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[General] Relevant AAPC-CPC Answers, AAPC-CPC Valid Test Tutorial

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【General】 Relevant AAPC-CPC Answers, AAPC-CPC Valid Test Tutorial

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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q90-Q95):NEW QUESTION # 90
A patient has a colonoscopy in which the provider removes three polyps from the transverse colon. The first polyp is removed by means of a hot snare technique, and the following two polyps are removed using hot biopsy forceps. What CPT code(s) should be reported for this encounter?
  • A. 0
  • B. 45385, 45384-59
  • C. 45385, 45384-59, 45384-59
  • D. 1
Answer: B
Explanation:
When coding colonoscopies, remember that the number of removal techniques is what has a bearing on code selection and not the number of lesions and/or polyps that are being removed. In this case, two techniques are being used: I) the snare technique (CPT 45385) and 2) the hot biopsy forceps technique (CPT 45384). Modifier 59 is appended onto the secondary code to indicate that separate polyps '.vere removed by two different techniques. CPT 45388 is reported when a provider uses any methods other than snare and hot biopsy forceps to remove a lesion and/or polyp.

NEW QUESTION # 91
An established 27-year-old female patient is seen with complaints of fatigue and muscle aches that began 3 days ago. The physician draws two vials of blood, collects a urine sample, and performs a pregnancy test. The patient is instructed to drink 8 ounces of water daily, rest, and follow up in 3 days for her results. What CPT codes should be reported for this encounter?
  • A. 99213, 81025, 36410, 81005
  • B. 99212, 81025, 36416, 81007
  • C. 99213, 81025, 36415, 81002
  • D. 99212, 81025, 36410x2, 99000, 81020
Answer: C
Explanation:
The documentation demonstrates that the number and complexity of problems addressed is low (fatigue and muscle aches are self-limited problems), the amount or complexity of data to be reviewed and analyzed is moderate (three unique tests), and the risk of complications, morbidity, or mortality of patient management is minimal (the patient was advised to drink more water). (To determine the final level of medical decision making, choose the lowest of the highest two elements. In this scenario, the final level of medical decision making is low, and the CPT code is
99213. Vihen reporting a routine venipuncture, use CPT code 36415. CPT code 36410(a) is reported when it is medically necessary for the physician to draw a patient's blood, and 36416 describes capillary blood collected through a skin prick-certainly not enough to fill two vials. CPT code 99000 can be used to report a specimen being transported to an outside laboratory, but that is unknown in this scenario. A generic urinalysis is reported with CPT code 81002 unless specifically stated that an automated analyzer (81005), a commercial kit (81007), and/or an agar test (81020) was utilized.

NEW QUESTION # 92
Code the following note:
A 43 -year-old new female patient with a history of type I diabetes was referred to my office by Dr. White, her primary care physician. Patient complains of blurred vision that began 2 weeks ago, however, reports compliance to a strict, healthy diet and to prescribed 10 mg of dexamethasone every day for 1 month. Given that the only change appears to be the dexamethasone, I suspect the blurred vision is an adverse reaction and will decrease the dosage to 5 mg per day. Patient will follow up with me in 1 week if symptoms persist.
Total time spent on todays encounter is 30 minutes.
  • A. 99244, H53.8, T38.OX5A, ElO.9
  • B. 99203, H53.8, ElO.69
  • C. 99243, H53.8 ElO.39
  • D. 99204, HS3.8, ElO.9
Answer: D
Explanation:
When choosing between an outpatient evaluation and management code or a consultation service code, bear in mind the following four elements: request, reason, report, and intent. Although the first three elements are documented and support a consultation service, the endocrinologist is assuming immediate care of the patienYs condition. In this case, the visit is not a consultation but a new transfer of care, which is encompassed by CPT codes 99202-99205. For this visit, coding based on medical decision-making as opposed to the total time spent on the encounter that day would be more advantageous. This is because coding based on time would lead a coder to report CPT code
99203 or a low level of medical decision making, whereas the medical decision-making is actually moderate, represented by CPT code 99204.
The documentation reflects that the blurry vision is most likely due to the dexamethasone:
therefore, a causal relationship is not assumed betvveen the two conditions and should not be coded as such. Because an adverse reaction is suspected and not confirmed, it should not be coded. This general rule does not apply to inpatient encounters.

NEW QUESTION # 93
A 74-year-old patient presents with a fever. She is admitted into observational care after her labs confirm a diagnosis of pneumoni a. She has a medical history of being HIV positive. How should this be reported?
  • A. 99222, B20, 118.9
  • B. 99223, 118.9, B20
  • C. 99236, 118.9, B20
  • D. 99235, B20, 118.9
Answer: A
Explanation:
Hospital inpatient and observation care services (99221-99236) are selected based on the level of medical decision-making. In this scenario, reporting a code from the initial hospital inpatient and observation care services would be most appropriate (99221-99223), as the documentation indicates the patient is being admitted. When leveling this service, consider that the patient has an acute illness with systemic symptoms (pneumonia) and a stable, chronic illness (HIV). Labs were reviewed to confirm the diagnosis, and a decision was made to admit the patient into observation. Therefore, the final level of medical decision-making is moderate, making the E/M code 99222. Even though pneumonia is the reason for admission, ICD-IO-CM guidelines stipulate that a confirmed HIV diagnosis takes precedence in sequencing when the reason for admission is HIV related.

NEW QUESTION # 94
Assign the appropriate CPT codes for the following surgical note: A 15-year-old patient is being treated for obstructive sleep apnea and adenoid tissue hypertrophy. After being placed under general anesthesia, a dental mirror is placed in the oropharynx to allow visualization of the nasopharynx. Suction electrocautery is used to remove the adenoid tissue that regrew after the initial adenoidectomy. Attention is then turned to the tonsils. The plane of tissue between the tonsillar capsule and the underlying muscles are cauterized, and the tonsils are removed. Bleeding is controlled by silver nitrate and gauze packing. Procedure is completed without complications, and patient is discharged to recovery.
  • A. 42826, 42836-51, 135.2, G47.33
  • B. 42999, 647.33, 135.2
  • C. 42826, 42831-59, 135.2, G47.33
  • D. 42821, G47.33, 135.2
Answer: D
Explanation:
An adenoidectomy and a tonsillectomy were performed in this surgical encounter (the root word -ectomy literally means the surgical removal of an anatomical structure). The adenoidectomy was done first and, if coded alone, would fall under one of Evo categories: primary (CPT 42830-
42831) or secondary (CPT 42835-42836). A primary adenoidectomy refers to the initial removal of the adenoid, whereas a secondary adenoidectomy occurs when adenoid tissue that was once removed has grown back. Because the documentation states that "the adenoid tissue ... regrew after the initial adenoidectomy," a coder can infer that this procedure is secondary. However, distinguishing betvveen the two procedures is not necessary when done in conjunction with a tonsillectomy because the procedures are bundled into two nonspecific CPT codes (42820 and
42821). Billing for an adenoidectomy and a tonsillectomy separately, as shown in answers A and C, is considered unbundling and is not allowed under the Correct Coding Initiative (CCI) edits.
Regarding the sequencing of the diagnoses, ICD-IO-CM guidelines state that when V,vo conditions meet the definition for principal diagnosis, either can be sequenced first In this scenario, J 35.2 or G47.33 could have been first listed because the procedures were to resolve both conditions in the same encounter.

NEW QUESTION # 95
......
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