Per CPT coding guidelines, a “complete” diagnostic ultrasound of the retroperitoneum includes at least the following organs:
Which of the following is an example of a qualifier?
Where a specific branch of a body part does not have its own body part value in PCS, the body part is coded to the closest __________branch that has a specific body part value.
Which of the following key attributes is the one that provides the framework for all other structural attributes?
True or false? For every code where ICD-10-CM provides codes for laterality, bilateral is listed as an option.
Which of the following is a feature of ICD-10-CM?
A patient in end-stage renal failure requires outpatient hemodialysis 3 times a week while he is awaiting kidney transplant. He has an A-V fistula in his left arm for vascular access. Which of the following code sets is appropriate for reporting physician services for this 55-year-old male for the month of August?
An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct anesthesia code and ICD-9-CM codes. Modifiers are not used in this example.
A newborn female is born with polydactyly of the right foot with a total of 5 normal toes and 2 extra digits that do not contain bony structures. Which of the following code sets would be reported by the ASC facility tying off and removing these digits at the age of 2 weeks?
An ambulatory surgery operative report for a 75-year-old male patient states that the patient received a full- thickness graft of the cheek following lesion removal of a basal carcinoma. The lesion plus margins are documented to be 3.2 cm in diameter. A 10-sq-cm graft is applied with donor skin from his thigh, closed by suture. Which of the following code sets is correct for this surgery?
This patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which of the following code sets will be reported for this service?
A 6-month-old infant, born prematurely, presents for his monthly injection for RSV. The nurse documents Synagis 40 mg, IM. Which of the following code sets is correct for reporting this office visit?
The physician documents that the patient has blood-loss anemia. Which diagnosis code is supported by this documentation?
A 5-year-old patient was brought into the emergency room with a deep 2-cm laceration of his scalp. The child was combative and would not allow staff to cleanse the wound. The mother held the child in her lap while the ED physician administered 10 mg of Versed intranasally.
When the child was sufficiently sedated, one of the ED nurses monitored the patient’s vital signs, and the physician performed a layered repair of the laceration. The intra- service time for the procedure did not exceed 30 minutes. Assign the correct CPT code(s) for the procedure and sedation for this case:
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A myocardial infarction is considered acute for _____ weeks according to the ICD-10-CM Official Guidelines for Coding and Reporting.
Per CPT guidelines, a separate procedure:
A list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in:
In ICD-9-CM coding, to report Jakob-Creutzfeldt disease with dementia, you would need:
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
A 85-year-old female lives alone. She recently was in the hospital with aspiration pneumonia. There are infiltrates still present on the chest x-ray, and home healthcare is focused on the treatment of the pneumonia. She also has type II diabetes mellitus. She had partial colectomy last year for acute diverticulitis. What diagnosis would be reported in M0240?
A 9-year-old boy is seen in the emergency department and receives 560 units of rabies immune globulin and rabies vaccine as intramuscular injections after being bitten by a squirrel that exhibited signs of being infected. The documentation contains an expanded problem focused history, a detailed examination and high-level medical decision making. How are these services coded?
In ICD-10-CM the fifth character for category G43, Migraine, denotes what?
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What is the legal term used to define the protection of health information in a patient–provider relationship?
In a joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS) and Administration on Aging (AOA), which program was released in 1995 to target fraud and abuse among healthcare providers?
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Which of the following elements is not a component of most patient records?
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A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system?
Identify the diagnosis code(s) for carcinoma in situ of vocal cord.


