Code the following conditions.

1. Acute and Chronic pericarditis.
2. Acute and chronic cholecystitis.
3. Acute and chronic frontal sinusitis.
   
4. Enteritis due to Clostridium difficile.
5. Closed fracture of tibia and fibula.
6. Hypertensive cerebrovascular disease.
7. Gangrene due to diabetes mellitus, type I.
8. Acute bronchitis due to Psuedomonas.
9. Amyloid cardiomyopathy.
10. Traumatic arthritis following fracture of left ankle 3 years ago.
11. Severe mental retardation due to previous viral encephalitis.
12. Flaccid hemiplegia affecting dominant side due to cerebrovascular accident 4 months ago.
13. First- and second-degree burns, right foot due to a controlled bonfire.
14. Infected third-degree burn left thigh.
15. Second-degree burn, right forearm; first-degree burn right little finger; third-degree burns to right chest wall.
16. Fracture, right patella with abrasions of right forearm.
17. Fracture, left femur shaft - requiring internal fixation, with fracture of left clavical.
18. Multiple myeloma.
19. Metastatic cancer to the brain, primary unknown.
20. Hepatocellular adenoma.
21. Admission for radiotherapy for lymphoma nodes of the neck.
22. Closure of colostomy.
23. General medical exam for sports physical.
24. Obstructed labor due to cephalopelvic disproportion. Liveborn single infant delivered by cesarean section.
25. 29-year old female at 28 weeks' gestation with uncontrolled diabetes.
26. Blighted ovum.
27. Single newborn female, delivered by cesarean section, with evidence of cleft palate and cleft lip.
28. Single newborn male, delivered vaginally, absence of left earlobe.
29. Newborn twin girl, delivered at home, not requiring hospitalization (mate also liveborn).
30. Urticaria due to penicillin (properly taken and prescribed).
31. Coma due to accidental overdose of Valium.
32. 16-year old male, unrestrained driver, struck from the side by a truck at an intersection, arrives in ED unconscious and did not regain conciousness until 3 days later. Multiple injuries include: depressed skull fracture with subdural hemorrhage; ruptured spleen without penetrating wound; closed fracture of pelvis, multiple sites with disruption of pelvic circle.

    CPT-4 Questions

    Code the following using the appropriate CPT-4 code(s), appropriate modifier(s) and appropriate ICD-9CM code(s) when possible..

33. An orthopaedic surgeon treats a metacarpophalangeal dislocation of the patient's right index finger with percutaneous skeletal fixation and manipulation.
    
    1. DX
    2. CPT
34. A radiologist reads an outpatient two-view chest x-ray film on a patient who presents with diagnoses of cough and r/o pneumonia. No evidence of pneumonia is identified on the films.
    
    1. DX
    2. CPT
35. A 70-year old new patient presents at a multispecialty clinic for a routine history and physical with no complaints. A complete history and physical are preformed as well as a general health panel (baseline lab work) and a two-view chest x-ray, both performed by the clinic laboratory.
    
    1. DX
    2. CPT
    3. CPT
    4. CPT
36. Mr. Williams, 52 years old, presents to the gastroenterology lab for a screening colonscopy due to his family history of colon cancer. The colonoscopy was completed, the colonic preparation was excellent. Results were negative for any colon anomalies..
    
    1. CPT
    2. DX
    3. DX
37. Patient admitted for inpatient hospital care, complaining of right lower quadrant pain. Comprehensive history and exam were performed and medical decision-making was moderate. The patient was discharged later the same day with diagnosis of right lower quadrant pain, etiology unknown.
    
    1. DX
    2. CPT
38. A physician is called to the ICU to provide care to a patient who has received second-degree burns over 50% of his body, involving the anterior and posterior trunk, head and neck and right arm. The burns occurred when the patient’s lawn mower caught on fire. The physician provides support for 2 hours. After leaving the unit, the physician returns later the same day to provide an additional hour of critical care support to the patient.
    
    1. DX
    2. DX
    3. DX
    4. CPT
    5. CPT
39. The consulting physician cannot initiate either diagnostic or therapeutic services until receiving approval from the requesting physician? True False
    
40. The physician directs the emergency medical technicians via two-way communications with an ambulance en route to the emergency room with a patient in apparent cardiac arrest.
    
    1. DX
    2. CPT
41. Patient presents at the Emergency Department with multiple trauma. A urologist performs an abdominal tap (which show frank blood), a comprehensive workup of the patient for admission and monitors the patient for one hour while the operating room is being prepared to repair the patient’s ruptured bladder. The patient undergoes a simple partial cystectomy for ruptured bladder in the operating room and is subsequently admitted to the hospital.
    
    1. DX
    2. CPT
    3. CPT
    4. CPT
    5. CPT
42. A 40-year old patient undergoes craniotomy for removal of a malignant mass of unknown nature in the thalamic region of the brain. Code the anesthesia services.
    
    1. DX
    2. CPT
43. An oral maxillary surgeon requested general anesthesia for a child with active autism to facilitate drainage of an abscess from a dentoalveolar structure. Code the anesthesia services.
    
    1. DX
    2. DX
    3. CPT
44. Code the oral maxillary surgeon’s services in the scenario above.
    
    1. DX
    2. DX
    3. CPT
45. A 37 year-old patient is prepared for laparoscopic repair of a recurrent right inguinal hernia. Due to adhesions from the previous inguinal hernia repair, the procedure was converted to an open hernia repair.
    
    1. DX
    2. DX
    3. DX
    4. CPT
46. An ophthalmologist repairs two horizontal muscles for alternating esotropia, and a lid retraction repair.
    
    1. DX
    2. DX
    3. CPT
    4. CPT
47. Mr. Smith has an appendectomy done June 8 then has a cholecystectomy for acute cholecystitis on August 27th, by the same surgeon. Code the surgeon’s services for August 27th.
    
    1. DX
    2. CPT
48. After an assault with a knife, a patient requires simple repair of a 3-cm laceration of the neck, simple repair of a 4-cm laceration of the back, simple repair of a 5-cm laceration of the forearm, and complex repair of a 3-cm laceration of the abdomen.
    
    1. DX
    2. DX
    3. DX
    4. DX
    5. DX
    6. CPT
    7. CPT
49. Dr. Smith performs an anterior segment of the left eye for removal of embolus.
    
    1. DX
    2. CPT
50. Patients's labor is obstructed by bony pelvis. Dr. Jackson performs a cesarean section due to cephalopelvic disproportion. Single male is delivered. Dr. Jackson provides no antepartum or postpartum care.
    
    1. DX
    2. DX
    3. DX
    4. CPT
51. Mr. Gibson, 6-week post op cervical lymph node resection for Burkitt’s tumor, receives radiation treatment to a single area at 4MeV.
    
    1. DX
    2. CPT
52. The physician admits the patient in to the hospital for treatment of a newly diagnosed lung cancer. The initial hospital care consists of a comprehensive history and physical examination, but the medical decision-making is of low complexity as the diagnosis had been established, and now treatment is to begin. The patient is sent to radiology department for brachytherapy where a radioelement application, intracavitary, simple is applied. Code the physician’s services.
    
    1. DX
    2. DX
    3. CPT
53. Code the radiologist's services in the scenario above.
    
    1. CPT
    2. DX
    3. DX
    
    

    Assign the appropriate CPT-4 code(s) for the following:

54. A breast biopsy is performed in conjunction with an esophagoscopy.
    
55. Mary, 32-weeks into her multiple pregnancy (triplets), reports to radiology for a repeat transabdominal uterine echography in real-time with image documentation. All three fetus will be examined.
    
56. Bilateral mammography to detect unsuspected cancer in an early stage for an asymptomatic woman..
    
57. MRA of head and neck, without contrast.
    
58. Dr. Green, radiologist, provides interpretation of an outside MRI at the request of another physician and provides a written report.
    
59. Lists the appropriate code(s) for reporting laboratory services that include the following tests: Total calcium; carbon dioxide; chloride (blood); creatinine (blood); serum potassium; serum sodium and quantitative urea nitrogen.
    
60. Collection of specimen by arterial puncture for blood gas determination (pH only).
    
61. A hysterectomy is performed for leiomyoma. The uterus containing leiomyomas is submitted in one container; the right tube and ovary are separately identified in a second container; the left tube and ovary are separately identified in a third container. A fourth container contains the vermiform appendix. Code the pathology services.
    
62. The pathologist provides a limited consultation of an abnormal 48-hour dexamethasone suppression panel. Medical interpretive judgment is supplied to the requesting physician. The patient’s records were not reviewed.
    
63. One hour of physical therapy is provided for a stroke patient to improve gait.
    
64. Forty-five minutes of individual psychotherapy, insight oriented, behavior-modifying services provided in the clinician’s office.
    
65. Comprehensive ophthalmologic services, established patient visit, with determination of refractive state.
    
66. Intramuscular administration of human rabies immune globulin.
    
67. Cardiovascular treadmill, physician supervision only.
    
68. Allergist prepares a dosage schedule for patient allergic to three different insect venoms (honeybees, hornet and yellow jackets). The treatment includes venom for all three stinging insects combined into two multiple dose vials, containing 5 doses.