CCEP Lesson 10-Mid-Term Assessment

The professional coder abides by a set of ethics related to assignment of codes that represent documentation in the medical record.  The coder realizes there are multiple federal laws that dictate various rules and regulations to coding. 

Select all that apply. 

Choose the best meaning for the prefixes, “mono-” or “uni-”

The patient has dysphagia. Choose the best description for the prefix “dys-”

The patient has menorrhagia. What does the suffix “-orrhagia” mean?

What is the medical term for inflammation of skin?

What is the medical term for x-ray of the bile ducts?

What is the medical term for abnormally fast heart rate?

What is the medical term that represents bony changes that can cause inflammation and pain in joints?

Although there are occasional exceptions to this rule, typically only one E/M can be assigned
by a given clinician on a given day (date). Common examples include a circumstance where
the patient is seen in the clinic at 9AM for pelvic pain, the patient is sent to the hospital for
labs and ultrasound, then returns at 3PM when the results of the study are ready for
interpretation and final treatment decisions. One E/M is reported today with consideration
of all clinician work. A second common one-visit-code-per-day would involve an inpatient
seen during hospital rounds in the morning, then re-evaluated at 6PM. It is also important
to remember that if Dr. B is “covering for” Dr. A, services of the two clinicians are coded as
ONE visit code.

When a patient receives an office or other outpatient E/M service on the same day that the
patient is admitted to the hospital by Dr. A (or any of her colleagues in her group practice),
all E/M services for the day are rolled into the admission E/M code.

A circumstance where two office or other outpatient E/M services MAY BE assigned by same
clinician, same day is:

Dr. Smith is a new employee of ABC Clinic. He is seeing Mr. Many Problems for the first
time today. Mr. Problems has always been seen by Dr. Jones who just recently retired from
ABC Clinic. Today, Dr. Smith performed a medically necessary history, comprehensive exam
and moderately complex medical decision making. What CPT E/M code should be assigned
by Smith today?

A patient with suspicious chest pain is admitted to observation by his doctor from ABC
Community Health Center. A comprehensive history, comprehensive exam and moderately
complex MDM are documented. After several studies and GI treatment, the pain resolved,
and the patient was sent home the same day. What E/M should be assigned?

The nurse practitioner performs a scheduled follow-up visit of a 65-year-old in a nursing

facility who is recovering from pneumonia. The patient has responded well to treatment
and no complications are noted. Which E/M code is reported?

What are the three elements of MDM for an Evaluation and Management Services (E/M)
code?

A subsection of CPT E/M codes, Prolonged Services contains interesting codes for occasional
use. Select all statements from the list below which are true for this subsection.

A patient is admitted with a head injury resulting in a loss of consciousness. On the initial
visit, the physician could not obtain history as the patient was not alert or oriented. A
thorough exam was completed. Head CT was ordered and preliminarily reviewed by the
physician. The patient needs special nursing attention which the physician spent time
explaining to the staff. The physician had to read the actual x-rays which were brought to
the floor for her review. Altogether the physician documented floor time of 80 minutes
which was chiefly devoted to coordinating the complex care of this patient. What Initial
Hospital Care should be coded today?

There are several categories of “Critical Care” codes including codes for adults, children and
neonates. All of these patients must have problems that involve significant systems failure
and serious risk. Obviously, careful description of the clinical circumstance is
expected. From a code assignment perspective, what is the most important documentation
item for determining appropriate service code(s)?

When considering time-based coding for office/other outpatient E/M services (99202-
99215), which of the following represents time that MAY be counted towards today’s
encounter?

The acutely ill patient is seen by Dr. Elizabeth Hernandez in the clinic today. After careful
history and exam, it becomes clear that the patient will need to be admitted to the
hospital. Dr. Hernandez sent the patient to the hospital for direct admission, she called the
nurses and gave specific instructions, and she ordered labs and x-rays. When the labs and
x-rays were completed, Dr. Hernandez went to the hospital, provided further examination,
reviewed all studies and ordered treatment. What type of service code will Dr. Hernandez
assign today?

In which section of CPT would you find a code for a Physical Therapy evaluation?

Which of the following represents appropriate coding for bronchoscopy with transbronchial
lung biopsies of two separate lobes?

If your physician performs and documents the service described by code 33210 and a more
significant service of the same type is performed on the same day, both should be reported
because of the (separate procedure) indication at CPT code 33210. This indication means it
should always be reported separately in addition to the CPT code for the more significant
procedure.

Which of the following are CPT modifiers? Select all correct answers.

A female patient is in your general practice for chemotherapy for her active breast cancer
(central portion of breast). She sees the oncologist for tumor management, the oncology
clinic is 75 miles away. She is having chemotherapy in your clinic today. What is your
number one diagnosis?

There are several columns in the Neoplasm Table in ICD-10. Which of the following
statements best describes “uncertain behavior”?

Which of the following are included in the ICD-10-CM, Section 1, chapter specific guidelines
for Chapter 2 – Neoplasms (C00-D49)? Select all that apply.

Patient presents today for treatment of anemia due to colon cancer. Select the answer that
correctly reflects this scenario.

Which of the following is true regarding the Anti-Kickback Act (AKS) and its consequences?

Mr. Smith continues to suffer from ataxia after having a stroke a few months ago. Which of
the following represents correct coding for his condition?

Your physician saw a patient today with a diagnosis of diabetic gastroparesis (nerves to the
stomach are damaged or don’t function, causing delayed emptying of the stomach). Which
of the following represents appropriate coding for this condition?

A 14-year-old patient is seen today with sore throat, subjective fevers and fatigue. Rapid
strep test is positive. Rest, fluids and symptomatic measures are reviewed with parents and
antibiotics are prescribed for strep pharyngitis. The PA identified the diagnosis as
streptococcal pharyngitis. Which of the following represents appropriate coding?

Mrs. Jones has been having increasing pain in her right knee recently. She was treated by
me a few years ago for a lower femur fracture suffered in a skiing accident and has since
developed traumatic arthritis in that knee. She will be referred out for physical therapy and
will follow-up in a month. Which of the following represents correct coding for her condition
today?

A three-year-old patient is brought in by Mom for evaluation of vomiting, diarrhea and
fevers since yesterday. Child is alert and cooperative with no signs of dehydration. Mom
will push fluids and bland diet was discussed. Suspect viral gastroenteritis. Mom was
instructed to follow-up if any symptoms worsen or if child does not improve by
Friday. Select all appropriate code/s for today’s visit.

Joe is seen today for review of recent lab workup. The physician provides the usual
education on diet and exercise and counsels Joe on the importance of follow-up for his new
diagnosis of Type II diabetes mellitus. Which of the following should be coded for Joe’s
visit?

Your internist saw a patient in the hospital today and turned in the following information for
coding: Subsequent inpatient care: 99232, Diagnosis: severe streptococcal sepsis. Which of
the following represents appropriate ICD-10-CM coding for this service?

Assign a diagnosis code for a patient with adenoma of the ileum.

Which of the following Federal fraud and abuse laws prohibits physicians from making
referrals for certain designated health services to entities with which they have financial
relationships?

What is the ICD-10-CM code for Skene’s gland abscess?

CPT codes for procedures and services that are reported on a billing claim must be linked to
the ICD diagnosis code(s) that justify the need for the services or procedure. This is a
critical “linking” activity between the service and the diagnosis because billed items must
include validation for which answer below:

ICD-10-CM codes are categorized as a (the) “diagnosis code set”. These codes identify
diagnoses. The “code set” that identifies services is called the HCPCS Coding System (or
code set). This code system/set includes which types of codes?

Which Appendix in CPT contains official descriptions for all CPT modifiers and many HCPCS
modifiers?

Which of the following are true when using modifier 25?

There are official symbols in your CPT book. The symbol which is a plus sign (+) means:

CMS’s NCCI or CCI edits are used to identify which of the following:

Which of the following is true?

From the list below, identify the many ways CMS’s Physician Fee Schedule RVU data base
file (The Base) is useful to coders.

An established patient is seen with a new complaint of rectal bleeding. A moderately
complex medical decision-making is completed during the evaluation. During this encounter
the physician needed to do a flexible sigmoidoscopy to evaluate this bleeding. How would
the service be coded?

A patient was seen two days ago for evaluation of an abscess on his back. He was put on
antibiotics and instructed to return today for a recheck. It was actually worse today, so the
physician performed an I&D. What services should be coded today?

A 5-year-old came into the clinic after falling off the monkey bars. He had sustained a scalp
laceration. He had a complete evaluation including mental status check. The wound was
decontaminated and sutured. What would be coded today?

The patient had warts frozen off her hand three weeks ago. She returns today for retreatment. What would be coded today?

The patient comes in with knee joint pain and has x-rays and blood work as well as a
complete evaluation. The doctor prescribes an anti-inflammatory medication and does a
knee joint injection with cortisone. What would be coded today?

Two weeks after a cortisone injection in the knee was done by the doctor, the patient
returned improved but with continued knee discomfort. The physician agreed to re-inject
the knee. What would be coded today?

A patient is evaluated in the ER by a surgeon. The patient has a gunshot wound to the
abdomen and the surgeon will take the patient to surgery immediately. What would be
coded today?

A patient is seen with gallbladder disease. The surgeon schedules surgery for next
week. What is coded today?

The patient was evaluated last week, and gallbladder surgery was planned. The patient is
in the office today for his H&P as surgery will be done first thing in the morning. What is
coded today?

The patient will have hernia surgery tomorrow. Your doctor has been asked to see the
patient today to clear the patient for the surgeon. What will your physician code today?

What does debulking refer to in the context of pathology?

The patient was seen by the dermatologist for a brown lesion on her right arm. She
described it as a birth mark. She wanted to have it removed. Physician excises a benign
neoplasm on the skin of the arm. The total size including the lesion and its narrowest
margin measured 0.9 cm. Assign the surgical CPT code(s).

An established patient was in two weeks ago for management of HTN and DM. The patient
is bothered by a verruca. The physician excises a verruca measuring 2 cm on the skin of
the face. He had to excise deep into the subcutaneous tissue. He closed the deep layers of
subcutaneous tissue with an absorbable suture. The skin closure was accomplished with 4-
0 nylon; the skin closure measured 2.7 cm. Assign the CPT code(s) for this minor surgical
procedure. (No modifiers)

What is the definition of histology?

Using local anesthesia, a physician excises a 1.2 cm malignant squamous cell carcinoma in
the scalp skin just above the left ear and closes the skin with a carefully planned Z-flap
closure (Adjacent tissue transfer). Assign the diagnosis code(s).

A physician excises a malignant squamous cell carcinoma on the skin of the scalp. Excision
of this lesion required a 10 square centimeter defect which could not be closed with a
simple closure. This 10 sq cm defect required a Z-plasty closure. Assign the CPT code(s) for
the surgical procedure.

What is the function of a titer test?

A 25-year-old patient came in for treatment of a lesion she thought was a common wart.
Upon examination the PA said it was an actinic keratosis. Liquid nitrogen was used to freeze
(destroy) the lesion. Assign the surgical CPT code(s).

52-year-old female returns today after examination of breast lumps and aspiration of left
breast cyst that was sent to pathology last week. Today, an open incisional biopsy of a
breast lesion was accomplished. Assign the surgical CPT code(s) for today’s procedure.

Which term refers to ‘a substance that is measured, usually a component of body fluid or
other body substance’?

Which CPT® code is used for direct optical observation of presumptive drug screening?

When are definitive drug tests typically performed?

A 68-year-old patient presents today for his “Medicare physical”. This patient had a
Welcome to Medicare Physical two and a half years ago. He forgot to come in for any
preventive services last year, but today wants “that Medicare physical thing that is free”.
The clinician is handed an article from a magazine that describes a wellness service that
includes a personalized prevention plan of service. The clinician provides and documents all
necessary components of the preventive service. Assign the appropriate HCPCS code for this
service.

Which entity issues the Advance Beneficiary Notice of Noncoverage (ABN) to Medicare
beneficiaries?

What CPT code is assigned by a pathologist who examines the tissue provided from a
conization procedure on the cervix? His exam includes both gross and microscopic methods
of surgical pathology.

When would a qualitative test be preferred over a quantitative
test?

A patient is seen again in follow-up for her left arm 3rd degree burn (10% of body surface
area). Using sterile technique, the LUE burns were cleaned and redressed, patient care
instructions given. Return in three days. Enter the CPT service code only.

Which CPT® code range is used for therapeutic drug assays?