Certified Medical Coding Specialist Case Studies & Practical Application 3

Question 1

A physician performs a colonoscopy with biopsy and removal of two polyps via hot snare. Which CPT coding approach is correct?

Accepted Answer

Code only the polypectomy since it is the more complex procedure

Answer

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?

Accepted Answer

Code B20 first with B59 as secondary

Answer

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?

Accepted Answer

The screening code, with the polyp as an additional finding

Answer

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?

Accepted Answer

Code the chest pain as documented since no definitive diagnosis was established

Answer

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?

Accepted Answer

Code the open appendectomy only (44950)

Answer

When a laparoscopic procedure is converted to open, only the open procedure code is reported; the conversion is not separately billable.

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Case Studies & Practical Application 3