Question 1

A 22-year-old woman was diagnosed as being 8 weeks pregnant. This is her first pregnancy. The proper term to describe her condition is

Accepted Answer

Primigravida refers to a woman who is pregnant for the first time.

Question 2

An eating disorder that is characterized by a body image of disturbed perception accompanied by an intense fear of gaining weight resulting in not eating and producing side effects such as cachexia and hair loss is called

Accepted Answer

Anorexia nervosa is characterized by a distorted body image and an irrational fear of gaining weight, leading to extreme dietary restriction and starvation. This can result in severe physical consequences such as cachexia (wasting away of the body) and hair loss.

Question 3

Jane is seen by the plastic surgeon today for injection of three units of Botox into her face, including her forehead and glabellar frown lines for cosmetic reasons. Select the appropriate CPT and ICD-10-CM codes for the injections and medication.

Accepted Answer

The answer of Jane is seen by the plastic surgeon...

Question 4

A premature newborn is sent home with a recording apnea monitor. Select the appropriate CPT and ICD-10-CM codes for the monitor.

Accepted Answer

E0619 is the correct CPT code for an apnea monitor, and P28.3 is the correct ICD-10-CM code for primary apnea of newborn.

Question 5

George, a 59-year-old diabetic man with polyneuropathy, is prescribed a four-lead TENS unit as a method to provide a non-invasive, low-risk approach to reduce his pain. Select the appropriate CPT and ICD-10-CM codes for the unit.

Accepted Answer

The correct CPT code for a four-lead TENS unit is E0730, and the ICD-10-CM code for diabetes with polyneuropathy is E11.42.

Question 6

Sally is a long-term alcoholic who has made the decision to receive treatment for her disease. However, before beginning her psychotherapy, Sally is required to undergo a behavioral health screening and alcohol assessment. Select the appropriate CPT and ICD-10-CM codes for these two procedures.

Accepted Answer

H0001 is used for alcohol and/or drug assessment, H0002 is for behavioral health screening, and F10.20 is the ICD-10-CM code for Alcohol dependence, uncomplicated, which matches the scenario described.

Question 7

A diabetic patient underwent a partial amputation of his foot due to gangrene. Today, the patient is fitted for a partial foot with a molded socket, ankle height, and toe filler. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of A diabetic patient underwent a partial amputation...

Question 8

A 76-year-old female was admitted for intravenous antibiotic therapy to treat pneumonia due to pseudomonas bacteria, and a level 3 initial inpatient visit was provided. On the second and third days, the patient had not yet responded to treatment, which was noted after an expanded problem-focused examination and interval history. On day 4, the patient showed significant improvement and the doctor recorded a problem-focused history and examination. On day 5, the patient was discharged home and the doctor spent 30 minutes in discharge day management. Select the appropriate CPT and ICD-10-CM codes for the physician visits.

Accepted Answer

The correct coding reflects the level of care provided on each day, including the initial inpatient visit coded as 99223 for a detailed level service, subsequent inpatient visits on the second and third days coded as 99232 for a detailed level service due to the patient not responding to treatment, a subsequent inpatient visit on the fourth day coded as 99231 for a straightforward level service due to improvement, and discharge day management coded as 99238 for 30 minutes spent. The ICD-10-CM code J15.1 is correct for pneumonia due to Pseudomonas.

Question 9

Jane, an 89-year-old female, lives in an assisted living facility. The physician provides monthly supervision of care for this patient that requires complex and multidisciplinary care modalities, including completion of reports and coordination of care with the staff for the purposes of ongoing management of medications for her diabetes and COPD. The physician spends approximately 35 minutes doing this service. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Jane, an 89-year-old female, lives in an...

Question 10

A 45-year-old patient with BCBS is seen by a consultant at the request of her internal medicine physician for opinion and management recommendations regarding her subacute bronchitis. The consultant performs a comprehensive history and exam with decision making of moderate complexity. He returns the patient to her primary physician and sends a report discussing his findings and recommendations. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a consultation with a comprehensive history and exam with moderate complexity decision making is 99244. The ICD-10-CM code for subacute bronchitis without further specification is J20.9.

Question 11

Jones accompanied a newborn girl with respiratory failure who had been born 23 hours earlier from the community hospital to the university children's hospital. The ride takes 95 minutes. Dr. Jones provided critical care services to the infant during the ambulance ride. The patient was admitted to the neonatal ICU at the new facility. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Jones accompanied a newborn girl with respiratory...

Question 12

Smith works for "Doctors to You" and visits Jane, an established patient with this company, in her home. Jane is complaining of nausea, vomiting, and diarrhea for the past three days after eating tuna fish purchased from a local restaurant. After an expanded problem-focused interval history and expanded problem-focused examination, the diagnosis of food poisoning is made, and Jane is administered medication to treat the nausea and given instructions to prevent dehydration and reduce the diarrhea. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a home visit for an established patient that requires an expanded problem-focused history and examination is 99348. The ICD-10-CM code for food poisoning due to ingestion of contaminated tuna fish is T61.771A, indicating poisoning by, adverse effect of, and underdosing of other fish and shellfish, initial encounter.

Question 13

A 14-year-old boy who is a new patient presents with acute contact dermatitis. During the expanded problem-focused history, the doctor learns that the boy just came back from a camping trip and was out in the woods when his skin began to itch. The examination was also expanded. The physician sends the patient home with a prescription and instructs him to return if the condition does not improve in a few days. While checking all of the patient's immunizations, the physician notes that the patient is in need of a tetanus vaccination, so that is also given. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct codes are 99202 for the expanded problem-focused visit, 90471 for the administration of the vaccine, 90714 for the tetanus vaccine, L25.5 for unspecified contact dermatitis, and Z23 for the encounter for immunization.

Question 14

An established patient presents to the office with an acute, deep cough, along with wheezing. The patient has a history of allergies along with chronic rhinitis. After an expanded problem-focused exam, the physician learns that the patient's home has just been found to have mold in the walls. The physician has spent an additional 15 minutes providing resources and counseling with the patient regarding the effects of mold and treatment of his URI. The physician has also recommended lab tests and x-rays. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code is 99213 for an established patient with an expanded problem-focused exam and additional counseling. The ICD-10-CM codes are J06.9 for acute upper respiratory infection, Z77.120 for contact with mold, and Z87.09 for a personal history of other diseases of the respiratory system.

Question 15

A 38-year-old insulin-dependent established patient called his physician complaining of having some rectal bleeding after using the bathroom. The physician agreed to meet the patient in the outpatient department of the hospital. The physician performed an expanded problem-focused history with a detailed examination. The patient is to have blood work and a stool culture and is to be scheduled for a lower GI series. The physician's diagnosis was Hematochezia etiology unknown. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for an established patient's office visit with an expanded problem-focused history and detailed examination is 99214. The ICD-10-CM codes are K92.1 for Hematochezia, E11.9 for the patient's diabetes (assuming insulin-dependent diabetes is type 2 unless specified otherwise, but no specific complications are mentioned), and Z79.4 for long-term (current) use of insulin.

Question 16

Clarkston visited the nursing home today to see how the stage 3 pressure ulcer he debrided was doing. He also changed the dressing on the pressure ulcer. The original damage was through the full thickness of the dermis and into the subcutaneous tissue on the right buttock. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a follow-up visit in a nursing home setting is 99308, and the appropriate ICD-10-CM codes are Z48.817 for encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and L89.313 for pressure ulcer of right buttock, stage 3.

Question 17

Dr. Medevial sees Daphnee age 45, for her annual preventative exam. Since Daphnee is an established patient, Dr. Medevial wants a CBC. The CBC is drawn by the nurse, but due to equipment failure, the tube will be sent to MetCare Labs for processing. MetCare labs will be paid directly by Dr. Medevial for the processing. Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT codes are 99396 for an established patient's preventive exam, 85025 for a CBC (Complete Blood Count), and 36415 for the blood draw. The ICD-10-CM code Z00.0 is used for a general adult medical examination without abnormal findings. This combination accurately reflects the services provided during Daphnee's visit.

Question 18

Clinical History: Symptoms of SOB, chest pain on inspiration, as well an oxygen saturation of 84.
Study performed: Ventilation and perfusion studies of the lungs.
Interpretation: Particularly positive ventilation and perfusion lung scan. There are no segmental defects to suggest a pulmonary embolus.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a ventilation and perfusion lung scan is 78582, which is used for a lung scan that includes both ventilation and perfusion. The symptoms described, such as shortness of breath (SOB) and chest pain on inspiration, are coded as R06.00 (Dyspnea, unspecified) and R07.1 (Chest pain on breathing), respectively. The interpretation of the lung scan did not confirm a pulmonary embolus, so the ICD-10-CM code for pulmonary embolism (I26.99) is not appropriate here.

Question 19

Clinical History: Patient with neuropathy and pain in arm. Diagnosed with possible cervical disc.
Study performed: Cervical Myelogram -injection procedure and radiological supervision and interpretation.
Impression: Moderate ventral extradural defect C5-6 with bilateral C-6 root encroachments.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The answer of Clinical History: Patient with neuropathy and pain...

Question 20

Clinical history: Shortness of breath - crackles and change in sound in base of lungs.
Study performed: Chest X-ray, PA and lateral.
Impression: Poor inspiratory effort which accentuates the basilar lung markings and cardiac silhouette, partially limiting evaluation. Small vertically oriented linear infiltrate subsegmental atelectasis is noted in the L retrocardiac region adjacent to the diaphragm. There is minimal hazy increased density and decreased definition in the L costophrenic angle suggesting pleural effusion. Segmental atelectasis and some pleural effusion.
Select the appropriate CPT and ICD-10-CM codes.

Accepted Answer

The correct CPT code for a chest X-ray with two views (PA and lateral) is 71046. The ICD-10-CM codes J90 and J98.11 correspond to pleural effusion and segmental atelectasis, respectively, which are the conditions identified in the patient's diagnosis.

Quiz 27: Coding and Surgical Procedures