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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q71-Q76):

NEW QUESTION # 71
Assign the appropriate CPT codes for the following surgical note: A 15-year-old patient is being treated for obstructive sleep apnea and adenoid tissue hypertrophy. After being placed under general anesthesia, a dental mirror is placed in the oropharynx to allow visualization of the nasopharynx. Suction electrocautery is used to remove the adenoid tissue that regrew after the initial adenoidectomy. Attention is then turned to the tonsils. The plane of tissue between the tonsillar capsule and the underlying muscles are cauterized, and the tonsils are removed. Bleeding is controlled by silver nitrate and gauze packing. Procedure is completed without complications, and patient is discharged to recovery.

A. 42826, 42831-59, 135.2, G47.33
B. 42821, G47.33, 135.2
C. 42999, 647.33, 135.2
D. 42826, 42836-51, 135.2, G47.33

Answer: B

Explanation:
An adenoidectomy and a tonsillectomy were performed in this surgical encounter (the root word -ectomy literally means the surgical removal of an anatomical structure). The adenoidectomy was done first and, if coded alone, would fall under one of Evo categories: primary (CPT 42830-
42831) or secondary (CPT 42835-42836). A primary adenoidectomy refers to the initial removal of the adenoid, whereas a secondary adenoidectomy occurs when adenoid tissue that was once removed has grown back. Because the documentation states that "the adenoid tissue ... regrew after the initial adenoidectomy," a coder can infer that this procedure is secondary. However, distinguishing betvveen the two procedures is not necessary when done in conjunction with a tonsillectomy because the procedures are bundled into two nonspecific CPT codes (42820 and
42821). Billing for an adenoidectomy and a tonsillectomy separately, as shown in answers A and C, is considered unbundling and is not allowed under the Correct Coding Initiative (CCI) edits.
Regarding the sequencing of the diagnoses, ICD-IO-CM guidelines state that when V,vo conditions meet the definition for principal diagnosis, either can be sequenced first In this scenario, J 35.2 or G47.33 could have been first listed because the procedures were to resolve both conditions in the same encounter.

NEW QUESTION # 72
A patient tests positive for coronavirus (SARS-CoV-2) and bronchitis after presenting with a cough. What diagnosis code(s) should be reported?

A. U07.1,J40, Z20.828
B. 140, 897.29, R05.9
C. U07.1,J40
D. J40,B97.29, Z20.828

Answer: C

Explanation:
The underlying condition should always be first listed, which in this case would be the SARS- COV-2 infection (U07.1). The description of the code then prompts the biller to list the manifestations, which would be the unspecified bronchitis 040). In answer A. cough would not be coded as a symptom because the patients illness is confirmed. Answers C and D, which include a suspected exposure code, can also be eliminated because this code is used only when the existence ofthe illness in the patient is unknown or negative.

NEW QUESTION # 73
Medical necessity has been established if a laboratory runs additional testing on a urine sample to determine the presence of a drug class that was not in question during confirmation testing.

A. False
B. True

Answer: A

Explanation:
The statement is false. To establish medical necessity, the provider/laboratory must indicate the drug class they are screening for prior to the test.

NEW QUESTION # 74
Which statement is true regarding the diaphragm?

A. It forms tendons, ligaments, cartilage, and fat.
B. It performs an important function in blood flow.
C. It separates the thoracic cavity from the abdominal cavity.
D. It is a collection of organs held together by connective tissue.

Answer: C

Explanation:
The diaphragm separates the thoracic cavity from the abdominal cavity by means of skeletal muscle. When the diaphragm contracts, air is drawn into the lungs. It therefore plays a key role in respiration. The mediastinum is surrounded by loose connective tissue and contains several anatomical structures including the heart. Connective tissue is distributed throughout the body to form tendons, ligaments, cartilage, and fat.

NEW QUESTION # 75
A 79-year-old female patient is admitted to a skilled nursing facility for continued monitoring as she completes her course of antibiotics for bronchitis. Upon admission, a nurse practitioner spends 20 minutes with the patient, performing an evaluation of recovery and rebuilding of stamin a. On day 3, the patient's physician completes an initial comprehensive assessment and determines the patient is recovering well on her current dosage of antibiotics. What CPT code should be reported on day 3?

A. 0
B. 1
C. 2
D. 3

Answer: C

Explanation:
CPT defines an initial nursing facility service (NFS) as "the first encounter with the patient by the admitting physician to nursing facilities." Although the patient can be evaluated and treated by other medical staff in the meantime, only the physician responsible for the admission may report the initial comprehensive visit (99304-99306). If other medical personnel do provide treatment, those visits would be reported using the subsequent nursing facility care encounter codes (99307-
99310). Nursing facility care services require a medically appropriate history and/or examination, and a review of medical decision making. In this scenario, the number and complexity of problems addressed at the encounter is low (one stable, acute illness), the amount and/or complexity of data reviewed or analyzed is straightforward (minimal or none), and the risk of complications and/or morbidity or mortality of patient management is moderate (prescription drug management). After considering that the patient is established, the level of complexity for the visit is considered low and the encounter should be reported with CPT code 99304.

NEW QUESTION # 76
......

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