Certified Medical Coding Specialist Case Studies & Practical Application 3 — Questions and Answers
Question 1: A physician performs a colonoscopy with biopsy and removal of two polyps via hot snare. Which CPT coding approach is correct?
- Code only the biopsy since it is the lesser procedure
- Code only the polypectomy since it is the more complex procedure (Correct answer)
- Code both the biopsy and the polypectomy with modifier -59
- Code the colonoscopy once with a bundling modifier
Correct answer: Code only the polypectomy since it is the more complex procedure
When a biopsy and polypectomy are performed at the same site, the polypectomy is the definitive procedure and the biopsy is not coded separately.
Question 2: A patient with known HIV disease is admitted for Pneumocystis carinii pneumonia. Which sequencing is correct per ICD-10-CM guidelines?
- Code the pneumonia first, then the HIV
- Code B20 first with J85.3 as secondary
- Code B20 first with B59 as secondary (Correct answer)
- Code the pneumonia with a note that HIV is present
Correct answer: Code B20 first with B59 as secondary
ICD-10-CM instructs that B20 (HIV disease) is always sequenced first, followed by the specific AIDS-related condition such as B59 (Pneumocystosis).
Question 3: A 70-year-old patient undergoes a screening colonoscopy and a polyp is found and removed. What is the first-listed diagnosis?
- The polyp as it was the condition treated
- The screening code, with the polyp as an additional finding (Correct answer)
- The colonoscopy procedure code
- Colorectal cancer screening with no findings
Correct answer: The screening code, with the polyp as an additional finding
For screening exams, the screening code (Z12.11) is listed first; any findings such as a polyp are coded as additional diagnoses.
Question 4: A patient is seen in the ED for chest pain. The workup is negative and the physician documents 'chest pain, etiology unclear.' How should this be coded?
- Assign a code for the most likely cause
- Code the chest pain as documented since no definitive diagnosis was established (Correct answer)
- Leave the diagnosis blank until a follow-up is done
- Assign acute myocardial infarction as a rule-out
Correct answer: Code the chest pain as documented since no definitive diagnosis was established
In the outpatient/ED setting, suspected or rule-out diagnoses are not coded; only the symptom (chest pain) is coded if no definitive diagnosis is made.
Question 5: A surgeon performs a laparoscopic appendectomy that is converted to an open procedure. How is this coded?
- Code the open appendectomy only (44950) (Correct answer)
- Code the laparoscopic attempt only (44970)
- Code both the laparoscopic and open procedures
- Code the open appendectomy with modifier -22
Correct answer: Code the open appendectomy only (44950)
When a laparoscopic procedure is converted to open, only the open procedure code is reported; the conversion is not separately billable.
Question 6: A physician documents 'acute respiratory failure due to COPD exacerbation.' Which is the correct principal diagnosis for an inpatient admission?
- Acute respiratory failure always sequences first
- COPD exacerbation always sequences first
- Either may be sequenced first per coding guidelines (Correct answer)
- Code only the COPD; respiratory failure is integral
Correct answer: Either may be sequenced first per coding guidelines
ICD-10-CM guidelines allow either acute respiratory failure or the underlying condition to be sequenced first when both are present, based on the circumstances of admission.
Question 7: A patient is discharged with documentation of 'probable sepsis.' This is an inpatient record. How should this be coded?
- Code the symptoms of sepsis only, not the condition itself
- Code sepsis as documented, since inpatient guidelines allow coding of probable diagnoses (Correct answer)
- Query the physician before coding
- Code the underlying infection that is most likely causing symptoms
Correct answer: Code sepsis as documented, since inpatient guidelines allow coding of probable diagnoses
For inpatient records, coding guidelines allow coders to code conditions documented as 'probable,' 'suspected,' or 'likely' at discharge.
Certified Medical Coding Specialist Case Studies & Practical Application 3
A physician performs a colonoscopy with biopsy and removal of two polyps via hot snare.
Which CPT coding approach is correct?