CPT Questions

1. CPT is the abbreviation for Current Procedural Terminology. True False
   
2. Coders can code exclusively from the CPT index. True False
   
3. There are 7 major sections of the CPT manual. True False
   
4. The AMA updates the CPT-4 manual bi-annually. True False
   
5. List one new code.
6. List one revised code.
7. List one modifier –51 exempt code.
8. List one “add-on” code.
9. Find one unlisted code.

   Indicate the appropriate modifier.

10. Physician provides an office visit during which the decision for surgery is made.
11. During the postoperative period for a right total knee replacement, patient returns to the same surgeon for sprain of left knee.
12. At the same visit a patient is being evaluated for existing chronic lung disease, the physician evaluates and elects to biopsy an irritated skin lesion.

    E/M services- New vs. Established Patient.

13. Mary is seen while admitted to the hospital for a consult. Two weeks later, she presents to the consulting physician’s office for treatment.
14. Tim was in the army for 2 years. During that time, he did not see his hometown physician. The office policy is to place any inactive files on microfilm after 18 months of inactivity. After Tim’s tour of duty, he returns to his hometown physician with foot pain.

    Consult vs Referral

15. Joyce has been seeing her primary care physician for a rash. The condition is not responding to treatment. The primary care physician suggests Joyce make an appointment with a dermatologist for continued care.
16. Jim is being treated by a orthopedic surgeon following hip surgery. Jim is showing no signs of improvement. The surgeon asks a psychiatrist to evaluate Jim to determine if the problem is more psychosomatic in nature than physical.

    Select appropriate modifier

17. If more than one surgical service is performed by the same physician on the same patient at the same session you need to append modifier to the lesser-valued CPT code.
18. If two surgeons work together as primary surgeons performing distinct parts of a single reportable procedure each surgeon should report their distinct operative work by adding modifier

    Answer appropriately

19. When using an unlisted procedure code third-party payers will usually require submission of what?
20. When billing Evaluation and Management Codes name the three key components that enable you to choose the appropriate level of service.
21. When billing a new patient visit you must meet two of the three key components? True False
    
22. List the three parts to documenting the history component.
    

23. Every history must include a chief complaint for the visit. True False
    
24. Name the department of a hospital where there is no distinction made between new and established patients:
25. When services are rendered by a physician who’s opinion or advice has been requested by another physician or agency in the evaluation and/or treatment of a patient is called a
26. List the three steps of meeting the criteria for billing a consultation.
    

    Answer with the appropriate CPT codes.

27. Destruction by any method, Flat wart.
28. Excision, benign lesion, skin, arm – over 4.0 cm.
29. Dipstick urinalysis (non-automated) with microscopy.
30. Gonioscopy under general anesthesia
31. Radiological examination of left hand, 2 views.
32. Patient enters the Emergency Center with acute abdominal pain and possible appendicitis. The patient is taken to the operating room where an exploratory laparotomy is performed. It was determined that the patient did indeed have acute appendicitis and an appendectomy was performed.
33. Patient is referred to a vascular surgeon for gangrene of right great toe. The patient is an insulin dependent juvenile onset diabetic. The patient undergoes amputation of the right great toe.
34. Patient is found to have a malignant neoplasm of the breast and undergoes a partial mastectomy.
35. Patient has a malignant neoplasm of the cerebellum. The patient is sent to Radiation Oncology for stereotactic radiation treatment consisting of one session.
36. A 10-year old patient is seen by the Pediatric physician for a bite on the lower leg. The physician determines the bite is an infected mosquito bite and decides to do a puncture aspiration of the infected bite. Code only the procedure and the diagnosis.
    CPT DX
37. The gastroenterologist sees a patient with complaints of right upper abdominal pain, bloody stool, and a family history of colon cancer. The gastroenterologist performs a diagnostic colonoscopy with a single biopsy to rule out colon cancer. The findings were normal and unremarkable.

    Answer appropriately

38. An established patient is seen by Dr. Smith with the complaint of a productive cough. This patient was last seen by Dr Smith 5 days prior to this encounter for the removal of a premalignant facial lesion (this procedure has a 10-day global period). Indicate the correct modifier to be added to the E&M service 99212.
39. Patient has a right and a left breast lesion and undergoes a bilateral breast biopsy. Indicate the appropriate modifier to the CPT code 19120.
40. A two-year-old child is seen for a return visit to follow-up on an acute upper respiratory infection. It is indicated by the mother that for the last two days that the child has been pulling at his left ear. Upon exam the physician notes a cerumen obstruction. The physician decides the obstruction needs to be removed.
    1. Add the appropriate modifier to the E&M code: 99212-
    2. What is the CPT code for the cerumen removal:
    3. Match the diagnosis to the service:
       a.) CPT DX
       b.) CPT DX
41. Patient comes to the clinic with complaints of abdominal pain and nausea for a couple of days. After the appropriate exam and tests were performed the patient was diagnosed with cholelithiasis, and a cholecystectomy was scheduled to be performed the next day. Indicate the appropriate modifier when the decision for major surgery is determined.
    Is this modifier appropriate to be used with an E&M service: Yes No
    
42. A patient is seen for re-evaluation of chronic hypertension. The physician performs a detailed history and physical examination and medical decision making of moderate complexity. During this encounter, the patient states that he is having trouble hearing. The physician examines the patient’s ears and discovers that the right ear is blocked with cerumen. After irrigation and removal of a wax plug, the patient is able to hear better. The patient’s hypertension will be treated with a new medication and re-evaluation is scheduled for one month.
    CPT DX CPT DX
43. An established patient presents with uterine bleeding requiring a hysteroscopy with endometrial biopsy; the patient is also evaluated for a breast cyst. The breast evaluation consists of an expanded problem- focused history and physical exam and medical decision making of low complexity.
    CPT DX CPT DX
44. A 33-year-old male, new patient, presents to the physician’s walk-in service after sustaining a head injury while renovating his house. According to the patient, a lighting fixture fell and hit his head as he was attempting to hang it. He immediately applied compresses to the temporoparietal wound area, and his wife drove him to the office. He reports heavy bleeding, but only shows light hemorrhage at this time. He cannot confirm loss of consciousness, but denies dizziness or blurred vision. Denies nausea or vomiting. Denies dystaxia. Does not complain of headache except in the immediate area of the wound. The patient has never has a tetanus shot.
    A complete review of systems is performed and the past medical, family and social histories are taken. The remainder of the detailed history is completed. The temporoparietal scalp wound is debrided of dried blood and blood clots. After irrigation, the cranial muscle fascia is noted through the wound. A layered closure is performed on this 5.5 cm wound. A detailed neurological evaluation is then performed to rule out increased intracranial pressure. There are no neurological signs or deficits noted. Medical decision making is of low complexity. Finally, a tetanus toxoid inoculation is administered. The signs for intracranial pressure changes are reviewed with the patient and he is given follow up instructions.

    CPT CPT CPTCPT
    DXDX

    ICD-9-CM Questions
    
    

45. Medical necessity establishes the reason for the patient visit? True False
    
46. Always code to highest level of specificity? True False
    
47. Tabular listing of diseases can be found in which Volume?
48. Volume 2 was created to help solve the dilemma of finding the correct code and is known as the
49. Main terms are listed alphabetically and can be found in Volume?
50. What diagnosis code is used to report personal/family history?
51. All 3 digit ICD-9 codes require a 4th or 5th digit in order to code to the highest specificity? True False
    
52. Choosing a diagnosis code when ancillary services are the only services provided. You code the problem first and use the appropriate V code second? True False
    
53. What does CMS stand for?
54. ICD-9 code 564.8 is coded the highest level of specificity. True False
    
55. It is not necessary to locate the code in the Tabular List after finding the code in the Index. True False
    
56. The first step in correct coding is to identify the main term. True False
    

    Answer with the appropriate diagnosis code.
    
    

57. Acute streptococcal tonsillitis
58. Cat-scratch fever
59. Embedded tooth
60. Postoperative wound infection
61. Sponge kidney
62. Crib death
63. Stein-Leventhal Syndrome
64. Nasopharyngeal polyps
65. Abnormal thyroid scan
66. Multiple fractures (closed), multiple sites of hand.
67. Chest pain