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AAPC Certified Professional Coder (CPC) Exam Sample Questions (Q414-Q419):
NEW QUESTION # 414
(Dr. Winston sees a patient with abdominal pain in the observation unit in the hospital. This is hisfirst visitwith this patient during this stay. He spent a total time of85 minuteson that patient on that date of service, including review of the observation admission, labs, X-rays, and EKG results, and examining the patient with amoderate level of medical decision making. What CPT coding is reported?)
- A. 99223, 99418
- B. 0
- C. 99222, 99418
- D. 1
Answer: D
Explanation:
This is aninitial hospital/observation evaluation(first visit during the stay), so the correct code family is theinitial observation/inpatient E/Mlevel. The stem providestotal time = 85 minutesand also statesmoderate MDM. Under current E/M rules, you can select the code based oneither MDM or total time(when time is used, it includes the physician's qualifying time on that date). The time of85 minutesfits the time range for99223(the highest initial hospital/observation level by time) even if MDM is described as moderate. The prolonged service add-on99418requires meeting the threshold beyond the primary code's time before it can be added; with 85 minutes, you do not reach the additional increment needed to report 99418. Therefore, you report99223 only. CPC exam tip: when time is explicitly provided and is high, it often drives the level; do not add prolonged time unless the documented time clearly exceeds the primary code's requirement by the necessary increment.
NEW QUESTION # 415
A 60-year-old male suffering from degenerative disc disease at the L3-L4 and L5-S1 levels was placed under general anesthesia. Using an anterior approach, the L3-L4 disc space was exposed. Using blunt dissection, the disc space was cleaned. The disc space was then sized and trialed. Excellent placement and insertion of the artificial disc at L3-L4 was noted. The area was inspected and there was no compression of any nerve roots. Same procedure was performed on L5-S1 level. Peritoneum was then allowed to return to normal anatomic position and entire area was copiously irrigated. The wound was closed in a layered fashion. The patient tolerated the discectomy and arthroplasty well and was returned to recovery in good condition. What CPT coding is reported for this procedure?
- A. 0
- B. 1
- C. 22857 x 2
- D. 22857, 22860
Answer: D
NEW QUESTION # 416
A 3-day-old died in her sleep. The pediatrician determined this was the result of crib death syndrome. The parents give permission to refer the newborn for a necropsy. The pathologist receives the newborn with her brain and performs a gross and microscopic examination. The physician issues the findings and reports they are consistent with a normal female newborn.
What CPT code is reported?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: D
Explanation:
* Procedure: Gross and microscopic examination of a newborn autopsy.
* CPT Code:
* 88028: This code is for the autopsy, gross and microscopic examination of a stillborn or newborn.
* Code Selection Justification: The procedure described matches the comprehensive postmortem examination of a newborn.
References:
* AMA CPT Professional Edition (current year)
* ICD-10-CM (current year)
* HCPCS Level II (current year)
NEW QUESTION # 417
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30- gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the area. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT coding is reported for this case?
- A. 0
- B. 14001, 11606-51, 12034-51
- C. 14001, 11606-51
- D. 1
Answer: C
Explanation:
For the excision of an 11 cm lesion with a rotation flap repair, the appropriate CPT codes are 14001 for the adjacent tissue transfer or rearrangement (12 sq cm flap) and 11606-51 for the excision of a malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm. Modifier 51 indicates multiple procedures. The detailed operative report specifies the lesion size and the technique used, justifying these codes.
References: CPT Professional Edition (current year), AMA.
NEW QUESTION # 418
Refer to the exhibit.
Refer to the supplemental information when answering this question:
View MR 065174
What E/M code is reported for this encounter?
- A. 0
- B. 1
- C. 2
- D. 3
Answer: A
Explanation:
To determine the correct E/M code, we need to consider the three key components: history, examination, and medical decision making (MDM).
History:
The documentation indicates an expanded problem-focused history. This is supported by the detailed history of present illness, including the patient's description of symptoms, family history, and review of systems with pertinent positives and negatives.
Examination:
The examination is also expanded problem-focused. The physician focused on the relevant systems (head, neck, throat) and documented specific findings related to the chief complaint (thyromegaly).
Medical Decision Making:
The MDM is straightforward. The physician is evaluating a new problem (bilateral thyroid nodules) with a low level of risk. Although further workup is planned, this alone doesn't automatically increase the MDM complexity.
Based on these components, 99213 is the most appropriate code.
Why other options are incorrect:
99212: Requires a problem-focused history and examination, which is less comprehensive than what was documented.
99214 and 99215: Require a higher level of MDM (low or moderate complexity) and/or a more detailed examination. The documentation doesn't support this level of service.
Reference:
CPT Codes 99211-99215: Office or other outpatient visit for the evaluation and management of an established patient
1995 and 1997 Documentation Guidelines for Evaluation and Management Services: These guidelines provide detailed criteria for selecting the appropriate E/M code based on history, examination, and MDM.
AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.
NEW QUESTION # 419
......
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