Practice Q's

Question 1

A 44-year-old patient with an ingrown toenail on her right second toe presents to the podiatrist’s office to have a nail permanently removed along with the nail matrix.

Which ICD-10-CM diagnosis code and CPT code are reported?

Answer 1

ICD-10-CM code:
L60.0

CPT code and modifier:
11750-T6

Question 2

Dameriea, a patient who is well known to Dr. Coles and whose last visit was 6 months ago, presents to the office today with severe vomiting for the past 2 days. Dr. Coles completes a problem-focused history and exam and a straightforward MDM. Dr. Coles suspects food poisoning and recommends rest and fluids.

Which ICD-10-CM diagnosis code and CPT code are reported?

Answer 2

ICD-10-CM:
R11.10

CPT:
99212

Question 3

14-month-old Dameriea who has bilateral congenital clubfeet presents to the DME provider for a foot abduction rotation bar with shoes.

Which ICD-10-CM code and HCPCS code are reported?

Answer 3

ICD-10-CM:
Q66.89

HCPCS:
L3140

Question 4

Dameriea was brought to the same day surgery today for a neuroma on his left second finger that he has had for months. He is taken to the OR where Versed is administered, and his left hand is prepared and draped. Dr. Coles excises the neuroma from the patient’s cutaneous nerve of the left second finger.

What is the correct CPT code and modifier?

Answer 4

CPT code and modifier:
64774-F1

Question 5

Dameriea was at dinner with friends where he accidentally ate pecans in the dinner salad and went into anaphylactic shock due to ingestion of pecans, initial encounter.

What is the correct ICD-10-CM code?

Answer 5

ICD-10-CM code:
T78.05XA

Question 6

Dameriea has stage 4 kidney failure and is seen today in the office for an injection of Aranesp, 1 mcg (non-ESRD use).

What is the correct HCPCS code?

Answer 6

HCPCS code:
J0881

Question 7

Dameriea attended a 30-minute group session for diabetes self-management training in the office today.

What is the correct HCPCS code?

Answer 7

HCPCS code:
G0109

Question 8

Dameriea is a 65-year-old patient seen today for carcinoma of the anterior wall of the bladder.

What is the correct ICD-10-CM code?

Answer 8

ICD-10-CM code:
C67.3

Question 9

Dameriea is admitted to same day surgery today with a paraesophageal hernia. He is taken to the OR where a laparoscopic repair of paraesophageal hernia with mesh was performed without any complications.

What is the correct CPT code?

Answer 9

CPT code:
43282

Question 10

A patient had an implantable vascular access device with subcutaneous port placed seven weeks ago for chemotherapy. This is administered each week in the ambulatory surgery department of the hospital.

The full cycle is now complete and the vascular access device is no longer needed. Today, the physician surgically removed the centrally tunneled central venous catheter and subcutaneous port. No services for the carcinoma of the transverse colon are provided.

The cancer has not been resected yet because the chemotherapy was utilized in an attempt to shrink the tumor before surgery was initiated.

The correct codes for reporting by the physician will be:

Answer 10

ICD: Z45.2, C18.4
CPT: 36590

Question 11

Summary of the clinic record of a family practice physician:

The patient is a 3-year-old male with Down syndrome who was seen in the office yesterday for bilateral otitis media. He was given a prescription for Septra liquid suspension.

On repeat visit today, the mother reports that the patient complained of a “tummy ache” after the first dose and has vomited six times since being seen yesterday. PO intake is decreased but still sufficiently hydrated. Has not been able to keep down any antibiotics. A medically appropriate history is documented.

Documentation states that the ears have increased redness with the right TM bulging more than yesterday. Considerable wheezing is noted on lung exam. No other significant findings are documented on exam.

The patient is treated with 500 mg of Ceftriaxone sodium, IM, and given a prescription for an albuterol metered dose inhaler with spacer. The patient and mother are taught the proper use of the inhaler. The medical decision making is high.

The physician documents the diagnoses as:

Acute otitis media
First-time wheezer
Vomiting
Down Syndrome

What ICD-10-CM, CPT, and HCPCS codes would be reported for this visit? Include E/M code(s).

Answer 11

Acute otitis media: H66.93
First-time wheezer: R06.2
Vomiting: R11.10
Down Syndrome: Q90.9
CPT E/M and modifier: 99215-25
CPT for demonstration of metered dose inhaler: 94664
CPT for therapeutic IM injection: 96372
HCPCS for 500 mg of Ceftriaxone sodium: J0696 X 2

Question 12

The following documentation is from the health record of a 54-year-old female patient:

CC: Refill of estrogen patch and follow-up.

HPI: Severe hot flashes have been controlled. Energy level is back to a reasonable level.

ROS: All other systems are reviewed and are negative.

She is able to meet her work commitments as a community college instructor.

Exam: Unremarkable.

Assessment: Menopausal symptoms controlled by estrogen patch. Refill for six months given. Return PRN.

What ICD-10-CM and CPT codes (including E/M codes) would be reported for this for this clinic visit?

Answer 12

ICD: N95.1, Z79.890
CPT: 99213

Question 13

An established patient sees his physician in the office with complaints of chest pain. The physician admits the patient on December 1 under observation status at the local community hospital. The physician completes a comprehensive history that includes a complete review of all body systems and a complete past, family, and social history.

The physician performs a comprehensive examination but finds no significant issues. The patient does admit to a great deal of stress at work. Medical decision-making is of moderate complexity. On the second day of care, the physician continues to observe the patient when he conducts a detailed examination and medical decision-making of moderate complexity.

The patient is subsequently discharged home the next (3rd) day with a diagnosis of mild depression; the physician spends 18 minutes with the patient discussing discharge and follow up care. The patient was in observation status for 3 days.

What CPT E/M code would the physician report for the third day of care?

Answer 13

99238

Question 14

Dameriea sees Dr. Coles for the first time today. When he made the appointment yesterday, he had stomach cramps, diarrhea, and a fever but today he is feeling better, with no fever or diarrhea, and the cramps are less severe. Dr. Coles thinks that Dameriea may have eaten something that did not agree with his stomach, and it seems to be resolving, so he recommends a bland diet for the next 2 to 3 days.

Select the appropriate E/M code for a new patient office visit in which a medically appropriate history and/or physical examination and medical decision-making of low complexity were performed.

What is the correct CPT E/M code for this encounter?

Answer 14

99203

Question 15

Dameriea has a Dupuytren’s contracture of the right hand, and today he is the OR for surgical correction. Dr. Coles performs a palmar fasciotomy of the right hand by open technique. Dameriea tolerated the procedure well.

What is the correct CPT code and modifier?

Answer 15

26045-RT

Question 16

Mr. Coles is 87 and has had several recent falls. He has not been seriously injured, but his children are concerned so he visits his family physician for evaluation.

Evaluation for repeated falls.

What is the correct ICD-10-CM code?

Answer 16

R29.6

Question 17

Dameriea has an ectropion of the right upper eyelid. He presents to the SDS today for repair. Cecil’s right eye is prepped and draped, and Dr. Coles performs an extensive repair of the ectropion. The patient tolerated the procedure well and is taken to recovery.

What is the correct CPT code and modifier?

Answer 17

67917-E3

Question 18

Dr. Coles admits Dameriea to close her colostomy.

Admission for planned colostomy closure.

What is the correct ICD-10-CM code?

Answer 18

Z43.3

Question 19

A 22-year-old patient presents with an abscess in the subcutaneous tissue of the upper right chest. Dr. Coles performs an incision and drainage, expressing pus. A dry gauze dressing is applied, and the patient is sent home with care instructions.

Which CPT code should be assigned?

1. 10060
2. 10061
3. 23930
4. 10180

Answer 19

10060

Question 20

Patient requires repair of 3.4-cm laceration of the left forearm, single-layer closure with 4-0 Dexon; repair of 2.0-cm laceration on the left upper arm, single-layer closure.

Which CPT code(s) should be assigned?

1. 12002
2. 12002, 12002
3. 12032
4. 12031, 12032

Answer 20

12002

Question 21

Dameriea’s wound requires debridement of skin, subcutaneous tissue, and muscle. A total surface area of 18 sq cm was debrided down to and including removal of subcutaneous tissue.

Which CPT code should be assigned for these repairs?

1. 11010
2. 11042
3. 11043
4. 11044

Answer 21

11043

Question 22

Dr. Coles excises a 2.9 cm malignant lesion from the cheek with 1.0 cm margins all around.

Assign the CPT code.

Answer 22

11646

Question 23

Dameriea fell into an empty swimming pool and hurt his shoulder. The MRI shows a full-thickness tear of the right rotator cuff.

Which ICD-10-CM diagnosis codes are assigned for this encounter?

1. S46.011A, W17.3XXA
2. S46.012B, W17.3XXA
3. S46.001A, W17.3XXA
4. M66.20, W17.3XXA

Answer 23

S46.011A, W17.3XXA

Question 24

Mr. Coles has a history of symptomatic HIV.

Which ICD-10-CM diagnosis code should be reported?

1. R75
2. B20
3. Z11.4
4. Z21

Answer 24

B20

Question 25

Dameriea presents today for injections for management of pain due to malignancy. The cancer has metastasized to the pancreas. The primary site was the right lung which a lobectomy was performed 3 years ago and there has been no recurrence at the primary site. Which ICD-10-CM diagnosis codes should be reported? 1. G89.3, C78.89, Z85.118 2. Z85.07, Z85.118, G89.3 3. C34.91, C78.89, R52 4. C78.89, G89.3, Z85.118

Answer 25

G89.3, C78.89, Z85.118

Question 26

Assign the HCPCS code for a freestanding traction stand for pelvic traction.

Answer 26

E0900

Question 27

Six-year-old Dameriea was climbing a tree in his backyard when a branch broke, and he fell to the ground. He has some scrapes and bruises, but his grandma takes him to the ER just incase. Dr. Coles checks Dameriea over, noting that he has minor abrasions and contusions on his hands, right arm, knees, right leg and face but full range of motion and is negative for any indications of head injury or bone fractures. He sends Dameriea home and suggests popsicles, rest, and a little less tree-climbing What CPT code would you assign for this case?

Answer 27

99282

Question 28

26-year-old Dameriea recently moved from New York City to Seattle. He has not yet had a need for medical services, but he now needs to refill his prescription for oral contraceptives, so he schedules an appointment with Dr. Coles During the brief exam, Dameriea indicates that he has no medical concerns, and Dr. Coles finds that he is in perfect health, but because Dameriea is a new patient, Dr. Coles orders diagnostics to establish a baseline for future treatment. He orders a cardiac stress test, a pulmonary function test, a CBC, and a UA. He also instructs his assistant to perform vision and hearing tests to complete the visit. What is the CPT code for this scenario?

Answer 28

99202

Question 29

Patient presents with complaints of urinary frequency, pain when urinating, and blood in the urine. Dr. Coles examines the patient and orders a urinalysis in the office, which is positive for E. coil UTI. What code(s) should be repoted?

Answer 29

N39.0, B96.20

Question 30

Dameriea presents to Dr. Coles with complaint of RUQ pain. The pain is sharp and intermittent but persistent. Patient states that the pain is increasing in frequency. Dr. Coles suspects gallstones and writes an order for an abdominal ultrasound and will follow-up with Dameriea after those results are received. What ICD-10-CM code(s) would you assign?

Answer 30

R10.11

Question 31

Dameriea's grandma received a text that one of his classmates who had been at school that morning tested positive for COVID-19. Dameriea says he feels fine, but his grandma takes him to the urgent care to be tested. The results are negative. What ICD-10-CM code(s) would you assign?

Answer 31

Z20.822

Question 32

On November 3rd, Dameriea has a right breast lumpectomy. Pathology indicates that the margins were not clear, and so, on November 13th, he undergoes a complete mastectomy. Which CPT codes and modifiers should be assigned for these procedures (for each day)?

Answer 32

Nov. 3: 19120-RT Nov. 13: 19303-58-RT

Question 33

Dameriea presents to the office today for routine check of his HTN and prediabetes and to determine if there is a need to adjust his medications. He asks Dr. Coles to take a look at a squishy lump on his shoulder. Dr. Coles performs a simple I&D of the cyst. Which CPT codes and modifiers should be assigned for these procedures?

Answer 33

99213-25, 10060

Question 34

70-year-old Mr. Coles, who has Medicare and dos not meet the criteria for high risk for colon cancer, is in the endoscopy suite today for a screening colonoscopy. During the screening, Dr. Coles discovers a polyp in the transverse colon and removes it using the hot snare technique. What codes would be assigned if there were no abnormalities found? What codes would be assigned since there were abnormalities found?

Answer 34

No abnormalities: HCPCS: G0121 ICD-10-CM: Z12.11 Abnormalities: CPT: 45385-RT ICD-10-CM: Z12.11, K63.5

Question 35

Sharron feels a small lump in her right breast and visits Dr. Coles (at his office) to have it checked out. Dr. Coles also feels the lump at the UIQ (upper inner quadrant) and performs an ultrasound. Through ultrasound, he can visualize the mass but cannot say for sure if it is benign or malignant and so decides to perform a FNA (fine needle aspiration) biopsy using ultrasound to guide the needle to the mass. He sends the fluid to pathology for study. What are the codes assigned to this case?

Answer 35

CPT: 10005-RT ICD-10-CM: N63.12 Place of Service Code: 11

Question 36

If Dameriea had a furuncle of the groin and Dr. Coles performed a simple I&D, what codes would be assigned?

Answer 36

CPT: 10060 ICD-10-CM: L02.224

Question 37

Dr. Coles is called in to consult on a patient who has been admitted to General Hospital. The patient, Dameriea, has poorly controlled insulin-dependent Type 2 diabetes mellitus with ulceration on his right heel and midfoot with necrosis down to the muscle. Without immediate intervention, Dameriea could lose his foot. The ulcer measures 7.0 cm x 5.2 cm and Dr. Coles performs a surgical debridement of the skin, subcutaneous tissue, and extensor digitorum brevis muscle. The wound is packed. What codes are assigned to this encounter?

Answer 37

CPT: 11043, 11046 ICD-10-CM: E11.621, L97.413, Z79.4 Place of Service: 21

Question 38

Dameriea has several lumps in his left breast. Mammogram and ultrasound are suggestive of benign tissue, but Dr. Coles wants to be certain. The masses are at 1:00 and 4:00. Dr. Coles performs percutaneous biopsies of three lesions with placement of clips using MRI guidance. What codes are assigned?

Answer 38

CPT: 19085-LT, 19086-LT x 2, 77021-LT ICD-10-CM: N63.21, M63.23

Question 39

Dameriea presents to Dr. Coles for treatment of his primary focal hyperhidrosis. As Dr. Coles is injecting 50 units of Botox per axilla, Dameriea asks if he can take a look at his scalp. For several years, he's had intermittent issues with his scalp and eyebrows being dry and itchy. He has tried a dandruff shampoo, but that did not seem to help. He says it gets worse in the summer but does improve when the temperatures start to cool off. After finishing the injections, Dr. Coles examines Dameriea's scalp and eyebrows. He diagnosis seborrheic dermatitis and prescribes Ciclopirox shampoo, with instructions for daily use until control is achieved. What are the cods for today's visit?

Answer 39

For treatment of Hyperhidrosis: CPT: 96372 HCPCS: J0585 x 100 ICD-10-CM: L74.510 For evaluating the condition of the scalp and prescribing a shampoo to manage the treatment: CPT: 99213-25 ICD-10-CM: L21.8

Question 40

Dameriea has been diagnosed with carpal tunnel syndrome. He has tried wearing wrist splints and has taken several 14-day courses of oral prednisone, but her pain persists. Today, he returns to the office, and Dr. Coles injects 40 mg Methylprednisolone bilaterally. What are the codes assigned for today's visit?

Answer 40

ICD-10-CM: G56.03 CPT: 20526-50 HCPCS: J2920 x 2 Place of Service: 11

Question 41

62-year-old Dameriea has a past medical history of hypertension, chronic heart failure, and end stage renal disease and is suffering from primary osteoarthritis of the right knee. After sterile preparation and local anesthesia and using US guidance, Dr. Coles performs an intra-articular steroid injection for pain relief. The needle is placed into the right knee joint space, and 30 mg of Kenalog is injected into the joint for pain relief. What codes are assigned for this encounter?

Answer 41

ICD-10-CM: M17.11 CPT: 20611-RT HCPCS: J3301 x 3

Question 42

Dr. Coles performs an open reduction of right knee dislocation with repair of the torn anterior cruciate ligament by anchor suture. Following recovery, the patient is released to go home with aluminum crutches. What codes are assigned?

Answer 42

ICD-10-CM: S83.104A, S83.511A CPT: 27557-RT HCPCS: E0114

Question 43

Dr. Coles performs a closed reduction to a temporomandibular joint dislocation. What codes are assigned?

Answer 43

ICD-10-CM: S03.00XA CPT: 21480

Question 44

Dr. Coles performs an excision of basal cell carcinoma, abdominal wall, 1.2 cm in diameter, with 1-cm skin margin all around. What codes are assigned?

Answer 44

ICD-10-CM: C44.519 CPT: 11604

Question 45

Dr. Coles excises a benign lesion from Dameriea's scalp. The lesion measured 1.1 cm, and the margin excised was .4 cm all around. What codes are assigned?

Answer 45

ICD-10-CM: D23.4 CPT: 11422

Question 46

Dameriea presents to the operating room for excision of a 5.5 cm malignant melanoma of the left forearm. A 5 cm x 5 cm rotation flap was created for closure. Which ICD-10-CM and CPT codes should be assigned?

Answer 46

ICD-10-CM: C43.62 CPT: 14021

Question 47

47-year-old Dameriea received a full-thickness graft of the neck following lesion removal of a basal carcinoma. The lesion plus margins are documented to be 3.2 cm in diameter. A 10-sq-cm graft is applied with donor skin from his thigh, closed by suture. Which ICD-10-CM and CPT codes should be assigned for this case?

Answer 47

ICD-10-CM: C44.41 CPT: 11624, 15240

Question 48

Dameriea has a tumor in the soft tissue of his left hand. Dr. Coles performs an excision of this 2.3-cm mass and sends the tissue to pathology. The pathology report indicates that the tissue is malignant. Which ICD-10-CM and CPT code should be assigned for this case?

Answer 48

ICD-10-CM: C49.12 CPT: 26111-LT

Question 49

From the health record of a 16-year-old male patient requiring fracture care in the outpatient surgical unit: Operative Report Preoperative Diagnosis: Displaced comminuted fracture of the lateral condyle, left elbow Postoperative Diagnosis: Same Procedure: Open reduction, internal fixation Description: The patient was anesthetized and prepped with Betadine. Sterile drapes were applied, and the pneumatic tourniquet was inflated around the arm. An incision was made in the area of the lateral epicondyle through a Steri-Drape, and this was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two planes about 90 degrees. It was possible to manually reduce this quite easily, and the judicious manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. These pins were cut off below skin level. The wound was closed with some plain catgut suture subcutaneously and 5-0 nylon in the skin. Dressings were applied to the patient and tourniquet released. A long arm cast was applied. Assign the correct diagnosis and procedure codes: ICD and CPT code and Modifier

Answer 49

ICD: S42.452A CPT: 24579-LT

Question 50

Indication for Procedure: The patient is a 60-year-old female who has a persistently ingrowing great toenail on the left foot that has had two past infections. Procedure: Partial excision of toenail, permanent Procedure Description: The patient is placed in the supine position, with the knees flexed, and the left foot is flat on the table. The toe is prepped and cleansed, and local anesthetic administered. After waiting 10 minutes, a sterilized rubber band is placed around the base of the toe. The toe is resterilized and draped with the toe protruding. A nail elevator is slid under the cuticle to separate the nail plate from the overlying proximal nail fold. The lateral one fourth of the nail plate is identified as the site for the partial lateral nail removal. A bandage scissors is used to cut from the distal end of the nail straight back beneath the proximal nail fold. A straight, smooth, new lateral edge to the nail plate is created. The lateral piece of nail is grasped with a hemostat and removed in one piece, pulling straight out. Electrocautery ablation is used to destroy the nail matrix where the nail was removed. The matrix is treated twice. Antibiotic ointment is applied and a bulky gauze dressing is placed. The foot is placed in a surgical boot. Post-op instructions are given for daily cleansing with warm water, and strenuous exercise is to be avoided completely for at least one week. The patient tolerated the procedure well and understands the discharge instructions. The correct codes for reporting by the physician will be: ICD and CPT and Modifier

Answer 50

ICD: L60.0 CPT: 11750-TA

Question 51

This 52-year-old male was brought to the same-day surgery area for treatment of an open fracture of the distal phalanx of his middle finger on the left hand. Patient is right-handed and this injury occurred when the food-processing machine that he was operating at work tipped over and his hand got caught. He works in the local food factory here in town. The patient had open treatment performed to remove the fracture fragments without any internal or external fixation hardware used. Assign the correct diagnosis and procedure codes: ICD first sequenced code ICD external cause event/intent code ICD external cause place of occurance code ICD external cause activity code ICD external cause status code CPT code and Modifier

Answer 51

1. S62.633B 2. W31.82XA 3. Y92.63 4. Y93.89 5. Y99.0 6. 26765-F2

Question 52

Darcey has a recurring ganglion cyst in her right wrist. Dr. Gupta performs an excision of the recurrent ganglion cyst of the right wrist. Assign the correct codes for this encounter. ICD and CPT code with modifier

Answer 52

ICD: M67.431 CPT: 25112-RT

Question 53

George has had a palpable mass on his head for years and presents today for removal. Dr. Zhang excises a 3.3 cm tumor from the soft tissue of the scalp. Pathology report confirms that the tissue is benign. Assign the correct codes for this encounter ICd and CPT code with modifer

Answer 53

ICD: D23.4 CPT: 21012

Question 54

At the urgent care center, Dr. Cotter is called in to clean a deep wound to the right calf. This required debridement down to and including removal of the muscle and subcutaneous system; total surface area is 22 sq cm. Assign the correct codes for this encounter. ICD CPT Primary code CPT add on code Place of service code

Answer 54

S81.801A 11043 11046 20

Question 55

A 45-year-old female patient presents for wide excision of a 2.0 cm malignant melanoma on the left forearm. The area excised resulted in a 4.3 cm x 2.5 cm defect requiring rotational advancement flap closure. The pathology report shows clear margins. Assign the correct codes for this encounter. ICD and CPT codes

Answer 55

ICD: C43.62 CPT: 14021

Question 56

Mrs. O’Neill has a torn right rotator cuff. Dr. Banbury performs an arthroscopy of the shoulder with complete rotator cuff repair. Assign the correct codes for this encounter. ICD and CPT code with modifier

Answer 56

ICD: M75.121 CPT: 29827-RT