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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q117-Q122):

NEW QUESTION # 117
If all the following statements were documented by the anesthesiologist in one record, which would be chosen as the start time for anesthesia services?

  • A. Propofol is administered to the patient intravenously.
  • B. A pulse oximeter is attached to the patient,s finger while in the operating room.
  • C. Medical history and vital signs for the patient are obtained prior to the surgery.
  • D. Request for services is received for an operation that begins in 1 hour.

Answer: B

Explanation:
Anesthesia time begins when the provider begins to prepare the patient for anesthesia services. This usually will take place in the operating room or an equivalent area. Although answer B would not be incorrect as a chosen starting point, answer C is more accurate according to the anesthesia time definition. Preoperative evaluations of the patient, such as a history intake, cannot be counted as anesthesia time.


NEW QUESTION # 118
Which term describes a procedure in which real-time moving images of an organ are displayed on a screen so that a physician can examine its function and/or structure?

  • A. Magnetic resonance imaging
  • B. Fluoroscopy
  • C. Tomography
  • D. Computed tomography

Answer: B

Explanation:
Magnetic resonance imaging (MRI) uses magnets, radio waves, and a computer to display detailed pictures of the inside of the body. Tomography uses waves of energy to create three- dimensional, computer-generated images of any internal structure. Computed tomography is cross- sectional images of the body obtained by a narrow beam of x-rays that quickly rotates around the body.


NEW QUESTION # 119
Code the following procedure note:
A 45-year-old female was referred for a urodynamics study due to complaints of bladder pain and weak urination. The provider places a rectal catheter simultaneously with a urethral catheter and begins to fill the bladder with water.
Using calibrated equipment, cytometry was done with a medium fill rate of 40 cc/ minute. A strong desire to void occurred at 84 cc. and the patient is instructed to void. The provider determines that the maximum urinary flow rate is 12 cc per second with a voiding time of 45 seconds and a voided volume of 102 cc. She voided with a sustained detrusor pressure. An abdominal pressure measurement was also taken, indicating no urinary leaking with abdominal straining. EMG patches were placed on the anal sphincter and found to be elevated with increased intra- abdominal pressure. All catheters and EMG patches were removed, and the procedure was completed without complications. A report will be forwarded to the referring provider, who will provide the interpretation of the results to the patient.

  • A. 51728-TC, 51784-TC, 51797-TC, 51741-TC
  • B. 51728-TC, 51784-TC, 51797-TC
  • C. 51726-TC, 51784-59-TC, 51797-59-TC, 51741-59-TC
  • D. 51726-TC, 51784-51-TC, 51797-51-TC

Answer: A

Explanation:
A urodynamics study is a diagnostic test to evaluate the function of the bladder. When performed using calibrated equipment, it becomes known as a complex cystometrogram (51726-
51729). In CPT code 51728, a complex cystometrogram is performed in conjunction with voiding pressure studies. In the provider's documentation, the bladder is filled with water, and voiding times and volume are recorded, thus fulfilling the requirements for this code. CPT code 51726 in answers A and B only describe a complex cystometrogram without the voiding pressure studies.
Electromyography (EMG) studies were performed without a needle to evaluate pelvic floor activity and are represented by 51784. An intraabdominal voiding pressure study (51797) can be inferred in that the provider had earlier inserted a rectal catheter and, after instructing the patient to cough, obtained an abdominal pressure measurement. A complex urinary flow study (51741) was performed in obtaining the maximum urinary flow rate through calibrated equipment. This procedure is missing in answers B and C. Modifier TC (indicating only a technical component) is amended on all the procedures because the provider is not interpreting the results to the patient.
Modifiers 51 and/or 59 is not amended on any procedure (A and B) because these are routinely billed together.


NEW QUESTION # 120
A patient is seen in the emergency room with a thermal burn to the left thigh because of a fire. The patient denies feelings of hypothermi a. Vitals are obtained, and a physical examination reveals that approximately 4% of the body is affected by second-degree burns, and nonviable tissue needs to be removed to avoid the risk of infection. After consent is obtained, the physician debrides the wound, cleanses the area, and applies a gauze. The patient is discharged and told to follow up with their primary care physician in 2 days. What CPT code(s) should be reported for this encounter?

  • A. 0
  • B. 99282-25, 16020
  • C. 16020, 99282
  • D. 99283-25, 16020

Answer: D

Explanation:
When billing for physician services in the emergency room, it is appropriate to report a standalone E/M when the documentation supports its necessity in determining the need for appropriate treatment. Modifier 25 is necessary to the E/M code when being billed alongside a procedure and/or surgery to indicate a separately billable service. In this case, the documentation supports decision-making of moderate complexity. CPT code 99283 meets these criteria, whereas CPT code 99282 reflects a medical decision-making of low complexity and does not accurately portray the services rendered. The emergency room visit is always the first listed code, followed by the procedure and/or surgery performed.


NEW QUESTION # 121
A patient with a history of colon cancer was treated with radiation therapy. CT scans and blood tests show the malignancy has been eradicated. The patient is directed to take 81 mg of aspirin daily over the course of the next year to help prevent reoccurrence of the malignancy. What ICD-IO-CM code(s) should be reported by the provider on subsequent visits related to this patient's condition?

  • A. C18.9
  • B. Z85.038
  • C. Z48.3, C18.9
  • D. Z08, Z85.038

Answer: D

Explanation:
Regarding Z08, ICD-IO-CM guidelines state: "The follow-up codes are used to explain continuing surveillance following completed treatment of a disease. They imply that the condition has been fully treated and no longer exists." When using a follow-up code as the primary reason for an encounter, a history code indicating what condition the patient originally had should be assigned as secondary. Aftercare codes are used to describe the continued treatment of a disease. In this case, the malignancy has been eradicated, the disease no longer exists, and aspirin is being used merely as a preventative measure. History codes can never be reported as first listed; rather, a follow-up code or other current disease and/or condition should precede it.


NEW QUESTION # 122
......

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