FREE AAPC Certified Professional Coder Questions and Answers

Question 1

A patient undergoes surgery with anesthesia and is arousable with painful stimulation. What is the level of sedation the patient MOST likely received?

Accepted Answer

Deep sedation

Answer

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.

Question 2

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?

Accepted Answer

97110, 97140 x 2, 97010, S46.011D, W19.XXXD

Answer

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.

Question 3

A diaphragm resection and repair are done using a biologic mesh to reduce the formation of adhesions. Which procedure code should be reported?

Accepted Answer

39561

Answer

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.

Question 4

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?

Accepted Answer

99213, 81025, 36415, 81002

Answer

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.

Question 5

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?

Accepted Answer

99202

Answer

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.

AAPC - American Academy of Professional Coders Practice Test

AAPC - American Academy of Professional Coders Practice Test

FREE AAPC Certified Professional Coder Questions and Answers