FREE Certified Coding Associate Questions and Answers

Question 1

A healthy patient who is a matching donor arrives at the hospital for surgery on behalf of his brother, who requires a kidney transplant. The admitting physician performs a thorough history, thorough examination, and extremely complicated medical decision-making. What kind of code would be appropriate for this encounter?

Accepted Answer

99223

Answer

The patient is a healthy donor admitted for surgery, and the physician performs a thorough history, thorough examination, and extremely complicated medical decision-making. This description aligns with a high-level initial hospital inpatient or observation care service. Code 99223 represents an initial hospital inpatient or observation care, typically requiring three key components: comprehensive history, comprehensive examination, and medical decision making of high complexity.

Question 2

What relevant International Classification of Diseases, 10th Revision (ICD-10) code(s) apply to nausea and vomiting symptoms?

Accepted Answer

R11.2

Answer

In ICD-10-CM, R11.2 is the code specifically designated for 'Nausea with vomiting, unspecified.' While R11.0 is for nausea and R11.10 is for vomiting, when both symptoms are present together, R11.2 is the more specific and appropriate code to capture the combined condition. This ensures accurate and complete reporting of the patient's symptoms.

Question 3

An anesthesiologist who is knowledgeable with coding in his area is verifying the modifiers used by a new coder for an anesthetic service that was rendered yesterday. He also instructs and supervises anesthesiology residents, one of whom assisted him during this identical procedure under his direct supervision. The head modifier QY is used in the coder's documentation for anesthesiology services, and the surgical procedure's total modifier combination is QY-QS-P1. How would the doctor talk to the coder about the work's accuracy?

Accepted Answer

The physician would tell the coder to replace modifier QY with modifier GC for a sequence of GC-QS-P1.

Answer

Modifier QY indicates medical direction of one CRNA by an anesthesiologist, which is incorrect for a teaching physician directly supervising a resident. Modifier GC is used when a teaching physician provides direct supervision and participates in the management of a service. The correct sequence for modifiers typically places the pricing/payment modifiers (like GC) before informational modifiers (like QS for monitored anesthesia care) and physical status modifiers (like P1).

Question 4

An OB-GYN (obstetrician-gynecologist) sees a 34-year-old woman for the purpose of draining a sizable cyst that had grown on her vulva as a result of shaving. The patient yells in pain during the lidocaine injection but instructs the doctor to continue. The doctor uses a knife multiple times to try to break the cyst's surface after allowing a few minutes for numbing to take effect, but the patient's pain-related anguish simply gets worse. The doctor stops the procedure as soon as the patient declines a second dosage of lidocaine via tears. The patient is then pacified and given an antibiotic before being released. What format should be used to report the incision and drainage procedure?

Accepted Answer

The incision and drainage procedure is reported with modifier 53.

Answer

Modifier 53 is used to indicate a 'Discontinued Procedure.' In this scenario, the physician initiated the incision and drainage procedure but had to stop due to the patient's severe pain and refusal to continue, even after initial attempts. Since the procedure was started but not completed, modifier 53 accurately reflects that the service was discontinued.

Question 5

Which of the following E/M service codes applies to a routine pediatric checkup for a healthy 8-year-old boy?

Accepted Answer

99393

Answer

Code 99393 is used for a 'Periodic comprehensive preventive medicine reevaluation and management of an individual, established patient; 5-11 years.' A routine pediatric checkup for a healthy 8-year-old boy, who is an established patient, perfectly fits this description. The other codes are for different types of E/M services, such as office visits for established patients or new patients, not preventive care.

Certified Coding Associate Exam Practice Test

Certified Coding Associate Exam Practice Test

FREE Certified Coding Associate Questions and Answers