CPC Practice Exam 4

A 45-year-old woman scheduled to retrieve a tissue sample from a lesion to test for cancer. The tissue samples were retrieved using a sharp blade to retrieve a full-thickness tissue sample. A simple closure was performed.

What CPT code should the provider document?

A physician performs an arthrodesis procedure for a patient with lumbar spinal stenosis. The procedure was performed on 3 interspaces in the lumbar region.

Which CPT and ICD-10 code should the physician report?

A 2-year-old girl born with cleft palate is scheduled for a surgery to improve the appearance of her nose. Her physician recommended she undergo a complete rhinoplasty to elevate her nasal tip. In addition, the physician performed a major septal repair.

What CPT code should the physician report?

4. A physician decides to perform a paraoesophageal hernia repair. The patient was experiencing abdominal pain, gastrointestinal bleeding and reflux. Surgery was recommended to prevent a strangulated hernia. During the procedure, the physician pushed the stomach and other protrusions back into place. The surgeon utilized mesh materials to prevent another hernia.

Which CPT code should be reported?

A 71-year-old male reports to his physician with pain in the testes. His physician decided to perform an ultrasound on the testes. The radiologist interpreted the results and found well-defined epididymal cystic lesions, with low-level fine internal echoes. The cystic lesions measured 1-2 cm with posterior acoustic enhancement. The patient was diagnosed with an epididymal cyst and the physician will conduct an excision of the of the spermatocele with an epididymectomy.

Which ICD-10 and CPT code should be reported?

The physician diagnosed a 38-year-old male patient with cubital tunnel syndrome. The patient has been experiencing pain and decided to undergo surgery. The physician conducted an ulnar nerve release operation, in which he divided the overlying ligament (Osborne’s ligament), increasing the size of the tunnel and reducing pressure on the ulnar nerve.

Which CPT code should be reported?

A patient comes into her doctor’s office for her weekly blood sugar check. Her blood is drawn by the LPN on staff, and the visit takes approximately 5 minutes.

What E/M code should be assigned?

8. When does anesthesia time begin?

A patient was in an MVA in which his face struck the steering wheel. He had multiple contusions and facial swelling. The physician suspected a zygomatic-malar or maxilla fracture. The radiologist took an oblique anterior-posterior projection, which showed the facial complex clearly. Anterior-posterior and lateral views were also taken.

What CPT code should the physician utilize?

Physician orders a patient’s blood to be tested for levels of urea nitrogen, sodium, potassium, transferase alanine, and aspartate amino, total protein, ionized calcium, carbon dioxide, chloride, creatinine, glucose, and TSH.

What CPT code should the physician utilize?

A 45-year-old patient with end-stage renal disease has in-home dialysis services initiated on the 15th of the month. The physician provides dialysis every day. On the 19th, the patient was admitted to the hospital and discharged on the 24th. The physician and patient began in-home dialysis again on the 25th and continued every day until the 31st.

Which CPT code(s) should be used?

The term “Salpingo-Oophorectomy” refers to

Cryopreservation is a means of preserving a body part through which of the following

The Radius is the

The spleen belongs to what organ system

Courtney was standing on a chair in her apartment’s kitchen trying to change a light bulb when she slipped and fell. She struck the glass top stove. She presents to the ER with a simple laceration to her left forearm that has embedded glass particles.

What ICD-10 codes should be assigned?

A patient with Hodgkin’s disease takes Neosar as part of his chemotherapy regimen. He receives 100 mg once a week through intravenous infusion.

What HCPCS code should be assigned?

Wound exploration codes include the following service(s):

An ABN must be signed when

OPERATIVE NOTE

PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniation at C4-C5 and C5-C6

POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniation at C4-C5 and C5-C6

PROCEDURE PERFORMED:
1. Anterior discectomy, C5-C6
2. Arthrodesis, C5-C6
3. Partial corpectomy, C5
4. Machine bone allograft, C5-C6
5. Placement of anterior plate with a Zephyr, C6

ANESTHESIA: General

ESTIMATED BLOOD LOSS: 60 mL

COMPLICATIONS: None.

INDICATIONS: The patient presents with progressive weakness in the left upper extremity as well as an imbalance. He has a very large disc herniation that came behind the body at C5 and a large disc herniation at C5-C6. Risks and benefits of the surgery include bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement. These were all discussed with the patient, and he understood and wished to proceed.

DESCRIPTION OF PROCEDURE: A patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. He was placed in the supine position with all pressure points noted and well padded. He was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with the carotid moved laterally and trachea and esophagus moved medially. I placed the needle into the disc spaces and at C5-C6. Distracting pins were placed in the body of C6. The disc was then completely removed at C5-C6 There was significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. Multiple free fragments were noted. This was taken down to the level of ligament, and both foramina were opened. Part of the body of C5 was taken down to ensure that all fragments were removed and that there was no additional constriction. The nerve root was then widely decompressed.

Machine bone allograft was placed into C5-C6, and a Zephyr plate was placed in the body C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. The fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for the skin. The patient tolerated the procedure well and went to recovery in good condition.

What CPT code(s) should the physician report?