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23812501714501350 West Street ? Pittsfield, Massachusetts 01201 ? 413-499-4660 ? HYPERLINK "" berkshirecc.eduPittsfield MA 01201001350 West Street ? Pittsfield, Massachusetts 01201 ? 413-499-4660 ? berkshirecc.eduPittsfield MA 01201Basic Procedural Coding Final Exam May 12,2014Choose the best answer for each of the following questions. Questions 26-30 cover HCPCS Level II coding.The CPT manual is published and maintained by:American Medical AssociationDepartment of Health and Human ServicesCenters for Medicare and Medicaid ServicesAmerican Hospital Associationa.43200b.43234c.43235d.43260A patient was taken to the endoscopy suite. The endoscope was passed into the esophagus and continued into the stomach and into the duodenal bulb. Based on this documentation, what CPT code would be selected to represent this procedure?The physician documents that she changed the cardiac pacemaker battery. In CPT, the battery is called a(n}:GeneratorElectrodeDual systemCardiovertera .51610, 74450-26b.51610,74450c.74450-26d.74450A patient undergoes a retrograde urethrocystogram . The same physician performs both the injection and the supervision and interpretation. What is the correct CPT code assignment for this physician?a.88300,88305b.88305c.88307d.88300, 88307The pathologist performed a gross and microscopic examination of a kidney biopsy. What is the correct CPT code assignment?A patient was seen by his family practitioner two years ago. A cardiologist in the same group practice now sees this patient for the first time. For E/M code selection for the cardiologist, the patient would be classified as:Newb. EstablishedPatient is seen by her primary care physician for headaches. The physician performs a physical exam, reviews data, and outlines management options. Which of the following key components is missing from this case?TimeHistoryMedical decision makingCoordination of careThe CPT book is updated: a. As neededFor use in JanuaryMonthlyFor use in OctoberFor the December 7,2012 patient encounter, the hospital will submit codes on what billing form?UB-04HCFA-1500CMS-1500UHDDSa.49496b.49501c.49507d.49521Reference codes 49491-49525 for inguinal hernia repair. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia (patient is 47 years old)?The surgeon performed a procedure that is unfamiliar to the coder and he or she is having trouble locating an appropriate CPT code. What should be the coder's next action?Assign an 11Unlisted procedure" codeCall the insurance companyCall the surgeon's officeResearch the description about the procedureArthrocentesis, ring finger of left hand. Appe nd the correct CPT/HCPCS modifier.LTb. 26c.F1d. F3a.11400, 11402, 11402b.11056c.11200d.17000,17003,17003What is the correct CPT code for electrosurgical removal of three (3) nevi of the arm (size approximately 2.0cm,1.5cm,0.5cm)?The patient has a total abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes:58150 and 58700. The assignment of these two codes togethe r would be referred to as:Global packingUnbundlingMaximizingOptimizationa.00474b.00406c.00404d.00400,00406A patient with Medicare undergoes a modified radical mastectomy. What would be the correct CPT code assignment for the anesthesiologist's services?What is the correct code assignment for bilateral EMG of cranial nerves?a.95867b.95867 50c.95868d.95868 50a.96401b.96372c.96374d.96369What is the correct CPT code assignment for IM injection of Leukine?Which of the following is a key factor for selecting a correct code for preventive medicine services?Age of patientCoordination of carePhysician timeReview of systemsThe RBRVS system used for physician services reimbursement was developed with goals. Which of the below is not one of the stated goals?To establish a fair and equitable approach to compensating physiciansTo enhance cost effective medical careTo allow for quality measure payment incentivesTo eliminate distortions in current feesSelect the appropriate CPT code(s) for the following surgical scenario: Preoperative Diagnosis: Mass, superior aspect of the left breast Postoperative Diagnosis: Benign mass, superior aspect of the left breast Operation :ExcisionThe patient is a female who has had a lump palpable over the superior aspect of her left breast for the past several months.Surgical Technique:The patient was lying down supine. The left breast was scrubbed with betadine scrub and paint and draped in the classical fashion. The patient has a transverse incision near where we are feeling this lump,which was over about the 11o'clock position,high up in the superior aspect of the left breast. A transverse incision was made underneath the breast tissue and adipose tissue was completely taken out. Hemostatic was ascertained with electrocoagulation. The wound was closed using interrupted 3 0 Vicryl sutures, the skin wasclosed with subcuticular running 5-0 Dexon. Benzoin and Steri-Strips and a pressure dressing were applied. All counts were normal.19120-LT b. 19125-LTc. 19120-LT, 12031 d. 19125-LT,12031A patient is seen in the emergency room with a foreign body in his right eye. A slit lamp exam shows a foreign body approximately 2 to 3 o'clock on the edge of the cornea. This foreign body appears metallic. Iris is intact. There are no cells in the anterior chamber. Two drops of Alcaine were used in the right eye. Foreign body was removed without difficulty . Choose the appropriate CPT code(s) .67938-RT b. 65220-RT c. 65235-RT d. 65222-RTThe radiologist provides only the supervision and interpretation of a hysterosalpingography .What is the correct CPT code assignment for the radiologist?a.74740b.74740-26c.58340, 74740d.58340, 74740-26A physician draws blood to test for levels of T3 on a non-Medicare patient. The blood is sent toan outside laboratory for analysis. When billing for the physician's services, which of the following modifiers should be appended to the CPT code 84480?52b. 59c.90d. 91An EGD:involves an examination of the abdomen with a scopeinvolves an examination of the upper Gl tract with a scopeinvolves an examination of the esophagus, stomach, and duodenum and/or jejunum using a scopeall the aboveAccording to the CPT, the concise statement generally in the patient's own words that describes the reason for the encounter is known as:SymptomChief complaintHistoryConcurrent careWhat is the correct HCPCS LevellI code for two feet of oxygen tubing?A4615A4616 X 2 c. A4615 X 2d. A4616Screening colonoscopy for a Medicare patient with history of colon cancer. a. G0105b. G0106 c. G0104 d. G0121Pacemaker, single chamber, rate-responsive (implantable) with lead, pacemaker, other than transvenous VDD single pass.C2620b. C1786, C1898 c.C1786d. C1786,C1900A HCPCS Level II code that is highlighted in yellow indicates what :There is a quantity alert related to the codeThe code is newThe code should not be usedThe code may or may not be paid subject to a carrier's discretionInjection,Heparin sodium, per 1000 units.Jl642Jl640 c. J1644d. J1642 X 10True or False Compliance programs are important for ensuring consistency in coding and billing. When coding CPT it is ok to use a code that may not exactly describe the service or procedure performed. Coding and chart reviews are never necessary.Appendix D in CPT contains a comprehensive summary of CPT additions, deletions, and revisions since last year. Physical status modifiers are for use only on anesthesia CPT codes. Modifier 59 can be used on any CPT code including unlisted codes such as 29999. CPT 99212 would be assigned if a patient is seen for a cough and sore throat. The physician performs a problem-focused history, expanded problem-focused examination, and medical decision-making is straightforward . CPT 15820-E2 would be assigned to a Medicare patient's bill when the physician performs a blepharoplasty on the left upper eyelid. Provider and physician services are reported on the CMS-1500 form. When coding from CPT you should always identify what section the service will be coded from and follow the guidelines for that section of CPT only.Match the following:Modifier P4 A . Instrument to view inside the body1119F Initial evaluation for conditionB. Indicates the CPT code includes moderate sedationModifier 73 Indicates that a particular event changed the serviceEndoscope Corrects abnormal alignment of eyesStrabismus Surgery E. Located in anesthesia section of CPT46. L3381 F. Key component of E/M CPT codeCircled bullet G.CPT modifier approved for only hospital outpatientMedical decision making H.Tempora ry codes representing emerging technology. Category Ill codes I. Category II codeModifier J . National codeBonus Questions- code the following cases using CPT or HCPCS Level II as appropriate including modifiers. You must get the entire case correct for bonus points to count.Libby was thrown from a horse while riding along the side of the road;a truck that honked the horn as it passed her startled her horse. The horse reared up, and Libby was thrown to the ground. The condyle of her left tibia was fractured and required insertion of multiple pins to stabilize the defect area. A Monticelli multiplane external fixation system was then attached to the pins. Code the placement of the fixation device only.Operative ReportProcedure: Excision of back lesionIndications for Surgery: The patient has an enlarging lesion on the upper midback.Findings at Surgery: There was a S-cm, upper midback lesion.Operative Procedure: With the patient prone, the back was prepped and draped in the usual sterile fashion. The skin and underlying tissues were anesthetized with 30mIof 1% lidocaine with epinephrine. Through a S-cm transverse skin incision,the lesion was excised . Hemostasis was ensured. The incision was closed using 3-0 Vicryl for the deep layers and running 3-0 Prolene subcuticular stitch with Steri-Strips for the skin. The patient was returned to the same-day surgery center in stable postoperative condition. All sponges, needle,and instrument counts were correct. Estimated blood loss is Oml.Pathology Report Indicates: Dermatofibroma, skin of back.This work was developed by Berkshire Community College through the Massachusetts Community Colleges and Workforce Development Transformation Agenda (MCCWDTA) . “This workforce solution is 100% funded by a grant awarded by the U.S. Department of Labor, Employment and Training Administration, TAACCCT grant agreement # TC-22505-11-60-A-25.The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. Massachusetts Community Colleges are equal opportunity employers. 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