CPC Sample Questions Answers

A 42-year-old male is diagnosed with a left renal mass. Patient is placed under general anesthesia and in prone position. A periumbilical incision is made and a trocar inserted. A laparoscope is inserted and advanced to the operative site. The left kidney is removed, along with part of the left ureter. What CPT® code is reported for this procedure?

A 60-year-old male has three-vessel disease and supraventricular tachycardia which has been refractory to other management. He previously had pacemaker placement and stenting of LAD coronary artery stenosis, which has failed to solve the problem. He will undergo CABG with autologous saphenous vein and an extensive modified MAZE procedure to treat the tachycardia.

He is brought to the cardiac OR and placed in the supine position on the OR table. He is prepped and draped, and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from his left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anastomosis. Two bypasses are performed: one to the circumflex and another to the obtuse marginal. The left internal mammary is then freed up and it is anastomosed to the ramus, the first diagonal, and the LAD. An extensive maze procedure is then performed and the patient is weaned from bypass. At this point, the sternum is closed with wires and the skin is reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU.

Choose the procedure codes for this surgery.

View MR 004397

MR 004397

Operative Report

Preoperative Diagnosis: Calculi of the gallbladder

Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis

Procedure: Cholecystectomy

Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.

Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.

What CPT® coding is reported for this case?

A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.

What anesthesia coding is reported?

The CPT® code book provides full descriptions of medical procedures, although some descriptions require the use of a semicolon (;) to distinguish among closely related procedures.

What is the full description of CPT® code 69644?

Which entity offers compliance program guidance to form the basis of a voluntary compliance program for a provider practice?

A catheter was placed into the abdominal aorta via the right common femoral artery access. An abdominal aortography was performed. The right and left renal artery were adequately visualized. The catheter was used to selectively catheterize the right and left renal artery. Selective right and left renal angiography were then performed, demonstrating a widely patent right and left renal artery.

What CPT® coding is reported?

The outermost protective layer of skin is called the:

A 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws wereplaced at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.

Select the procedure codes for this scenario.

A 65-year-old man had a right axillary block by the anesthesiologist. When the arm was totally numb, the arm was prepped and draped, and the surgeon performed tendon repairs of the right first, second, and third fingers. The anesthesiologist monitored the patient throughout the case.

What anesthesia code is reported?

A surgeon removes the right and left fallopian tubes and the left ovary via an abdominal incision. How is this reported?

An elderly patient comes into the emergency department (ED) with shortness of breath. An ECG is performed The final diagnosis at discharge is impending myocardial infarction.

According to ICD-10-CM guidelines, how is this reported?

The procedure is performed at an outpatient radiology department. From a left femoral access, the catheter is placed in the abdominal aorta and is then selectively placed in the celiac trunk and manipulated up into the common hepatic artery for an abdominal angiography. Dye is injected, and imaging is obtained. The provider performs the supervision and interpretation.

What CPT® codes are reported?

Patient has cervical spondylosis with myelopathy. The surgeon performed a bilateral posterior laminectomy with facetectomies at each level and foraminotomies performed between interspaces C5-C6 and C6-C7. Bilateral decompression of the nerve roots is achieved.

What CPT® coding is reported?

A business requires drug testing for cocaine and methamphetamines prior to hiring a job candidate. A single analysis with direct optical observation is performed, followed by a confirmation for cocaine.

Which codes are used for reporting the testing and confirmation?

A 45-year-old female presents to the ED with chest pain. The provider has an Albumin Cobalt Binding Test to determine if the chest pain is ischemic in nature.

That lab test is reported?

An incision is made in the scalp, a craniectomy is performed to access the area where electrodes are present. The electrodes are removed. The surgical wound is closed.

What procedure code is reported?

A 6-French sheath and catheter is placed into the coronary artery and is advanced to the left side of the heart into the ventricle. Ventriculography is performed using power injection of contrast agent. Pressures in the left heart are obtained. The coronary arteries are also selected and imaged.

What CPT® code is reported?

A 25-year-old woman underwent percutaneous breast biopsy on the right breast with placement of a Gelmark clip. The procedure was performed using stereotactic imaging.

What CPT® codes will be reported?

View MR 099405

MR 099405

CC: Shortness of breath

HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an asthmatic.

Current medications being used to treat symptoms is Advair, which is not working and breathing is getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the last 16 hrs. ED physician admits her to observation status.

ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No nausea or vomiting. No abdominal pain, diarrhea, or constipation.

PMH: Asthma

SH: Lives with both parents.

FH: Family hx of asthma, paternal side

ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child’s family and no changes reported.

PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well developed. Well nourished. Well hydrated.

Eyes: normal. External eye: no hyperemia of the conjunctiva. No discharge from the conjunctiva

Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.

Lymph nodes: normal.

Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb. improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory retraction was observed.

Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs were heard.

GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly

Skin: normal warm and dry. Pink well perfused

Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back and when she rolls over. No CVA tenderness.

Assessment: Asthma, acute exacerbation

Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment. CXR ordered and to be taken in the morning.

What E/M code is reported?

A 65-year-old gentleman presents for refill of medications and follow-up for his chronic conditions. The patient indicates good medicine compliance. No new symptoms or complaints.

Appropriate history and exam are obtained. Labs that were ordered from previous visit were reviewed and discussed with patient. The following are the diagnoses and treatment:

Hypokalemia - stable. Refill Potassium 20 MEQ

Hypertension - blood pressure remaining stable. Patient states home readings have been in line with goals. Refill prescription Lisinopril.

Esophageal Reflux - Patient denies any new symptoms. Stable condition. Continue taking over the counter Prevacid oral capsules, 1 every day.

Patient is instructed to follow up in 3 months. Labs will be obtained prior to visit.

What CPT® code is reported?

A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins.The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.

What CPT® coding is reported for the twin delivery?

The gynecologist performs a colposcopy of the cervix including biopsy and endocervical curettage.

What CPT® code is reported?

A patient suffers a ruptured infrarenal abdominal aortic aneurysm requiring emergent endovascular repair. An aorto-aortic tube endograft is positioned in the aorta and a balloon dilation is performed at the proximal and distal seal zones of the endograft. The balloon angioplasty is performed for endoleak treatment.

What CPT® code does the vascular surgeon use to report the procedure?

A cardiologist uses the hospital's equipment for a cardiac stress test as he doesn't own equipment for the test. He supervises the test and provides the interpretation and report of the test.

What CPT® codes are reported?

Patient had polyps removed on a previous colonoscopy. The patient returns three months later for a follow-up examination for another colonoscopy. No new polyps are seen.

What diagnosis coding is reported for the second colonoscopy?

The gastroenterologist performs a simple excision of three external hemorrhoids and one internal hemorrhoid, each lying along the left lateral column. The operative report indicates that the internal hemorrhoid is not prolapsed and is outside of the anal canal.

What CPT® and ICD-10CM codes are reported?