FREE AAPC Certified Professional Coder Questions and Answers
A patient presents to physical therapy status post repair of a complete rotator cuff tear in the right shoulder due to a fall. After applying ice to the shoulder for 8 minutes, the physical therapist performs a soft-tissue massage to the infraspinatus muscle that lasts 23 minutes. Just prior to discharge, the therapist spends 20 minutes instructing the patient on isokinetic exercises to help improve the range of motion. Which CPT and ICD-10-CM code(s) should be used to accurately describe the encounter?
Explanation:
Although CPT code 97530 does describe therapeutic activities, the focus is directed at improving functional performance, whereas the correct CPT code 97110 works to develop a range of motion. The CPT code for a soft tissue massage (or manual therapy 97140) is based on 15-minute increments, however, anything over 8 minutes prior to or after can be counted as a unit. Based on this, the 23 minutes spent can be counted as two units. Sequencing is based on the highest RVU.
Coding crosswalk for a rotator cuff tear is classified as a muscle strain, so answer B, which specifies "other injury," can be eliminated. Because the patient is in the recovery period of the injury, the seventh character would not be considered active but subsequent.
Code the following adverse effect:
Initial encounter of drug-induced tremors that was caused by Cyclosporin the patient takes for anemia.
The anemia is caused by a current diagnosis of colon cancer.
Explanation:
As this situation describes an adverse effect of a drug that has been correctly prescribed and properly administered, and because the anemia is caused by a malignancy, ICD-10-CM guidelines (Chapter 19) state that the adverse reaction diagnosis codes (G25.1, T45.1X5A) should be sequenced first, then the principal diagnosis of malignancy (C18.9), and then this is followed by the appropriate code for the anemia (D63.0).
Under the oversight of the pediatrician, a nurse reviews the vaccine and allergy history of a 13-year-old established patient just prior to administering a live varicella virus vaccine subcutaneously. What procedure code(s) should be reported?
Explanation:
Although CPT 99211 can be reported for limited assessments performed by no physician staff members, the vaccine and allergy history intake is considered vaccine-related and not separately reportable. CPT 90460 is reported when a physician provides counseling about the benefits and risks associated with the vaccine and signs and symptoms that would indicate an adverse reaction. Because the physician did not document seeing the patient at this encounter, report CPT 90471 for the administration of the immunization.
A complete pulmonary function test using a body plethysmograph is performed on a patient in conjunction with spirometry. After reviewing the results, a provider suspects the presence of an obstructive disease and administers a bronchodilating medicine just prior to repeating the test to reevaluate the expiratory flow rate. Which code(s) should be reported?
Explanation:
Answers A and B can be eliminated because the complete pulmonary function test includes interpretation of the test results; therefore, the review of this would not be considered separately identifiable. The CPT code 94060 includes spirometry before and after a bronchodilator has been administered, so a separate spirometry code (94010) would be inappropriate. Last, a modifier is not needed because the procedures are routinely done in conjunction with each other.
A diaphragm resection and repair are done using a biologic mesh to reduce the formation of adhesions. Which procedure code should be reported?
Explanation:
A diaphragm resection is reported with CPT codes 39560-39561. The use of a biologic mesh makes the repair complex, whereas a simple repair would implement only internal sutures.
If past family and social history is not documented for the evaluation and management of a new patient, what is the highest level of service that can be coded?
Explanation:
To code 99203-99205, the provider must document a detailed and/or comprehensive history intake, which must include past medical, family, and social history. For codes 99201-99202, a past medical, family, and social history intake is not required. Answers B and D are for the evaluation of an established patient and are not applicable to this scenario because the patient is new.
A patient undergoes surgery with anesthesia and is arousable with painful stimulation. What is the level of sedation the patient MOST likely received?
Explanation:
Minimal, moderate, and deep sedation all allow the patient to undergo a procedure without pain and without being completely unconscious. If a patient receives minimal sedation, they are responsive after receiving verbal stimulation. Moderate sedation causes a patient to respond only after tactile stimulation. General anesthesia causes the patient to be completely unarousable, even with painful stimulation.
An established patient presents complaining of clumpy, white discharge for 3 days. A vaginal exam reveals an old tampon, which is removed. Diflucan is sent to the pharmacy, instructions are given, and the patient is told to follow up in 1 week. How would the provider code the visit?
Explanation:
Although a foreign body was removed, 57415 in answers A and B cannot be reported because anesthesia was not used. The documentation supports an expanded problem-focused history and moderate-level decision-making, so the appropriate E/M would be a 99213. When comparing answers C and D, bear in mind that ICD-10-CM requires sequencing "the underlying condition first, followed by the manifestation."
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?
Explanation:
The documentation supports an expanded problem-focused history with a medical decision-making of low complexity. Therefore, the highest level of service rendered is 99213. When 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.
Code the following physician's note:
A 14-year-old established patient is seen with his mother to evaluate five 2 cm superficial lacerations to the left wrist. The patient admits to suicidal thoughts. Lacerations were treated with Steri-Strips. The patient and mother were counseled on suicide prevention and told to follow up with psych.
Explanation:
When the injury is treated with Steri-Strips or bandages, it should be reported with an E/M code and not a procedure code. The E/M is a 99213 because the history of the visit is expanded problem-focused, the exam is problem-focused, and the medical decision-making is low. A suicide attempt would not be coded because the documentation is not specific as to whether the lacerations were an attempt at suicide.
Which service is NOT included in the central nervous system assessment?
Explanation:
A central nervous system assessment is comprised of multiple screenings that are reported with CPT codes 96105-96146 and includes, but is not limited to, the following elements: use of standardized instruments for staging and rating clinical dementia; evaluation for behavioral symptoms using standardized screening instruments; and development, updating, revision, and/or review of an Advance Care Plan. A review of high-risk medications is also included in the central nervous system assessment; however, if in the same encounter, a prescription is issued, the clinician should document and report the treatment with an appropriate E/M.