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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q95-Q100):

NEW QUESTION # 95
A patient opts to replace his semi-rigid penile prosthesis with a multicomponent, inflatable penile prosthesis. What CPT code(s) should the urologist report if this was completed in one encounter?

• A. 54405, 54415-51
• B. 0
• C. 54415, 54405-51
• D. 1

Answer: B

Explanation:
Penile prosthesis procedure codes are based on the type of prosthesis being used. In this scenario, a semi-rigid prosthesis is being replaced by a multicomponent inflatable one. Currently, there are no CPT codes that encompass the removal of one type of prosthesis and insertion of another type. The most common course of action might be to code the removal and insertion separately and amend a multi-procedural modifier on the secondary code. However, CPT 54415 indicates that the prosthesis removed was not replaced by another, which is an inaccurate description of services rendered. In this case, only the insertion (CPT 54405) should be reported because it has the highest RVU value.

NEW QUESTION # 96
In which scenario would the modifier 53 be appended?

• A. An IUD removal is not completed because the patient reports severe pain when thespeculum is inserted.
• B. The surgeon decides to terminate a routine colonoscopy when the patient becomeshypertensive before receiving anesthesia in the outpatient procedure room.
• C. A surgeon decides to stop a gallbladder removal procedure in the hospital operating roomafter the patient has extensive bleeding at the incision site.
• D. A patient receives an x-ray of one femur when the doctor ordered bilateral views.

Answer: C

Explanation:
Modifier 53 is used to indicate that a procedure was terminated by the provider after anesthesia was given due to extenuating circumstances that affected the health of the patient.
Although option B is similar, the procedure that was discontinued was done so prior to anesthesia in the outpatient setting, in which case modifier 73 would be appended.

NEW QUESTION # 97
A patient is in labor with plans to deliver vaginally. An epidural is administered at 17:30. After several hours of pushing, the obstetrician determines that the cervix is swollen, and the baby must be delivered via a c-section. The patient consents, the baby is delivered, and both are discharged to the recovery room at 22:15. What CPT code(s) should the anesthesiologist report?

• A. 01967, 01968
• B. 01967, 01968, 99140
• C. 01967-23, 01968, 99140
• D. 01967-23, 01968

Answer: D

Explanation:
For a planned vaginal delivery with the use of an epidural, followed by a Cesarean delivery, the correct CPT codes are 10967 followed by add-on code 01968. CPT code 99140 is an add-on code portraying that the procedure was an emergency and that the patient and/or baby has a significant increase in the threat to life. The documentation gives no indication that these services were emergent Modifier 23 is reported for unusual anesthesia services. This would include-but is not limited to-the use of general anesthesia for a procedure that usually requires only a local anesthetic or none and/or a procedure extending more than 4 hours. In this case, the total procedure time was 4.75 hours, and modifier 23 is appended on the primary procedure code only.

NEW QUESTION # 98
A provider documents that he spent 20 minutes with a patient. Based on this, an E/M can be chosen solely based on time.

• A. False
• B. True

Answer: B

Explanation:
The statement is true. According to AMA time documented is considered the minimum time the physician or other qualified health care professional spent on face-to-face and non-face-to-face services. This includes time spent reviewing the patient's medical record, consulting other healthcare professionals, or ordering prescriptions, tests, and/or other services.

NEW QUESTION # 99
A female patient with type II diabetes, asthma, and hypertension is admitted with complaints of chest pain. Testing rules out heart attack and other underlying conditions as the cause. Which diagnosis codes should be listed on the discharge note?

• A. Z03.89
• B. R07.9
• C. R07.9, Ell.9, J45.909, 110
• D. Z03.89

Answer: C

Explanation:
The primary diagnosis on an inpatient record would be the primary reason the patient was admitted. In this case, because a definitive diagnosis could not be confirmed, the symptom of chest pain would be selected instead. The previously confirmed chronic conditions would also be coded because they affect the management of inpatient care. Diabetes would be coded to an unspecified code because the term "with" implies a causal relationship between the conditions that is not implicitly documented. Per ICD-IO-CM guidelines, a rule-out code is not assigned when "any signs or symptoms related to the suspected condition are present."

NEW QUESTION # 100
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