Pass the AAPC Certified Professional Coder CPC Questions and answers with ExamsMirror

A 55-year-old patient was recently diagnosed with an enlarged goiter. It has been two years since her last visit to the endocrinologist. A new doctor in the exact same specialty group will be examining her. The physician performs a medically appropriate history and exam. The provider reviewed the TSH results and ultrasound. The provider orders a fine needle aspiration biopsy which is a minor procedure.

What E/M code is reported?

This 27-year-old male has morbid obesity with a BMI of 45 due to a high calorie diet. He has decided to have an open Roux-en-Y gastric bypass. The patient is brought to the operating room and placed in supine position. A midline abdominal incision is made. The stomach is mobilized, and the proximal stomach is divided and stapled creating a small proximal pouch in continuity with the esophagus. A short limb of the proximal bowel of 155 cm is divided. It is brought up and anastomosed to the gastric pouch. The other end of the divided bowel is connected back into the distal small bowel to the short limb's gastric anastomosis to restore intestinal continuity. The abdominal incision is closed.

What are the procedure and diagnosis codes for this encounter?

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

What CPT® code is reported?

View MR 005398

MR 005398

Operative Report

Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.

Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.

Procedure: Right nephrectomy with partial ureterectomy.

Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.

What CPT® coding is reported for this case?

The gallbladder is in which organ system?

A physician performs excisional debridement on multiple wounds:

Lower back: 12 cm, involving fascia

Left shoulder: 8 cm, involving subcutaneous tissue

Left lower leg: 16 cm, involving subcutaneous tissue

What CPT® codes are reported?

An 8-year-old patient is placed under general anesthesia for treatment of a right orbital fracture due to a traumatic fall to the nose and face from a swing set. An on-call otolaryngologist is

asked to perform a general otolaryngologic examination to evaluate the patient. A mild nasal fracture is the diagnosis given by the otolaryngologist.

What is the CPT® and ICD-10-CM coding for the otolaryngologist's services?

Which place of service code is submitted on the claim for a service that is performed in an outpatient surgical floor?

Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1

Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.

Operation performed: Excision of right thigh benign congenital>1

nevus, excision size with margins 4.5 cm and closure size 5 cm.

Anesthesia: General.0

Intraoperative antibiotics: Ancef.0

Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general

anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.

Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.

This was passed to pathology for review. The wound required □ limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.

The patient was then cleaned and turned over to anesthesia for S extubation.

She was extubated successfully in the operating room and taken S to the recovery room in stable condition. There were no complications.

What is the radiology coding for this encounter?

A patient with severe diverticulitis in the sigmoid colon presents to surgery for a partial colectomy. The physician performs an exploratory laparoscopic laparotomy to verify the location of the diverticulitis. Once identified, it was noted that there was bleeding from the diverticulitis. The physician transects the descending colon and then transects at the line of the rectum.

The physician mobilizes the splenic flexure in order to create a colostomy with the proximal portion of the remaining colon. The distal portion of the colon is closed. The physician washes the patient's abdomen with saline, removes all trocars and instruments, and then closes the abdomen with sutures.

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