Diagnosis Coding with ICD-10
A patient has a history of being allergic to penicillin. What code should be assigned?
A patient is diagnosed with anemia and requires a blood transfusion. The code for anemia would be
found in category codes
A patient diagnosed with neuromyelitis optica would be assigned to category
A patient diagnosed with a benign neoplasm of the colon would be assigned to
The code for hypersecretion of calcitonin includes
C-cell hyperplasia of thyroid.
An “Includes” note provides
further definition of what’s included in a category.
examples of the types of characters included in a code.
a list of main terms in a particular code category.
a list of subterms in a specific subcategory.
A patient is diagnosed with alpha thalassemia. The coder mistakenly assigns code D50.0. What correct
ICD-10 code should be assigned?
The diagnosis of conjunctivitis would be coded using
A diagnosis with an associated complication would be assigned to a/an
External Cause of Injury code.
The External Cause codes
appear only on the maternal record.
are excluded from consideration in obstetrical coding.
are always reported as a first-listed diagnosis.
are never reported as a first-listed diagnosis.
In the outpatient setting,
uncertain diagnoses are reported.
uncertain diagnoses are listed for malignant neoplasm codes only.
uncertain diagnoses are not reported.
a query must always be sent to the physician.
The ICD-10 code for unspecified tularemia is
Laceration of the posterior tibial artery of the right leg is assigned to code
A code has five characters and requires a seventh character. If a sixth character isn’t available, what
should the coder do?
Use a placeholder X for the sixth character.
Use placeholder Y as the seventh character
Insert a “?” in the seventh character field
Query the provider for the seventh character
“Code first” and “Use aIDitional code” are examples of
the etiology/manifestation guideline.
the Includes notation.
What is the I-10 code for type 1 neurofibromatosis?
Code category H66.3 instructs the coder to
use H72.- for any associated perforated tympanic membrane.
use an aIDitional code for history of tobacco abuse.
use an aIDitional code for an adverse effect of a medication.
assign a Z code, if necessary.
A Scenario flag (fourth field) tells the coder
that the target codes combine to make a viable scenario.
the target codes used for mapping I-8 to I-9.
that the source codes map to one or more target codes.
the number of various combinations of diagnoses included in the source code.
O41.121 indicates that the patient has
first trimester chorioamnionitis.
placenta membrane disruption.
End of exam
Phrases such as associated with, due to, or with mention of are examples of
Procedure Coding With ICD-10-PCS
The process of breaking solid matter within a specific part of the body into different pieces is called
Code K11.5 would be assigned for which condition?
Necrotizing ulcerative stomatitis
What is the code for extraction of the vein in the left foot using an open approach?
What is the correct code for an ulnar nerve lesion?
According to the guideline for ICD-10-CM pathologic fracture coding, the 7th character of A is assigned
in fracture coding when
the patient is under the age of 21.
a fracture is in the healing phase.
the fracture is being surgically corrected using open reduction and internal fixation.
the patient is receiving active treatment for a fracture.
A patient tested for HIV but with inconclusive serology would be coded to
A patient is diagnosed with hypertension with stage 2 chronic kidney disease. What codes would be
I12.0 and N18.3
I12.9, N18.6, and Z99.2
I12.9 and N18.4
I12.9 and N18.2
A patient is diagnosed with controlled Type 2 diabetes on insulin without complication. Assign the
correct ICD-10-CM code.
What are the codes for acute prostatitis resulting from streptococcus?
What is the code for correcting a malfunctioning pituitary gland using an external approach?
The code for Woakes’ ethmoiditis is
A resection indicates that
a portion of the body part was removed.
the patient’s leg was immobilized in traction.
the entire body part was removed without replacement.
a surgical procedure was repeated later during the same encounter.
What code would be assigned for a patient diagnosed with Löffler’s endocarditis?
What is the code for tinnitus in the right ear?
What is the correct ICD-10-CM code for AIDison anemia?
A patient with anterior wall chest pain would be assigned to code
What is the I-10 code for pseudomembranous conjunctivitis of the right eye?
What is the correct ICD-10-CM code for alcohol dependence with withdrawal delirium?
What is the code for removing the autologous tissue substitute from the right clavicle using a
End of exam
What is the code for otitis externa of the left ear?
Evaluation and Management and Anesthesia Coding
Questions 1 to 20: Select the best answer to each question. Note that a question and its answers may be split across a page
break, so be sure that you have seen the entire question and all the answers before choosing an answer.
When appended to a CPT code, modifier -66 indicates
a surgical team worked together to perform a surgery.
a second operative session in the same day.
reduced anesthesia during a surgery.
a complex surgical procedure.
Modifier -90 is assigned for _______ only.
PCA allows patients to
administer their own analgesia.
sleep continuously for a specified time frame.
remain semi-conscious throughout a procedure.
remain completely awake during a procedure while under anesthesia.
A patient is in critical care for 125 minutes. What codes are assigned?
99291-25, 99291-50, 99292-75
Appendix E includes a list of
commonly prescribed medications.
CPT codes exempt from modifier -51.
An indented code appears
over the CPT code.
beneath the modifier that adjoins the CPT code.
adjacent to a CPT code.
beneath CPT codes that stand alone.
History, examination, and medical decision making are
key geographic data.
classified by demographics.
grouped according to physician specialty.
clinical information in the patient’s medical record.
A significant separately identifiable E/M service is indicated with a/an
aID-on code 52.
optional code 2523.
Modifier -54 indicates
bilateral procedures were performed.
only the surgical care portion.
specialized services were provided.
two surgeons worked simultaneously.
Vascular families can be found in Appendix
A patient undergoes a right hip arthroscopy with removal of a foreign body. The anesthesia is
complicated by emergency conditions. What codes should be assigned?
Which of the following code ranges are aID-on codes reported for prolonged physician services?
Which of these appendices was deleted in 2013?
AID-on codes are
never used by themselves.
classified as HCPCS Level IV codes.
an optional modifier.
always used by themselves.
The triangle symbol in CPT indicates a
code has been changed or modified in some way.
new code for a procedure or service.
code that requires a modifier.
code that requires a descriptor.
A complete list of CPT code aIDitions, deletions, and revisions can be found in Appendix
Codes that are exempt from the -63 modifier can be found in Appendix
If the physician reviews a minimal amount of data during the course of the patient’s encounter, this
would be reflected as a component of
medical decision making.
review of systems.
The dollar rate of each anesthesia unit is called the _______ factor.
base value unit rate
Modifier -59 indicates a/an _______ procedure.
End of exam
Surgical CPT Coding, Part 1
Which of the following statements is true of a skin graft?
It’s used to reverse skin on the recipient site without amending the donor site.
It’s obtained from the recipient site and placed on the donor site.
It’s obtained from the donor site and placed on the recipient site.
It’s used to rotate skin on the donor site without amending the recipient site.
Lesion excision codes are arranged in the CPT according to
donor site classification.
anatomic site and classification, such as simple, intermediate, or complex.
anatomic location and size of the lesion in centimeters.
Splints are used to
stabilize and immobilize a body part to allow for healing.
provide traction for closed fractures.
realign the tibia and the fibula.
If multiple arthroscopy procedures are performed on a patient, which modifier should be appended to
the CPT code?
A sinus endoscopy involves
inserting a scope for incision and drainage of the sinus cavity.
placing a scope through the patient’s nose and into the nasal cavity.
sinus microbial lavage.
inserting a scope for tissue revision.
With manipulation, without manipulation, or with or without traction are the three methods used to
describe which fracture treatment procedure?
Turbinates are the bones inside the
the zygomatic arches.
A physician who acts as a surgeon and a pathologist to view a lesion and determine its state of
malignancy is performing
Mohs micrographic surgery.
pathology analysis and restructuring.
lesion analysis and retrieval.
Micrographic Meridian Analysis.
A patient undergoes a closed treatment for a bimalleolar right ankle fracture. The physician manipulates
the fracture during the treatment. What code should be assigned?
The most common procedure performed in the incision category of the Respiratory Section is the
A coronary artery bypass graft
transfers blood through a graft via a coronary artery.
connects a vein to a coronary artery to transport healthy blood.
uses a skin graft to layer a diseased artery.
uses a healthy vessel to bypass a diseased artery to transmit blood.
Another name for a xenograft is a/an
Inserting pins, wires, and screws into the bone to attach devices for bone alignment is called _______
Closed treatment with manipulation occurs when the physician must
restructure the pieces of a bone using immobilization.
realign the muscles within the bone.
put the bones back into place.
replace torn ligaments to realign the bone.
A maxillectomy with an orbital exenteration should be coded as
The Rule of Nines is used to
calculate the percentage of the body area that is burned.
analyze nine pieces of tissue to pinpoint lung disease.
calculate the number of bones fractured in a specific area.
construct a nine-year surgical history for the patient.
Dislocation indicates that the bone has
been relocated to a new anatomic site for stabilization.
been displaced from its normal location.
split into two separate pieces.
been displaced and realigned by the physician.
Which codes should be used to report nasal polyp excisions?
32000 and 37520
30400 and 30450
30310 and 38900
30110 and 30115
A patient undergoes a total laryngectomy along with a radical neck dissection, as well as emergency
endotracheal intubation. The coder assigns code 31360 and 31500-51. According to CPT guidelines, this
code assignment is
incorrect. Code 31500 should be 31365.
incorrect. Code 31360 should be omitted.
incorrect. Code 31500 is modifier -51 exempt.
correct. Modifier -51 should be assigned to indicate multiple procedures.
Removal of infected, damaged, or necrotic tissue is called
Surgical CPT Coding, Part 2
The physician performs a percutaneous liver biopsy using ultrasound guidance. What code should be
reported for the percutaneous liver biopsy?
A strangulated hernia indicates that the
hernia cannot be placed back into the abdomen.
hernia is reversed in the abdomen.
blood supply to the hernia is cut off.
hernia is triangulated.
The _______ system carries fluids and proteins to the bloodstream.
A fetal contraction stress test is assigned to code
The blaIDer cuff connects the
urethra to the kidney.
kidney to the ureter.
ureter to the blaIDer.
ureter to the kidney.
A patient undergoes a proctosigmoidoscopy with a multiple biopsy. What code should be assigned?
A physician performs a stereotactic transperineal prostate biopsy. What code should be assigned?
The difference between the mediastinotomy codes is the
area of operation.
age of the patient.
A patient comes to the doctor’s office complaining of urinary frequency, urgency, and feeling as if his
blaIDer has not completely emptied. The physician inserts a prostatic stent to treat the patient’s condition.
Based on the patient’s symptoms, he most likely has
benign prostatic hyperplasia.
Removing part of the intestine and joining the remaining ends or developing an artificial opening is
A patient undergoes a total splenectomy. What code should be assigned?
The parotid, submandibular, and sublingual are examples of
Obtaining a biopsy of the mucous lining of the uterus is called
dilation and curettage.
A patient is seen for a complicated removal of indwelling stents. The same physician inserted the stents
several weeks earlier. What code should be assigned?
A patient undergoes a bone marrow biopsy. How is this coded?
A physician uses the heat from radiofrequency to destroy extra tissue in the prostate. What is the
correct code for this procedure?
A patient is seen for routine OB care, including antepartum care, cesarean delivery, and postpartum
follow-up. In this scenario, what code would be assigned?
Code range 43260–43278 applies to coding
transesophageal balloon dilations.
endoscopic retrograde cholangiopancreatographies.
Sengstaken esophagogastric tamponades.
flexible transoral esophagogastroduodenoscopies.
A physician inserts a percutaneous transhepatic stent into an obstructed biliary tract to open the area.
What code should be assigned?
End of exam
When a fertilized ovum is implanted outside of the uterus, the condition is called
Surgical CPT Coding, Part 3
Which of the following correctly lists the parts of the spine?
Cervical, sacrum, lumbar, epidural, and coccyx
Thoracic, lumbar, cranial, sacrum, and coccyx
Cervical, thoracic, lumbar, sacrum, and coccyx
Cranial, lumbar, coccyx, thoracic, and sacrum
AID-on code 69990 is used to report a/n
external ear incision.
skin tag excision.
miIDle ear incision.
A coder is assigning a code for Bordetella parapertussis. What code should be assigned?
Ongoing dialysis for end stage renal disease is assigned using codes
Which of the following biopsy specimens is included in a Level IV surgical pathology examination
(88305), but is not included in a Level V examination (88307)?
Lung, wedge biopsy
A DMD (dystrophin) deletion analysis with duplication analysis is assigned to what code?
A physician replaces a cranial neurostimulator pulse generator with inductive coupling and a connection
of four electrode arrays. The coder assigns 61886. Is this correct?
No. The coder should have assigned 61885.
No. The coder should have assigned 61886 and 61888.
Maybe. The coder should have queried the physician for aIDitional clarification on code 61886.
Yes. Code 61886 is correct.
A patient comes to the radiology department of a local hospital for a two-view chest x-ray. The
physician supervises the x-ray procedure, reviews the x-ray, and interprets the results. The coder assigns
code 71020. What modifier should be aIDed to the code?
A coder assigns 80055-52 for a pregnant patient who had a CBC, HBsAG, rubella antibody, VDRL,
RBC antibody screen, ABO and Rh blood typing. Why is this code incorrect?
You can’t assign modifier -52 with a panel.
The panel must include total serum cholesterol.
The patient required a blood transfusion.
An aIDitional panel was required.
The physician creates a subarachnoid-peritoneal shunt that doesn’t require a laminectomy. What code
should be assigned?
A concurrent infusion occurs with
four sites and two simultaneous infusions.
one site and two simultaneous infusions.
two sites and two simultaneous infusions.
three sites and four simultaneous infusions.
A patient receives a subcutaneous injection. This injection is reported with code
A caffeine halothane contracture test for malignant hyperthermia susceptibility with interpretation and
report is assigned to code
A benign growth in the miIDle ear is called a
Code 88304 assigned for specimens with low disease or malignancy probability is an example of a
_______ pathology code.
AID-on code 96376 can only be reported when the
injection requires aIDitional time due to extenuating circumstances.
patient is under age 18.
injection of medication is performed intravenously.
service is provided at a facility.
A coder must report the examination of body fluids that occurs after the patient’s death. What codes
would be reported?
Microbiology codes (87001–87999)
Anatomic pathology codes (88000–88099)
Cytopathology codes (88104–88199)
Surgical pathology codes (88300–88399)
Debridement of an open wound, including topical application, wound assessment, and use of a
whirlpool is assigned to code
End of exam
Invasive and noninvasive cardiovascular services are assigned to codes
Injecting dye into a blood vessel to visualize abnormalities in the vessel shown on x-rays is called
Part 1 Review the following scenario. Assign the CPT code(s). AID one or more modifiers, if necessary. A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is experiencing increased urination, straining during urination, and a continual feeling of fullness after the blaIDer has been emptied. The physician performs a cystourethroscopyto examine the condition of the blaIDer and urethra, and then subsequently performs a UroLift transprostatic implant procedure using three adjustable implants. CPTcode(s): ____________________________________________ (Part 1 is worth 40 points of your overall graded project.)
Review each of the following procedures. Assign the CPT code(s). AID one or more modifiers, if necessary. 1. An established patient comes to the office complaining of migraine headaches. The physician performs an expanded problem-focused history and exam. The physician’s medical decision making is of low complexity. During the office visit, the physician also removes a benign 0.5 cm lesion from the back of the patient’s left hand. CPTcode(s): ____________ ________________________________________________________ 2. A physician removes a foreign body from the anterior chamber of the patient’s eye. An allergy statement in the patient’s medical record indicates that the patient is allergic to local anesthesia. As a result, general anesthesia is administered. CPTcode(s): ____________ ________________________________________________________ 3. A surgeon performs a total abdominal hysterectomy with partial removal of the vagina, lymph node sampling, and removal of the ovary. The coder assigns code 58200-51. Is this code correct or incorrect? Why or why not? ________________________________________________________ ________________________________________________________ Part 2b Review each of the following procedures. Assign the HCPCS code(s). 4. A patient weighing 252 pounds sustains a hip fracture. The physician prescribes a Group 2 standard single power wheelchair with a solid seat, solid back, and a sling. HCPCS code(s): _______________ ________________________________________________________
A patient comes to the emergency room complaining of a chronic migraine. The nurse administers a 1 unit injection of onabotulinumtoxinA. HCPCS code(s): _______________ ________________________________________________________ 6. A patient with chronic venous insufficiency comes to the doctor’s office complaining of leg pain. The physician prescribes two thigh-length gradient compression stockings, 45 mmHg each. HCPCS code(s): _______________ ________________________________________________________ (Part 2 is worth 40 points of your overall graded project: 20 points for Part 2a; 20 points for Part 2b.)
Part 3 Review the following coding scenario. Assign the CPTcode(s) for the wound repaironly. A patient comes to the emergency room after sustaining a 12.2-cm wound to the left side of her face. She was cut with a piece of glass during a physical altercation with her husband. The physician performs a detailed history and examination. Medical decision making was of moderate complexity. The physician repairs the facial wound without difficulty; however, the wound requires extensive cleaning to remove the glass particles beforehand. The physician also repaired a superficial 2.5-cm wound to the left ear. Both wounds were closed using 4-0 Vicryl. CPTcode(s):__________________ ___________________________________________________________ (Part 3 is worth 20 points of your overall graded project.)