Certified Professional Coder (CPC) Quiz: Apply Case Coding Guidelines

OPERATIVE REPORT: Preoperative Diagnosis: Right carpal tunnel syndrome. Procedure: The patient was brought to the OR and a regional nerve block was administered. An incision was made over the carpal tunnel. The transverse carpal ligament was divided under direct visualization. Hemostasis was achieved and the wound was closed in layers. The patient tolerated the procedure well.

Which CPT® and ICD-10-CM codes are reported for this case?

A patient is seen in the emergency department following a dog bite to the left hand with a 2.5 cm laceration requiring layered closure. The wound involved the subcutaneous tissue. The physician documents the repair and administers a tetanus toxoid injection. The patient has no prior immunization history on file.

Which codes are reported for this encounter?

A gastroenterologist performs a diagnostic colonoscopy on a 55-year-old patient. During the procedure, a single 8 mm polyp is identified in the sigmoid colon and removed via hot snare polypectomy. A biopsy of an area of inflamed mucosa in the transverse colon is also taken.

Which CPT® code(s) are reported for this encounter?

A surgeon performs an open repair of a right inguinal hernia in a 35-year-old male. The hernia is documented as initial, reducible, and indirect. No mesh is used.

Which CPT® code is reported?

A dermatologist excises a 1.2 cm malignant melanoma from the patient's right upper arm. The excised diameter including margins is 2.3 cm. The wound is repaired with simple closure.

Which CPT® code is reported for the excision?

A 66-year-old Medicare patient with type 2 diabetes receives an annual wellness visit. During the visit, the physician also addresses the patient's poorly controlled diabetes, adjusting medications and documenting moderate complexity MDM.

Which codes are reported for this encounter?

OPERATIVE REPORT: A 50-year-old male undergoes right total knee arthroplasty. The procedure is performed under spinal anesthesia. The knee joint is exposed, the distal femur and proximal tibia are resected, and a cemented total knee prosthesis is implanted. The procedure is completed without complication.

Which CPT® and ICD-10-CM codes are reported by the surgeon?

A patient undergoes outpatient surgery for removal of a 2 cm benign lesion on the back and a 0.9 cm benign lesion on the right arm. Both procedures are performed under local anesthesia.

Which CPT® codes are reported?

A 40-year-old patient is seen in an urgent care center for an acute asthma exacerbation. The physician performs a detailed history and detailed examination with moderate complexity MDM. A nebulized bronchodilator treatment is administered during the visit.

Which CPT® codes are reported for this new patient encounter?

A patient with a documented allergy to penicillin is admitted for a left lower lobe pneumonia caused by Streptococcus pneumoniae. The patient also has a history of COPD, which required no additional treatment during this admission.

Which ICD-10-CM codes are reported and in what sequence?

A patient requires a durable medical equipment item: a standard manual wheelchair for use at home following a hip replacement. The patient is a Medicare beneficiary.

Which HCPCS Level II code is reported for the standard manual wheelchair?

A physician performs a preventive medicine visit for a new 35-year-old patient. During the visit, a separate, significant problem is identified and addressed — the patient is found to have uncontrolled hypertension requiring a new prescription and counseling.

Which CPT® codes are reported for this encounter?

A physician provides critical care services for a 68-year-old patient in the ICU for 45 minutes on Monday, 35 minutes on Tuesday, and 90 minutes on Wednesday. The physician documents and attests to critical care time each day.

How are the critical care services reported for Tuesday's encounter?

OPERATIVE NOTE: A 28-year-old female undergoes laparoscopic removal of an ectopic pregnancy located in the right fallopian tube. The tube was ruptured at the time of surgery. The right tube was removed in its entirety (salpingectomy). Estimated blood loss: 300 mL. Patient tolerated the procedure well.

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

A hospital-based radiologist performs the technical and professional components of a bilateral screening mammogram on a 52-year-old asymptomatic woman.

Which CPT® code is reported by the hospital (technical component) for a digital bilateral screening mammogram?

A patient receives an infusion of 500 mL normal saline over 2 hours for dehydration. No other drugs or services are administered during the visit.

Which CPT® code(s) are reported for the hydration infusion?

OPERATIVE REPORT: Bilateral myringotomy with placement of ventilating tubes was performed on a 3-year-old child under general anesthesia. Tubes were placed in both tympanic membranes through separate incisions.

Which CPT® code(s) are reported?

A surgeon performs a laparoscopic cholecystectomy with intraoperative cholangiography. The procedure is completed without conversion to open surgery.

Which CPT® code is reported?

A radiologist in an independent radiology group performs and interprets a CT scan of the abdomen with contrast, ordered for evaluation of abdominal pain. The hospital owns the equipment and employs the technologist.

Which CPT® code(s) and modifier are reported by the radiologist?

OPERATIVE REPORT: The patient is a 62-year-old male with a 4.5 cm infrarenal abdominal aortic aneurysm. An open repair was performed via a midline laparotomy. A Dacron tube graft was used to replace the aneurysmal segment. Procedure completed without complication. Estimated blood loss: 900 mL.

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