1. 7-year-old riding his bike struck a tree stump throwing him off his bike. He received multiple lacerations. He had a 3 cm dermis laceration on his scalp with two 0.5 cm lacerations on his face. His right arm had a 5 cm laceration and right leg has a 5cm laceration. The physician stapled the laceration for the scalp. Physician used steri-strips (adhesive strips) to close the wounds on the face. The legs and arms were cleaned by heavily irrigating them with normal saline and removal of embedded debris performed on both wounds, followed with a single-layer closure. Select the repair codes to report.

2. A 55-year-old male presents in the office with an ingrown toenail on the right and left foot. The procedure was discussed in detail and the patient elected to have it performed. The right foot was prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2 percent lidocaine and .05 percent Marcaine. A mini-tourniquet was placed around the toe for hemostasis in which part of the nail plate and maxtrixectomy were performed. Phenol was then applied, the toe was then flushed. Tourniquet was released and dressing applied. At this time the patient elected to only have one performed and will return in two weeks for the left foot. Code the procedure.

3. Procedure Diagnosis: Basal cell carcinoma, left chin. Procedure:Wide local excision of 3.0 cm with 0.3 cm margin basal cell carcinoma of the left chin with a 4 cm closure. Procedure: The patient’s left chin was examined. The site of intended excision was marked out. The site was then prepped. The patient was then prepped and draped in the usual fashion. A 15 blade scalpel was then used to make an incision in the previously marked site. It was carried down to the subcuticular fat. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The hyfrecator was used for hemostasis. The wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The skin closure was in a running subcuticular fashion. Steri-Strips were then applied. What are the procedure and diagnosis codes?

4. The physician removes a tumor from the patient’s neck using the Mohs micrographic surgery technique. During the first stage, the physician takes four tissue blocks and reviews them under a microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where the tumor is still present. The physician removes two additional tissue blocks. What are the appropriate CPT® codes for reporting the procedure?

5. This 45-year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried down thru the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL(inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4.5 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was then closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What is the correct CPT® code for this service?

6. Postoperative Diagnosis: 1. Impingement syndrome left shoulder. 2. AC synovitis left shoulderProcedure: Arthroscopy with subacromial decompression and AC resection left shoulder. The patient was placed supine on the operating table and prepped and draped in usual sterile fashion. The scope was introduced from a posterior portal and the joint was inspected. The rotator cuff looked in good condition. The articular surfaces looked good. The bicep also was in good condition. We went subacromially and there was a fair amount of bursal inflammation encountered. We did a thorough bursectomy. A ligament chisel was used to take down the coracoacromial ligament. A high-speed bur was used to do a subacromial decompression going from lateral to medial. We took off about 2 cm of bone anteriorly. Part of the acromion is surgically corrected. Next we opened the AC joint through an anterosuperior portal. High-speed bur was used to grind off about 10 mm of distal clavicle because there was a large subchondral cyst and we wanted to get this totally ground out, which we did. Then the wounds were irrigated out, Nylon suture was placed in our portals. The patient was placed in a bulky dressing and an arm sling and sent to the recovery room in stable condition. Code the procedure.

7. The patient presented for medial meniscal tear left knee. Arthroscopy with partial medial menisectomy left knee and arthroscopic picking (drilling pick holes) of the lateral femoral condyle left knee was performed. Code the procedure and diagnosis codes.

8. A 47-year-old patient was previously treated with external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned, and repositioned. Intrafragmentary compression was applied and three screws and the harvested bone graft were packed into the fracture site. What are the correct codes for this diagnosis and procedure?

9. Patient had a dual chamber pacemaker put in two days ago. He is having problems with the battery and the cardiologist found that it is malfunctioning. He is taken to the operating suite to replace the pacemaker battery. What CPT® and ICD-9-CM codes are reported?

10. 2-year-old male requires a central venous catheter. Using xylocaine local anesthesia a percutaneous approach is used in the neck and venous access is achieved. A subcutaneous tunnel is created from the anterior chest wall to the venotomy site and the catheter passed through the tunnel. The CV catheter is then placed at the superior vena cava and sutured in position. Which procedure code is used?

11. Pre-Operative Diagnosis: Right lung mass Indications: Patient with a mass in the right lung mass identified on routine X-ray presents for bronchoscopy and biopsy. Procedure: The patient was brought to the endoscopy suite and the mouth and throat were anesthetized. The bronchoscope was inserted and advanced through the larynx to the bronchus. The bronchoscope was introduced into the right bronchus. Using fluoroscopic guidance, the tip of the bronchoscope was maneuvered into the area of the mass. A closed biopsy forceps was passed through the channel in the bronchoscope and then through the bronchial wall. A tissue sample was obtained. There were no other abnormalities appreciated in the right side and the bronchoscope was removed. The specimen was labeled and sent to pathology for testing. The patient tolerated the procedure well. Pathology indicates that the lung mass is cancer. What are the procedure and diagnosis codes?

12. Preoperative Diagnosis: Lower left inguinal pain Postoperative Diagnosis: Inguinal herniaProcedure: This 30-year-old patient presented with lower left inguinal pain and on examination was found to have a left inguinal hernia. The decision to perform a left inguinal hernia repair was made. The procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mm Hg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well-defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well. What are the correct procedure and diagnostic codes?

13. Preoperative Diagnosis: Chronic tonsillitis. Chronic adenoiditis. Postoperative Diagnosis: Same.Procedure: Tonsillectomy and adenoidectomy. Patient is a 24-year-old male who was taken to the operating room and put under IV sedation by the anesthesia department. An initial curettage of adenoids was done and packing was placed. The left tonsil was then identified and dissected out extracapsular and removed with scissors. Hemostasis was maintained by packing the left tonsil. Next, the right tonsil was identified and incision was made. Dissection was done extracapsular and the right tonsil was then removed. Both the right and left tonsil were sent as specimens as well as adenoid tissue. What are the procedure and diagnosis codes?

14. Diagnostic  esophagogastroduodenoscopy of the esophagus, stomach, and duodenum was performed after esophageal balloon dilation (less than 30 mm diameter) was done at the same operative session. Code the procedure(s).

15. A 46-year-old female with history of cervical carcinoma underwent placement of an ileal conduit, with subsequent development of left hydronephrosis. A retrograde ureteral catheter was recently placed. She returns today for catheter exchange. Patient was placed in the supine position. The ileal conduit was accessed. The existing catheter was removed over a guidewire and replaced with a similar 10 French 50 cm long locking pigtail catheter. Contrast was injected for monitoring, confirming good position of the catheter placement. IMPRESSION: Left retrograde ureteral catheter exchange via the ileal conduit.

16. 70-year-old with significant pelvic prolapse and grade IV cystocele who has failed previous primary repair and is status post hysterectomy. She presents for anterior repair and colpopexy. Procedure: Patient placed in the dorsal lithotomy position and general anesthetic was induced without problems.  A midline incision is made from just above is made from just above the bladder neck to the vaginal cuff. She is noted to have a grade IV cystocele. Vaginal flaps were dissected to the level of the pubocervical fascia. Her vaginal mucosa was in good condition but near the urethra and bladder neck it was a little thinner. There is significant scarring on the left side from previous procedures. Ishcial spine is identified and swept fiber fatty tissue off of the sacrospinous ligament bilaterally. No scarring or adhesions in this area. Anterior needles were passed into place on the elevate mesh and these were fixed in a manner similar to the MiniArc. They were passed along just below the bladder neck toward the obturaton foramen and fixed in place. An anterior support was created without tension at the viscourethral junction. Apical needles were then used to pass the apical arms into place. There were gently fixed into place along the sacrospinous ligament approximately 2cm away from the ischial spine. This was done bilaterally. They passed in a single pass and were fixed in place confirmed by gentle tugging on both arms. Three Vicryl sutures had been placed and the vaginal apex were then passed over into the mesh and tied down. The apical arms were placed through the eyelets of the mesh and passed down toward the sacrospinous ligament bilaterally to create good apical support. Eyelet fasteners placed bilaterally and mesh arms trimmed providing excellent apical and anterior support. Vaginal mucosa was closed and vaginal packed placed. No complications. What CPT® code(s) describe(s) this procedure?

17. Preoperative Diagnosis: Right hydronephrosis Postoperative Diagnosis: Right hydronephrosisOperation: Cystoscopy and right retrograde pyelogram Procedure: Patient prepped and draped in the dorsolithotomy position. Placed under general anesthesia a 23 French cystoscope was passed into the bladder. No tumors were visualized. Urine from the bladder was sent for urine cytology. Then a 6 French access catheter was passed into the right uretal orfice. Contrast was injected and there were no filling defects noted. There was no fixed tumor and no stone. There was mild hydroureteral nephrosis against the bladder. There was a narrowing at the UVJ no abnormalities. Renal pelvis barbotaged with saline and renal pelvis urine sent to pathology for urine cytology. After the retrograde pyelogram was performed the access catheter was removed.

18. 5-year-old male has diminished hearing in the left ear due to chronic otitis media. He has had hearing aid prosthetic devices in the ear which have resulted in additional infections. Parents have decided on an osseointegrated implant to restore hearing. The mastoid cortex is exposed. Spiral drilling is performed to create a pilot hole. The stem of the titanium pedestal is placed in the tunnel adjacent to the cochlea and abutment subsequently secured to the fixture. Which CPT® code should be used?

19. The physician performs a right thyroid lobectomy. The patient was prepped and draped. After adequate general anesthesia, the neck was incised on the right side and sharp dissection was then used to cut down onto the strap muscles and sternodcleidomastoid muscles. The strap muscles were separated and transected on the right side. A small thyroid lobe was visualized and dissected free. There was no evidence of a tumor. The wound was closed with 3-0 interrupted Vicryl for the platysma, 4-0 Vicryl for the deep tissues and 6-0 fast absorbing gut for the skin. Code the encounter.

20. PROCEDURE: Bilateral lumbar medial branch block under ultrasound guidance for the L3, L4, L5 medial branches injecting the L4-L5, L5-S1 facets for diagnostic and therapeutic purposes. PROCEDURE: The patient was placed in the prone position and automated blood pressure cuff and pulse oximeter applied. The skin entry points for approaching the anatomic target points of the bilateral segmental medial branches or dorsal ramus of L3, L4, L5 were identified with a 22.5 degree from an ultrasound view and marked. Following thorough Chloraprep preparation of the skin and draping and 1% lidocaine infiltration of the skin entry points and subcutaneous tissues, a 22 gauge 6" spinal needle was placed under ultrasound guidance for the L4-L5 and L5-S1 facet joints. At each joint 1 mL consisting of 0.5% bupivacaine and Depo-Medrol was injected. A total of 80 mg of Depo-Medrol was given in both sides. Which CPT® codes should be used?

21. 15-year-old male is seen by the pediatrician in his office for having excessive thirst and frequent urination. A urine dip is performed showing +3 sugar and with some ketones. Glucometer reading is done showing a blood sugar range of 500-600. Physician sends the patient with his father to the hospital for emergency admission and insulin drip. The pediatrician meets the patient at the hospital and performs a detailed history, comprehensive exam and a high complexity medical decision making. How should the pediatrician code the E/M service for this visit?

22. A 62-year-old female returns to a family practice having shortness of breath, nausea and diaphoresis. It has been two years since her last visit to the practice. An comprehensive history is documented. A comprehensive general multisystem examination of eight organ systems is performed. An EKG, chest X-ray and labs are ordered. The physician also orders to have her records sent from her cardiologist. The medical decision making is high. The patient is diagnosed with exacerbation of congestive heart failure. What is the correct evaluation and management service for this encounter?

23. This morning a 48-year-old is placed in observation status from the emergency room with severe diarrhea and extreme thirst. The physician performs a comprehensive history, comprehensive examination and determines the patient is suffering from dehydration. The physician places the patient on IV saline 500 ml and conducts normal saline hydration for a couple hours. The medical making decision making is of moderate complexity. Patient is discharged home in the late evening on the same day and is told to return if symptoms occur again. The E/M service(s) for this encounter is:

24. Physician was called to the floor to evaluate a 94-year-old that had sudden weakness, hypotension, and diaphoresis. Physician found the patient in mild distress and dyspneic. Her BP 101/60, pulse 85. Labs were still pending. Arterial blood gas was drawn and interpreted by the physician. She was admitted to CCU for Acute Antero-lateral MI and hypotension. Physician spent total critical care time of 65 minutes. Select the appropriate CPT® code(s) for this visit:

25. The anesthesiologist performed MAC (monitored anesthesia care) for a patient undergoing an arthroscopy of the right knee. Code the anesthesia service.

26. General anesthesia is administered to a 9-month-old undergoing a tracheostomy. Code the anesthesia service.

27. 65-year-old woman is one year post with B-cell non-Hodgkin’s lymphoma. She is having recurrent fever and pain. Tumor recurrence was confirmed by CT studies and chest X-ray. She has failed prior chemotherapy and radiation treatments. A new treatment is being contemplated and she is referred for a radiopharmaceutical distribution imaging as a requirement before starting this new treatment. The provider injects small amounts of gamma-emitting radioactive material paying particular attention for potential reaction. A gamma camera is used to take planar images of the whole body for three days. Three sets of image data are interpreted. Qualitative assessment of distribution and determination of treatment with monoclonal antibody are provided. A report is dictated and placed in the medical record. Which CPT® code is reported?

28. Due to an elevated CEA level two years following a colon resection, the patient’s oncologist ordered a diagnostic liver ultrasound. Which radiology code is reported for this encounter.

29. 52-year-old male has a 3.2 cm metastasized lung cancer in his left upper lobe. The tumor can not be removed by surgery due to the patient having severe respiratory conditions. He will be receiving sterotactic body radiation therapy management under image guidance. There is a delivery of 25 Gy for four fractions under direct supervision of the radiation oncologist. The patient’s treatment set up is assessed to manage the execution of the treatment to make any adjustments needed for accuracy and safety. The oncologist reviews and approves all the images used to locate the tumor and images of fields arranged to deliver the dose.  What CPT® and ICD-9-CM codes should be reported?

30. A 42-year-old has a lesion on his pancreas. The physician passes the biopsy needle through the skin and removes tissue to be sent to pathology. Fluoroscopic guidance is used to obtain the biopsy. Physician's report and interpretation is placed in the record. Code this encounter.

31. Patient is undergoing in vitro fertilization to get pregnant. Following the retrieval of follicular fluid from the patient, the physician uses a microscope to examine the fluid to identify the ooctyes. What is the code for the laboratory service?

32. 22-year-old comes into the Emergency Department with convulsions. The ED physician orders a drug screening without identifying any specific drug class to be tested. The lab runs a multiple drug classes screening using an immunoassay. The lab report comes back positive for alcohol and benzodiazepines. The ED physician then orders a confirmatory test to be performed by the lab to confirm both positive results. What CPT® codes are reported?

33. A pathologist performs a comprehensive consultation and report after reviewing a patient’s records, specimens and official findings from other sources. What is the correct code?

34. Photodynamic therapy involving application of light externally to destroy premalignant lesions on the lower lip was provided to a 63-year-old patient. Code the encounter.

35. A four-year-old patient presents with pain in the left forearm following a fall from a chair. The injury occurred one hour ago. Her mom applied ice to the injury but it does not appear to help. The ED physician performs a detailed history, expanded problem focused examination and medical decision making of moderate complexity. An X-ray is ordered, which shows a fracture of the distal end of the radius as read by the radiologist. The ED physician consults with an orthopedic surgeon. The ED physician performs moderate conscious sedation with Ketamine for 30 minutes. The fracture is reduced and cast applied by an orthopedic surgeon. The child was monitored with pulse oximetry, cardiac monitor and blood pressure by the ED physician frequently. The patient was discharged with a sling and requested to follow up with the orthopedic surgeon. Code the services performed by the ED physician.

36. In the inpatient setting, the psychiatrist provides psychotherapy for 30 minutes to affect a change in the patient’s maladaptive behavior. What is the procedure code?

37. CKD is a disease of which system?

38. A person who has nephritis has inflammation in what location?

39. What is ascites?

40. Which of the following is a disorder of the facial nerve?

41. Complete this series: Pulmonary, Aortic, Mitral, and ________are valves of the heart.

42. Which of the following terms is one who has an overload of sodium?

43. The term paracentesis found in CPT® code 49082 means:

44. A 25-year-old is brought to the burn unit being rescued from a burning house. She sustained 25% second degree burns on her anterior trunk and back and 20% third degree burns on her legs and arms. Total body surface area burned is 45%. What ICD-9-CM code is reported for the burns classified according to the extent of body surface involved?

45. The patient is a 75-year-old woman who is here for follow-up after an incident last week in which she had an FB lodged in her throat. An emergency esophagoscopy was performed and the piece of hamburger meat removed and biopsy performed. She is positive for Barrett’s esophagus. She has GERD which is currently being treated by medication and is here today to be evaluated for photodynamic therapy.What diagnosis codes should be reported for today’s visit?

46. A 78-year-old patient, with known arrhythmia, presented to an outpatient clinic for the insertion of a cardiac event recorder. What is the proper HCPCS Level II code for this device?

47. The physician performed manipulation of a closed fracture of the distal radius on a 12-year-old male. He placed a short arm fiberglass cast. What is the HCPCS Level II code for the supply?

48. Which of the following statements regarding the ICD-9-CM coding conventions is TRUE?

49. Which modifier should be append to a CPT®, for which the provider had a patient sign an ABN form because there is a possibility the service may be denied because the patient’s diagnosis might not meet medical necessity for the covered service?

50. What is the patient’s right when it involves making changes in the personal medical record?