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."
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
