What is NOT a condition related to the thyroid gland?
Correct Answer: D
Toxic adenoma E05.2- is a thyroid nodule that may secrete hormones into the body that results in an overactive thyroid. Graves' disease E05.0- is an autoimmune disorder that attacks the thyroid, resulting in overactivity. Hashimoto's disease E06.3 is also an autoimmune disorder: however, it usually results in an underactive thyroid. Acosta disease T 70.29- is altitude sickness. Even if a coder is unfamiliar with these terms, by locating the ICD-IO-CM code that correlates to the condition, a coder can infer which body system a diagnosis relates to.
AAPC-CPC Exam Question 52
A patient is in labor with plans to deliver vaginally. An epidural is administered at 17:30. After several hours of pushing, the obstetrician determines that the cervix is swollen, and the baby must be delivered via a c-section. The patient consents, the baby is delivered, and both are discharged to the recovery room at 22:15. What CPT code(s) should the anesthesiologist report?
Correct Answer: D
For a planned vaginal delivery with the use of an epidural, followed by a Cesarean delivery, the correct CPT codes are 10967 followed by add-on code 01968. CPT code 99140 is an add-on code portraying that the procedure was an emergency and that the patient and/or baby has a significant increase in the threat to life. The documentation gives no indication that these services were emergent Modifier 23 is reported for unusual anesthesia services. This would include-but is not limited to-the use of general anesthesia for a procedure that usually requires only a local anesthetic or none and/or a procedure extending more than 4 hours. In this case, the total procedure time was 4.75 hours, and modifier 23 is appended on the primary procedure code only.
AAPC-CPC Exam Question 53
Code the following note: A 43 -year-old new female patient with a history of type I diabetes was referred to my office by Dr. White, her primary care physician. Patient complains of blurred vision that began 2 weeks ago, however, reports compliance to a strict, healthy diet and to prescribed 10 mg of dexamethasone every day for 1 month. Given that the only change appears to be the dexamethasone, I suspect the blurred vision is an adverse reaction and will decrease the dosage to 5 mg per day. Patient will follow up with me in 1 week if symptoms persist. Total time spent on todays encounter is 30 minutes.
Correct Answer: A
When choosing between an outpatient evaluation and management code or a consultation service code, bear in mind the following four elements: request, reason, report, and intent. Although the first three elements are documented and support a consultation service, the endocrinologist is assuming immediate care of the patienYs condition. In this case, the visit is not a consultation but a new transfer of care, which is encompassed by CPT codes 99202-99205. For this visit, coding based on medical decision-making as opposed to the total time spent on the encounter that day would be more advantageous. This is because coding based on time would lead a coder to report CPT code 99203 or a low level of medical decision making, whereas the medical decision-making is actually moderate, represented by CPT code 99204. The documentation reflects that the blurry vision is most likely due to the dexamethasone: therefore, a causal relationship is not assumed betvveen the two conditions and should not be coded as such. Because an adverse reaction is suspected and not confirmed, it should not be coded. This general rule does not apply to inpatient encounters.
AAPC-CPC Exam Question 54
Which patient is receiving critical care services?
Correct Answer: B
CPT guidelines define critical care as an illness or injury that acutely impairs one or more vital organ systems, where there is a high probability of imminent or life-threatening deterioration in the patients condition. Additionally, to report a critical care service, the documentation should provide evidence of high-complexity medical decision-making (e.gendotracheal tube insertion, defibrillation, fluid administration for shock, Narcan, etc.). Answer B is the only option listed that contains documentation to support critical care services. This male patient has Vyvo life-threatening conditions, in which emergent intervention is provided to prevent further deterioration. In ansvver A the female patient may have a life-threatening condition: however, administering oxygen via a nasal cannula and/or transfusing blood does not qualify as critical care. Management of a patient who receives chronic ventilator therapy is also not considered critical care because the medical decision-making involved in the therapy is quite low. The care a patient receives after having surgery would be considered routine and postoperative, regardless of where they are sent, unless a complication arises in which one or more of the vital organ systems begins to deteriorate in a fashion that poses a threat to life.
AAPC-CPC Exam Question 55
An orthopedic surgeon performs a meniscectomy for a right radial tear using an arthroscope. During the procedure, the surgeon removes a piece of the damaged meniscus from the lateral compartment of the knee and shaves the articular cartilage of the same compartment. A separate incision was made to remove a 6 mm loose body in the medial compartment. The surgery was completed without any complications. What procedure and diagnosis code(s) should be reported?
Correct Answer: B
The procedures performed on this encounter were the meniscectomy (removal of damaged meniscus from the lateral compartment) with a chondroplasty (shaving of articular cartilage, 29881) and loose body removal by means of an arthroscopy (29874). Because the removal of loose bodies is considered inclusive to the primary procedure, modifier 59 is appended as opposed to modifier 51 to indicate that it was a distinct procedural service due to the separate incision. Answers A and D can be eliminated based on the diagnosis chosen. S83.203A indicates the location of meniscus is unspecified: however, the surgeon removed the damaged meniscus from the lateral compartment, leading the biller to S83.281A.