Z51.-code as the first-listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secondary diagnosis
A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina c. Gastroenteritis; abdominal pain; angina d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina - b. Infectious gastroenteritis, chronic obstructive pulmonary disease; angina Rationale: Codes for symptoms, signs, and ill-defined conditions from Chapter 18 of the ICD-10-CM codebook are not to be used as the principal diagnosis when a related definitive diagnosis has been established. Patient has been diagnosed with acute major depression, sleep-related teeth grinding and psychogenic dysmenorrhea. The appropriate code assignment is: a. F32.81, F45. b. F32.9, F45. c. F32.9, F45.8, G47. d. F32.9, G47.53 - c. F32.9, F45.8, G47. A patient is admitted with abdominal pain. The physician documents the discharge diagnosis as pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis b. Pancreatitis; noncalculus cholecystitis; abdominal pain c. Noncalculus cholecystitis; pancreatitis; abdominal pain d. Abdominal pain; pancreatitis; noncalculus cholecystitis - a. Sequence either the pancreatitis or noncalculus cholecystitis as principle diagnosis.
Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders? a. Mental Health Association b. American Psychiatric Association c. Mental Health Foundation d. World Psychiatric Association - b. American Psychiatric Association A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus d. Chronic obstructive asthma - c. Asthma with status asthmaticus Rationale: Status asthmaticus means a severe, intractable episode of asthma that is unresponsive to normal therapeutic measures. A patient is seen in the emergency department for chest pain. After evaluation, it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "chest pain versus GERD." The correct ICD-10-CM code is: a. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out b. R10.11, Right upper quadrant abdominal pain c. K21.9, Gastro-esophageal reflux disease d. R07.9, Chest pain, unspecified - d. R07.9, Chest pain, unspecified
Rationale: "versus" indicates uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if it existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign/symptom the patient exhibits. A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Before billing, the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist - c. Code basal cell carcinoma Rationale: For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnosis. Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results A 32-year-old woman in her 30th week of gestation is evaluated in her obstetrician's office for her second pregnancy with pre-existing essential hypertension. Assign the correct ICD-10-CM diagnostic code(s). a. O10.913, Z3A. b. O10. c. O10.412, Z3. d. O10.013, Z3A.30 - d. O10.013, Z3A. Which of the following purpose and use goals does not apply to ICD-10-PCS? a. Improved accuracy and efficiency of coding b. Reduced training effort
c. Improved communication with physicians d. Improved collection of data about nursing care - d. Improved collection of data about nursing care When present, signs and symptoms that are not an integral part of the disease process: a. Should never be coded b. Should prompt a physician query c. Should be coded d. Should be coded with a Z-code - c. Should be coded Rationale: Additional signs and symptoms that may not be associated with a disease process should be coded when present. To help clarify terms that currently have overlapping meaning, ICD-10-PCS has defined root operations. What is an example of the root operation of Excision? a. Partial right nephrectomy b. Total nephrectomy c. Removal of left lung d. Complete mastectomy - a. Partial right nephrectomy Rationale: Root operation Excision is defined as a portion of the body part is cut out or off, without replacement. The assignment of a diagnosis code is based on ________. a. The coding professional's assessment of the health record b. The provider's statement that the patient has a particular condition c. Clinical criteria used by the provider to establish the diagnosis
d. Its inclusion in the discharge summary - b. The provider's statement that the patient has a particular condition. A patient was discharged with the following diagnoses: "Cerebral artery occlusion, hemiparesis, and hypertension. The aphasia resolved before the patient was discharged." Which of the following code assignments would be appropriate for this case? G81.90Hemiplegia, unspecified affecting unspecified side G81.91Hemiplegia, unspecified affecting right dominant side G81.92Hemiplegia, unspecified affecting left dominant side G81.93Hemiplegia, unspecified affecting right nondominant side G81.94Hemiplegia, unspecified affecting left nondominant side I66.9Occlusion and stenosis of unspecified cerebral artery I63.50Cerebral infarction due to unspecified occlusion or stenosis of cerebral artery I10Hypertension I50.9Heart failure, unspecified R47.01Aphasia a. I63.50, G81.94, R47.01, I b. I66.9, G81.90, R47.01, I c. I66.9, G81.91, I d. I66.9, G81.92, R47.01, I10 - b. I66.9, G81.90, R47.01, I A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management -
a. Congestive heart failure, respiratory failure, ventilator management Rationale: Because the respiratory failure occurred after admission, it is listed as a secondary diagnosis and the congestive heart failure is listed first. A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin - Hematuria; adverse reaction to Coumadin Rationale: The first listed diagnosis is the manifestation or the nature of the adverse effect. Code by referring to the Table of Drugs and Chemicals A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute ST elevation (STEMI) inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG × 3. Coumadin therapy and monitoring for the atrial fibrillation continued at Hospital B. Using the codes listed here, what are the appropriate ICD-10-CM codes and sequencing for both hospitalizations? I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I48.0 Paroxysmal atrial fibrillation I48.20 Chronic - c. Hospital A: I21.19, I48.91; Hospital B: I21.19, I48.91, 021209W
Rationale: Guideline I.C.9.e.1 for encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a post-acute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension - a. Catheter-associated urinary tract infection A 65-year-old female was admitted to the hospital. She was diagnosed with sepsis secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? a. A41.89, K57.92, R10. b. A41.01, K57. c. A41.89, K57.92, A49. d. A41.9, K57.92 - b. A41.01, K57. Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment? a. C67.3, Z85.51, 0T5B8ZZ, 0TJB8ZZ b. C79.11, 0T5B8ZZ c. C67.3, 0T5B8ZZ d. C79.11, C67.3, 0T5B8ZZ -
c. C67.3, 0T5B8ZZ For the body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on the documentation provided by: a. Clinicians who are not the patient's provider (namely, physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis) b. The attending physician's documentation only c. The consulting physician's report d. The history and physical report from the attending surgeon - a. Clinicians who are not the patient's provider (namely, physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis. These codes are used to assign a diagnosis to a patient who is seeking health services but is not necessarily sick. a. C codes b. E codes c. M codes d. Z codes - d. Z codes Rationale: Z codes indicate a reason for healthcare encounter The 38-year-old patient has an open reduction of a dislocation of the temporomandibular joint on the right side. The ICD-10-PCS code for this procedure is: a. 0RQC4ZZ b. 0RSD0ZZ c. 0RWC04Z d. 0RSC0ZZ - d. 0RSC0ZZ
Assign the correct CPT code for the following procedure: Reposition of the pacemaker electrode. a. 33226 b. 33243 c. 33217 d. 33215 - d. 33215 Rationale: Begin with the main term Repositioning; electrode, heart. This will lead you to 33215 and
c. -22, Increased procedural services d. -24, Unrelated evaluation and management service by the same physician during a postoperative period - d. -24, Unrelated evaluation and management service by the same physician during a postoperative period A patient is admitted to an acute-care hospital for alcohol abuse and uncomplicated alcohol withdrawal syndrome due to chronic alcoholism. His blood alcohol level on admission was 10 mg/100 mL. a. F10.230, F10.10, Y90. b. F10. c. F10.10, Y90. d. F10.230, Y90.0 - d. F10.230, Y90. Rationale: Index Alcoholism (chronic). Under F10, the "use additional code" note for blood alcohol level applies to this case since it is documented. A 45-year-old female is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. D50.0, N93. b. D62, N93. c. N93.8, D50. d. D50.0, D25.9 - a. D50.0, N93. Rationale: Anemia is sequenced first based on principal diagnosis guidelines. Since the anemia is not not specified as acute blood loss, it's coded to chronic blood loss because "chronic" is a nonessential modifier for "blood loss anemia" Patient admitted with left senile cortical cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of synthetic intraocular lens, via percutaneous approach.
a. H25.012, E11.36, 08DK3ZZ, 08RK3JZ b. E11.9, H25. c. E11.9, H25. d. H25.012, E11.36, 08RK3JZ - d. H25.012, E11.36, 08RK3JZ Rationale: When the type of diabetes mellitus is not specified, use E11.-, Type 2 Diabetes Mellitus. Per coding guidelines, there is an assumed causal relationship given between the type 2 diabetes and the cataract, so E11.36 would be appropriate. Corneal transplant procedures are coded to the root operation Replacement because transplant procedures in ICD-10-PCS describe organs or large sections of organs. The cornea is a body part that is replaced by biological or synthetic material. A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension. a. J44.1, J44.9, I12.9, N18. b. J44.1, N18.9, I c. J44.9, N18.9, I d. J44.1, I12.9, N18.9 - d. J44.1, I12.9, N18. Rationale: ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, code I12.9; in addition, category I directs the coder to also code chronic renal failure N18.9. Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. In this context, confirmation ________. a. Does not require documentation of the type of test performed; the physician's diagnostic statement that the condition is confirmed is sufficient b. Requires the documentation of the type of test in addition to the physician's diagnostic statement c. Must be provided by the laboratory findings report d. Requires that the public health agency be contacted - a. Does not require documentation of the type of test performed; the physician's diagnostic statement that the condition is confirmed is sufficient.
The four-year-old patient had an inguinal reducible herniorrhaphy. Assign the appropriate CPT code. a. 49495 b. 49500 c. 49505 d. 49491 - b. 49500 Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure. a. - b. - c. - d. -55 - d. - What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation? a. 46255 b. 46930 c. 46260 d. 46945 - b. 46930 Assign the level of medical decision-making: The 24-year-old patient was seen in the emergency department after an automobile accident. She complained of pain in her back and right leg. X-rays, UA, CBC were all normal. Discharge diagnosis: Thoracic/rib cage strain and contusion. Right leg contusion. She was discharged on Voltaren 50 mg three times a day for pain and Robaxin 750 mg three times a day for muscle spasms. She is told to return to work in a few days and to follow up with her family physician as necessary.
a. Straightforward b. Low complexity c. Moderate complexity d. High complexity - c. Moderate complexity Rationale: There are multiple new problems that are presented with some risk (namely, trauma) and ordered two drugs, with management options evident. The patient was admitted with major depression current episode severe, recurrent. What is the correct ICD-10-CM diagnosis code assignment for this condition? a. F33. b. F33. c. F32. d. F31.81 - a. F33. A 35-year-old male was admitted with heartburn that has not improved with over-the-counter medications. An esophagoscopy and closed esophageal biopsy at the upper esophagus was performed. The physician documented esophageal reflux with esophagitis as the final diagnosis based on pathological examination. Identify the correct diagnosis and procedure codes. a. K23, 0DJ07ZZ b. K20.90, 0DB58ZX c. K21.00, 0DB18ZX d. K21.91, 0DB18ZX - c. K21.00, 0DB18ZX Patient with flank pain was admitted and found to have calculi of both kidneys. A ureteroscopy with placement of bilateral ureteral stents was performed to expand the lumens so the stones could pass naturally. Assign the correct ICD-10-CM and ICD-10-PCS diagnosis and procedure codes.
a. N20.0, N23, 0T788DZ b. N23, N20.0, 0TC68ZZ, 0TC78ZZ c. N20.0, 0T768DZ, 0T778DZ d. N20.0, 0T788DZ - d. N20.0, 0T788DZ A female patient is admitted for stress incontinence. A urethral suspension to reposition the urethra via open approach is performed. Assign the correct ICD-10-CM diagnosis and procedure codes. a. N39.3, 0TJB8ZZ b. N23, 0TSD0ZZ c. N39.3, 0TSD0ZZ d. R32, 0TSD4ZZ - c. N39.3, 0TSD0ZZ Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia? a. 49496 b. 49501 c. 49507 d. 49521 - c. 49507 If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, ________. a. Assign code E10, Type 1 diabetes mellitus b. Assign code E11, Type 2 diabetes mellitus c. Query the endocrinologist or attending physician d. Check the physician orders or medical order record for additional information -
b. Assign code E11, Type 2 diabetes mellitus Rationale: Refer to Coding Guideline I.C.4.a.3 What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? a. 58555, 58559 b. 58559 c. 58559, 58740 d. 58555, 58559, 58740 - b. 58559 The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure? a. 49000, 58940, 58700 b. 58940, 58720-50 c. 49000, 58720 d. 58720 - d. 58720 Rationale: The exploratory laparotomy is the approach to the surgery. The code 58720 includes bilateral, so modifier 50 is not needed. Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April. a. 90965 b. 90964 c. 90966 d. 90970 - c. 90966
The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting? a. 97113 b. 97113-50 c. 97113, 97113 d. 97110 - c. 97113, 97113 Select the appropriate CPT code(s) to report a therapeutic subcutaneous injection of rabies immune globulin performed under direct physician supervision. a. 96372 b. 90471 c. 90375, 96372 d. 90375, 90473 - c. 90375, 96372 Rationale: In order to appropriately report administration of vaccines, both the product administered and the method of administration must be reported. An instructional note listed before CPT code 90476 states: "(For immune globulins, see codes 90281-90399. See codes 96365-96375 for administration of immune globulins)" Identify the CPT procedure code for partial right-sided thyroid lobectomy with isthmusectomy and subtotal resection of left thyroid. a. 60210 b. 60225 c. 60220 d. 60212 - d. 60212
The patient presented in the ED with severe abdominal pain, amenorrhea. Serum human chorionic gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient diagnosed with right tubal pregnancy. A laparoscopic removal of tubal pregnancy, right side, was performed. Which of the following is the correct code assignment? a. O00.80, 10T24ZZ, 0UT54ZZ b. O00.101, 10T24ZZ c. O00.109, 10T24ZZ d. O00.109, 0UT54ZZ - b. O00.101, 10T24ZZ Rationale: Per PCS Guideline C1: procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. The patient, a 47-year-old male with a protracted history of urinary retention due to benign prostatic hyperplasia, is being treated in the outpatient surgery suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which of the following code sets will be reported for this service? a. N40.1, R33.8, 53852 b. N40.0, 52601 c. D29.1, 53852 d. N40.3, R33.9, 53850 - a. N40.1, R33.8, 53852 Rationale: A use additional code note is present at N40.1 directing to assign additional codes for associated symptoms, so a secondary code is assigned for the urinary retention (R33.8). Identify the CPT procedure code(s) and correct modifier(s) for a screening mammogram and a diagnostic mammogram performed on a patient on the same day.
a. 77067-GH b. 77067, 77066-GG c. 77066-GG d. 77065, 77053-GH - b. 77067, 77066-GG Rationale: When submitting a claim for a screening mammography and a diagnostic mammography for the same patient on the same day, attach modifier GG to the diagnostic mammography