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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q106-Q111):

NEW QUESTION # 106
What must the documentation for a consultation include?

• A. Documentation of assumption of care, who requested the consultation, and the consultingproviders, professional opinion
• B. Who requested the consultation, the consulting providers, professional opinion, and awritten report that is provided to the referring physician
• C. Which family member prompted the consultation, a written report ofthe physical findings/recommendations, and the time spent discussing the recommended treatment plan
• D. The reason for the consultation, the time spent discussing the recommended treatmentplan, and a medical decision-making of moderate complexity

Answer: B

Explanation:
Per CPT guidelines, the Office of Inspector General, and Medicare, a consultation must include who requested the consultation, the consulting provider's professional opinion, and a written report of the findings, which is provided to the referring physician. Time can be used to select the level of E/M; however, it is not required if all three components of the documentation are met (history, exam, and medical decision-making). Additionally, once the provider assumes care, a subsequent code appropriate for that place of service would be reported (e.g., 99211-99215) and not a consultation code.

NEW QUESTION # 107
A low-risk obstetrical patient is told to come in for weekly ultrasounds in her first trimester. This is an example of what?

• A. Fraud
• B. Abuse
• C. Misuse
• D. Waste

Answer: D

Explanation:
In this case, the patient is not at risk, and most organs either are not developed and/or cannot be visualized in the first trimester. Thus, this would constitute as waste due to the provider overutilizing services that result in unnecessary cost. AAPC defines fraud as purposely billing "for services that were never given or to bill for a service that has a higher reimbursement than the service provided." Abuse is payment for services "that are billed by mistake by providers."

NEW QUESTION # 108
A male patient with cancerous cells in his right bronchus is given 150 mg of porfimer sodium via a single and slow intravenous injection and told to return to the office in 3 days.
Upon his return, the physician enters the right bronchus by means of a bronchoscope and activates LED for a total of 38 minutes to destroy the cancer cells. What should the physician report?

• A. 96573, 96409, J9600x2
• B. 96573, J9600x2
• C. 31641, 96570, 96571, J9600x2
• D. 31641, 96570, 96571, 96409,J9600x2

Answer: C

Explanation:
Photodynamic therapy applies a photosensitizing agent by either an external or endoscopic application. An external application is applied directly onto a patient's lesions, whereas an endoscopic application is an injection into the bloodstream, where it is absorbed by cells all over the body. Based on this differentiation, the documentation supports only an endoscopic application.
The code notes for CPT 96570 and 96571 indicate they are add-on codes to the bronchoscopy procedure, which is represented by CPT 31641. Any drug administration is inclusive to photodynamic therapy, making CPT 96409 not separately billable.

NEW QUESTION # 109
If a cardiologist bills an electrocardiogram (93010) in the emergency department and then follows up with the patient a week later for arteriosclerosis, he should bill an established patient E/M.

• A. True
• B. False

Answer: B

Explanation:
The statement is false. According to CPT, a new patient is one who has "not received professional services from the physician." In lieu of this, because the cardiologist only interpreted an electrocardiogram and did not actually provide care to the patient, a new patient E/M service should be billed.

NEW QUESTION # 110
Which healthcare professional may NOT report medical nutrition therapy?

• A. Registered nurse
• B. Dietician
• C. Nutritionist
• D. Endocrinologist

Answer: D

Explanation:
Medical nutrition therapy describes nutritional assessments and interventions in a face-to- face or group patient setting and is reported with CPT codes 97802-97804. These codes are used by nonphysician healthcare professionals only. When a physician provides nutritional advice, a preventative service or evaluation and management code should be reported.

NEW QUESTION # 111
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