A patient is seen with complaints of recurring infections in the foreskin. The physician recommends circumcision to help improve penile hygiene. The patient agrees, a local anesthetic is injected into the penis, and the procedure is completed by clamping the foreskin and trimming the excess skin. How should the physician report the encounter?
Correct Answer: C
A circumcision procedure includes a local anesthetic, also known as a ring block. Therefore, an additional anesthesia code (CPT 64450) should not be reported as a secondary code, nor should modifier 52 be appended on the primary procedure. The code notes for ICD-IO-CM code Z41.2 specifically state that this diagnosis should be used only when the procedure is elective and not related to a specific diagnosis. In this case, because the procedure is related to a recurring condition the patient is experiencing. the infection should be the primary diagnosis. The diagnosis crosswalk would be "infection" followed by "penis," which directs the coder to N48.29.
AAPC-CPC Exam Question 37
Which is NOT a violation of Health Insurance Portability and Accountability Act (HIPAA)?
Correct Answer: C
HIPAA is in place to reduce the level of risk associated with a potential violation and/or breach. In answer C, even though a breach has occurred, the hospital has appropriate preventative measures in place and is not in violation of HIPAA. Leaving a laptop in an unattended vehicle or medical records outside is high-risk behavior that gives opportunity for an unauthorized person to access protected health information (PHI) and/or electronic protected health. In answer D, a medical practice is required to perform a risk analysis to PHI and/or ePHI and recti$ any failures within a timely manner.
AAPC-CPC Exam Question 38
A 92-year old female with Medicare part A coverage receives ongoing hospice care due to dementi a. She goes to a physician's office to receive closed treatment of a hip dislocation following a fall. No anesthesia was used. How should the provider submit this claim?
Correct Answer: B
When a patient is receiving hospice care, Medicare will not reimburse the physician for services rendered that are unrelated to the terminal illness unless submitted with modifier GW. In Answers C and D, a separate, identifiable E/M is not to be billed because the procedure is considered minor (1- to 10-day global period) and includes an inherent E/M component.
AAPC-CPC Exam Question 39
A 69-year-old patient with a medical history of diabetes is evaluated in the emergency room for a urinary tract infection. After performing a medically appropriate history and exam, the physician prescribes 100 mg of Macrobid every 12 hours and admits the patient to observation status to monitor for sepsis. After seeing an improvement in symptoms, the physician discharges the patient the following day. What CPT and ICD-IO-CM code(s) should be reported for the entirety of the patient's stay?
Correct Answer: C
When a patient is admitted into observation status from the emergency room, only the observation code is reported for that day. When observation extends past the initial date of service, the initial treatment would be reported with CPT codes 99221-99223. In this scenario, the appropriate level of service would be 99221, based on the moderate level of decision-making. which can be ascertained by the number and complexity of problems addressed and the risk of complications and/or morbidity or mortality of patient management. Discharge from observation on a separate date is reported with CPT codes 99238-99239. Because the diabetes is documented and is a coexisting chronic condition during the time of the encounter, it should follow the reason for admission. Due to a lack of specificity in the diabetes diagnosis, a causal relationship with a UTI is not presumed, and Ell.69 should not be coded.
AAPC-CPC Exam Question 40
ICD-IO-CM codes R50.9, R05.9, R53.81, and 102.9 are all symptoms ofJ10.00.
Correct Answer: A
The statement is true. In general, R codes are descriptive of a patient's signs and symptoms. ICD-IO-CM crosswalk for an unspecified sore throat is 102.9 (acute pharyngitis) and is also considered a symptom of the influenza and pneumonia. Being that there is a definitive diagnosis of an influenza, these symptoms would not be reported to an insurance carrier with Jl 0.00.
