A child displayed emotional outbursts, inability to interact appropriately with peers and his teacher, and was not effective in grasping lessons deemed suitable for his age. The school counsellor requested psychological testing to determine if the child had been placed in classes appropriate to his abilities. Testing was administered by a clinical psychologist who spent 10 hours face-to-face with the patient, and 3 hours preparing the report of the results.

A patient presented with vomiting and diarrhea for the past three days. The physician determined the patient is dehydrated and ordered infusion of hydration fluids to run for two hours.

A patient has an implanted intravenous pump for the purpose of prescribed drug delivery at preset intervals. The patient is seen by the physician who provides maintenance and refills the pump with the medication.

A cancer patient will receive chemotherapy by intrathecal delivery. A spinal puncture will be necessary to accommodate the catheter.

Physical therapy evaluation was conducted for a polyarthritis patient for 45 minutes which included a history describing the social background, education and profession that is influencing the disability with a musculoskeletal examination testing the range of motion, muscle strength, height and weight. The clinical presentation is unstable so the PT did a high complexity MDM. Code the PT evaluation

Jeswin a patient who underwent a below knee amputation is -fitted with a artificial limb below the knee. The PT trained Jeswin to walk with the artificial limb for 30 mins on Monday. Code the PT service on Monday.

A patient has collapsed archon her left foot. The physician prescribed a custom orthotic insert to be worn inside the patient’s short to support the collapsed arch. The patient visits the physician to receive the orthotic and is instructed how to position it inside the shoe for maximum results. The patient walks around the treatment room and hallway to determine if there is a comfortable fit. The session lasted 15 minutes.

An anorexic patient is experiencing signs of severe dietary deficiency and electrolyte imbalance. She will need medical nutrition therapy to treat these symptoms. The provider spent 30 minutes, with the patient to discuss the seriousness of her eating disorder and the necessity of nutrition therapy. This is the initial assessment.

A patient with a long history of migraine headaches decides to try acupuncture in an attempt to reduce the headache pain. The provider used to acupuncture with electrical stimulation during a 15-minute face-to-face encounter with the patient.

A patient with polyneuropathy in the feet underwent osteopathic manipulation to improve tingling and numbness sensations. The provider manipulated both feet during the session.

A patient presented with a complaint of continuing left shoulder pain after falling from her patio onto a wooden step. No fracture was identified at the time of the fall. After assessing the patient, the chiropractor manipulated the shoulder region.

A patient continued to have low back pain after lifting a heavy bin while cleaning the basement. The chiropractor manipulated both the lumbar and sacral areas.

A patient received manipulations in the cervical, thoracic, and lumbar spine by a chiropractor.

A registered dietician provided diabetes management education to seven patients for 90 minutes.

A diabetic patient who has not been successful with managing his diet meets personally with a registered dietician for one hour to develop a diet plan.

A patient called to her physician to discuss the refill of a current prescription. She spoke with the nurse who discussed the patient’s current status and advised that the prescription would be called into her pharmacy. The call lasted 12 minutes.

A patient in a rural setting with limited travel resources visited his physician for a physical examination. Lab work was done. The physician advised the patient that if the results were negative, he did not need to return to the office. The nurse emailed the patient that the results were negative, and the patient did not need to return for six months unless new symptoms appeared. One month later, the patient emailed the office with a request to change his current medication to a less-expensive generic version. The nurse answered the email advising one of his medications could be changed to a generic version, and refills would be called to the pharmacy as needed. She also responded to several questions the patient had about his general health conditions. She spent 25 minutes entering this information.

A physician provided medical testimony in a suspicious death cases presenting to the emergency department from 6 pm until 7 am. The technician is required to return to the hospital within 40 minutes of notification.

An independent laboratory charges a fee to transport medical specimens from physician’s offices to the laboratory for testing.

A physician agreed to meet a patient at the office on Sunday afternoon to assess a repeat problem. Special equipment in the physician office is needed to evaluate the condition. Normal office hours are Monday-Friday.

A patient ingested a toxic substance and was administered ipecac in the Emergency Department to empty the stomach.

A physician performed a magnified anogenital examination on a young child to determine if assault had occurred.

A post-surgical is discharged from the hospital to home. The patient still has a urinary catheter needing attention for the next several days. The physician arranged the home care agency.

A patient was discharged recently from the hospital following a colon resection with colostomy. A nurse made a home visit to assist with the patient’s colostomy.

A nurse visited a patient in the home to manage infusion of a thrombolytic agent for two hours.

A patient on multiple prescriptions had concerns about possible drug interactions with a new prescription. She requested consultation from the local pharmacists before leaving the pharmacy. The pharmacist met with her for 23 minutes to discuss possible interactions with her current medications and assured her that is was not likely the new medications would cause significant side effects.

What code should you report for a psychiatric diagnostic interview examination?

What code should you report for hypnotherapy?

Give the correct CPT code for determination of refractive state?

Optokinetic nystagmus test

Evaluation of auditory rehabilitation status 1 hr -

Colin had a comprehensive audiometry threshold evaluation and speech recognition testing to the left ear. What code(s) capture this procedure?

An adult patient had the following immunizations with administration: Yellow fever vaccine, subcutaneous injection Hepatitis B (adult dose) vaccine, intramuscular injection Rabies vaccine, intramuscular injection How would you report these services?

Sally suffered from dehydration after running a marathon. She was taken into her primary care doctor’s office. Dr. Small checked Sally and ordered hydration therapy with normal saline. The hydration lasted 45 minutes. How would you report this service?

A patient had a bronchoscopy with destruction for relief of stenosis by laser therapy. During this procedure photodynamic therapy by endoscopic application of light was used to ablate abnormal tissue via activation of photosensitive drugs. The photodynamic therapy lasted 60 minutes. How would you report this procedure?

Dr. George asked the local pharmacist to review Ann’s new medications with her when she picked them up. Ann is a new patient who just moved into the area and required several new medications. Ann is hard of hearing and had a difficult time understanding Dr. George when he called her. The pharmacist spent 35 minutes with Ann and documented a review of her history, recommendations for improving health outcomes, and treatment compliance. The pharmacist faxed this note back to Dr. George’s office. How would the pharmacist report his services?

What code would report an internet assessment and management service provided by a qualified non-physician healthcare professional to an established patient not originating from a related assessment and management service provided within the previous seven days?

Jane has a family history of skin melanoma. Her primary care doctor asked for a consult with Dr. John. During Jane’s first visit with her new dermatologist, Dr. John, he documented a comprehensive history, comprehensive examination, and medical decision-making of moderate complexity. Dr. John also performed a whole body integumentary photography for monitoring of Jane’s skin. Dr. John sent a report back to her PCP and told Jane she should return in one year or before then if anything should change on her skin. What code(s) would you use to report Dr. John’s services?

What services can you report in addition to the general ophthalmological services or evaluation and management services?

A patient presents to her oncologist’s office for schedule chemotherapy. The patient is severely dehydrated. The physician decides to schedule the chemotherapy for another day and orders hydration therapy to be performed today instead of the chemotherapy. The therapy is ordered and administered for one hour and 10 minutes. Select the code(s).

The correct code for OMT performed on the cervical, thoracic and sacral regions would be:

A pediatrician is managing the care of a patient who is at home on a ventilator under the care of a home health agency. The patient has cystic fibrosis and is suffering from recurrent pneumonia. The MD did the initial plan of care for the home health agency and now is following this monitor vent management oversight on day 20. The provider has a total 45 minutes for this month how should he code?

A two-month-old comes in for a well check up and several shots (Rota, DTaP-Hib/IPV, PCV) with her pediatrician. He offers suggestions to the mom, completes the exam, and counsels her on the vaccinations. How should this be coded?

Mary, who has food allergies, came to her physician for her weekly allergen immune therapy that consists of two injections prepared and provided by the physician. The correct code is:

Photodynamic therapy involving application of light externally to destroy premalignant lesions on the lower lip was provided to a 63-year-old patient. Code the encounter.

The patient presents to see the nurse for his scheduled vitamin B12 injection. The physician ordered the injection at the patient’s last visit. The physician is in the office seeing other patients. The nurse administers the 1000 mcg of vitamin B12 intramuscularly. She schedules the patient for his next appointment.

4-year-old is getting over his cold and will be getting three immunizations in the pediatrician’s office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next one is the influenza (live) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and vaccines?

A patient with chronic renal failure is in the hospital being evaluated by his endocrinologist after just placing a catheter into the peritoneal cavity for dialysis. The physician is evaluating the dwell time and running fluid out of the cavity to make sure the volume of dialysate and the concentration of electrolytes and glucose are correctly prescribed for this patient. What code should be reported for this service?

An established patient had a comprehensive exam in which she has been diagnosed with dry eye syndrome in both eyes. The ophthalmologist measures the cornea for placement of the soft contact lens for treatment of this syndrome. What codes are reported by the ophthalmologist?

A patient who is a singer has been hoarse for a few months following an upper respiratory infection. She is in a voice laboratory to have a laryngeal function study performed by an otolaryngologist. She starts off with the acoustic testing first. Before she moves on to the aerodynamic testing she complains of throat pain and is rescheduled to come back to have the other test performed. What CPT® code(s) should be reported?

A cancer patient is coming in to have a chemotherapy infusion. The physician notes the patient is dehydrated and will first administer a hydration infusion. The infusion time was 1 hour and 30 minutes. Select the code(s) that should be reported for this encounter?

A patient that has multiple sclerosis has been seeing a occupational therapist for four visits. Today’s visit the therapist will be performing a comprehensive reevaluation to determine the extent of progress in parameters and if the patient is reaching his goals for common impairments associated with this neurologic condition, which includes performing activities of daily living, movement, muscle strength and reasoning abilities for independent living. What CPT® and ICD-9-CM codes should be reported?

Patient with hemiparesis on the dominant side due to having a CVA lives at home alone and has a therapist at his home site to evaluate meal preparation. The therapist observes the patient’s functional level of performing kitchen management activities within safe limits. The therapist then teaches meal preparation using one handed techniques along with adaptive equipment to handle different kitchen appliances. The total time spent on this visit was 45 minutes. Report the CPT® and ICD-9-CM codes for this encounter.

10-year-old patient had a recent placement of a chochlear implant. She and her family see an audiologist to check the pressure and determine the strength of the magnet. The transmitter, microphone and cable are connected to the external speech processor and maximum loudness levels are determined under programming computer control. Which CPT® code should be used?

Code for six body regions involved in osteopathic manipulative treatment.

A patient brings a child in for the first time to the outpatient pediatric clinic for an oral adenovirus’ Type IV vaccine. The physician’s assistant evaluates the child and administers the vaccine orally to the child. What procedure and diagnosis codes would be reported for the vaccination services?

Code for comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording. His bundle recording, including insertion and repositioning of multiple electrode catheters with attempted induction and repositioning of arrhythmia, despite failure of including arrhythmia.

An individual psychotherapy session is provided to a 3-year-old girl, who is deaf and has social withdrawal, and who was in the outpatient psychiatry department, the services lasted about 25 minutes. Toy dolls for the patient and the use of an interpreter were required. What are the correct procedure and diagnosis codes?

Code the rapid desensitization procedure, two hours.

Code chemotherapy injected into the pleural cavity with thoracocentesis.

Code for individual insight oriented psychotherapy session in the outpatient clinic lasting 75 minutes conducted at 2 p.m.

A non-Medicare patient is seen in the outpatient clinic for fever, flank pain, and blood in the urine. The patient has a comprehensive history and physical examination. A moderate complex medical decision making is required by the physician. The diagnosis made is urosepsis and bacteremia. The patient is given an IM antibiotic of Rocephin 250 mg. What codes are used to report the facility services?

A new patient visits an ophthalmologist for visual abnormalities and complains of headaches and clear discharge from the right eye. The patient has a family history of glaucoma and cataracts. There is a sibling history of diabetes mellitus. The ophthalmologist performs a general evaluation of the complete visual system, including basic sensorimotor examination, and takes a history, general medical evaluation, bilateral external ophthalmoscopic examination, gross visual fields, and tonometry. The ophthalmologist uses mydriasis to examine the posterior chamber of the eye and initiates a diagnostic and treatment plan. Medications are prescribed. Code this encounter using the medicine code choices.

Mae’s physician asked her to wear a glucose monitoring device to obtain more accurate information about her blood sugars. She had sensors placed and was then hooked up to a calibrated wearable device. Once this was complete, the technician provided Mae with training for the noninvasive ambulatory continuous glucose monitoring device. After wearing the device for 72 hours, Mae’s physician’s office removed the device, printed recordings, and downloaded analyses reports to its computer system. Which code captures this service?

Edna, a 72-year-old patient, returned to her regular pulmonologist for a follow-up visit. Dr. Harry docu mented Edna’s chief complaint as fatigue after recovering from a minor flu. His documentation supports a past history of smoking, COPD, and well-controlled diabetes. Edna lives with her husband, maintains her weight with a balanced diet, and exercises in the warm weather but feels “shut in” during the winter. Dr. Harry noted a detailed examination and a medical decision making of moderate complexity. Dr. Harry completed a six-minute walking pulmonary stress test to evaluate distance, dyspnea, desaturation, and heart rate. T Which code(s) should Dr. Harry report for today’s services?

A 19-year-old patient received immunizations at her health clinic. The immunizations were administered by a medical assistant at the same clinic. The patient was seen two weeks ago but was unable to complete the immunizations due to a stomach virus. Today, she is symptom free and receives an intramuscular influenza pandemic formulation, preservative-free vaccine and an intramuscular hepatitis A immunization. Which codes capture these services?

What codes are not reported in conjunction with the following code descriptor? Comprehensive electrophysiologic evaluations including insertion and repositioning of multiple electrode catheters with indication or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, and His bundle recording

An 11-year-old female had one face-to-face visit with her physician and received three daily dialysis services during a one-month period prior to her kidney transplant. How should these services be reported?

A pulmonologist provides intermittent positive pressure breathing (IPPB) treatment to an elderly patient.Nebulizer medication is used. Code the pulmonologist's services.

During the month of April, a 40-year-old patient presents for the first time to an allergist after suffering from persistent rhinitis, conjunctivitis, and allergy, related asthma symptoms. Following a detailed history, detailed exam, and moderate medical decision making it is decided that symptoms are due to pollen allergies The allergist administers 52 percutaneous scratch tests to determine which pollens caused the allergic reaction. After identifying four specific allergens the allergist recommends injection immunotherapy with extract provided by the practice. The patient returns weekly for three weeks to receive an injection subsequent to the initial visit during the month of April. Provide the allergist's service during that month.

An allergist prescribes rapid desensitization for a patient with penicillin sensitivity. A three hour session is required to achieve the physician's desired outcome for the patient. Code this service.

A physical therapist provides direct ultrasound treatment to a patient's back and leg for 30 minutes. The therapist remains in constant attendance. Code for this service.

A cardiologist administers cardiovascular stress test in his office, using maximal treadmill with continuous ECG monitoring as well as 2D echocardiography The cardiologist administers the test and provides a written interpretation and report to the patient's primary care physician. Code the cardiologist's services.

A provider spends 25 minutes with a patient in office to discuss health- problems and emotional issues related to the patient's history of anorexia nervosa. Evaluation and management services are provided on the same day as the therapy. Code the provider's services.

A three-year-old patient, who accidentally ingests a handful of diet pills (appetite depressants), is treated with gastric lavage. What are the CPT and ICD-9-CM codes for this scenario?

A physician performs an EEG with extended monitoring for two hours in the hospital. The correct CPT code for this procedure is

A physician periodically assesses the patient's response to hydration treatment through communication with the nurse. Treatment was required for three hours. What are the appropriate code(s) for this service?

A provider writes a report based on the review and interpretation of glucose data collected from a patient who had been monitored at home for the past 72 hours using a system set up and calibrated by the same provider. Services include training on the use of the monitor. At his new patient visit one year ago, the patient was diagnosed with adult onset diabetes mellitus Type I; and the initial office visit for the new patient included a detailed history and exam, and medical decision making of moderate complexity. Code the provider's services.

A new patient visits an ophthalmologist for visual abnormalities. He complains of headaches and clear discharge from his right eye. He has a family history of glaucoma and cataracts. There is a sibling history of diabetes mellitus. The ophthalmologist performs a general evaluation of the complete visual system including basic sensorimotor examination and takes a history, general medical evaluation, bilateral external ophthalmoscope examination, gross visual fields, and tonometry. The ophthalmologist uses mydriasis to examine the posterior chamber of the eye. The physician initiates a diagnostic and treatment plan and prescribed medications.Provide the CPT code for the ophthalmologist's services.

A patient with a significant change in behavior is referred to a psychiatrist for a series of standardized tests to evaluate cognitive processing. 50 minutes was spent by the psychiatrist administering tests which he then interprets for a subsequent written report. Which is the appropriate procedure code for the testing?

A cardiologist places a percutaneous catheter into the femoral artery of the left leg for a spatient with an acute myocardial infarction. Under fluoroscopic guidance, the intracoronary ultrasound catheter' tip is advanced into the coronary artery, confirming the presence of a blood clot (thrombus) in the artery. The physician infuses the thrombolytic Eminase into the affected artery to dissolve the clot. The catheter is removed and pressure is applied over the incision for 20 minutes. The patient recovers well from the procedure. List the appropriate CPT code that is used to report this procedure.

A physician reviews and interprets a patient initiated 30 days worth of spirometric recordings. The patient is suffering from an undiagnosed, diminished breathing capacity for a number of months. Use your CPT manual to report the code for the service.

A physician assess continuous infusion therapy over a two hour period in the office, for a 56-year-old patient with rheumatoid arthritis. The patient has a venous access device in place. What is the correct way to report the physician's services?

A child is seen for an 18,month examination and immunization injections. The physical examination reveals an ear infection; therefore, no immunizations are given at this time. One month later, the child returns for an HIB booster vaccine. No other services are rendered. Provide the code for the second visit when the immunization is performed.

The six,year,old patient is given a yearly IM split virus flu vaccine 0.5 ml immunization at the clinic. Provide the codes.

A 45,year,old female patient is admitted to the hospital and was suffering acute renal failure due to an accidental burning. The nephrologist inserts a temporary intraperitoneal catheter to facilitate the intraperitoneal dialysis. Code the nephrologist's services.

A patient with stomach cancer receives IV chemotherapy treatment twice a week. Today he is seen in the clinic for refill of his implantable pump. What procedure code would be appropriate for today's visit?

A physician administers an injection of Hepatitis B immune globulin (HBIG), which is obtained from pooled human plasma,IM. Which are the correct procedure codes for this service?

A patient is referred for a single-level, bilateral venous occlusion plethysmography of the legs

A 32-year-old female presents with the complaint of a seizing pain in the area of her lower hip. The chiropractor conducts an assessment of the patient and provides a chiropractic alignment to two spinal regions

A child was bitten by a dog that tested positive for rabies and is seen for an injections of rabies immune globulin.

An elderly patient visited a neighbourhood clinic to receive influenza and pneumonia immunizations.

A 35-year-old patient plans to travel a country with a high incidence of yellow fever. The patient receives the yellow fever immunization.

A patient was referred to a psychiatrist for management after displaying erratic and unusual behaviour at work. The patient disclosed a difficulty family situation and the psychiatrist arranged a family therapy session to include the patient. What is the correct code for the family psychotherapy session?

A patient receiving psychotherapy is ready to begin mainstream efforts into the community. The psychiatrist discusses the patient’s mental health history with a social agency who assists in locating employment and living arrangements.

A patient experienced a stressful personal event and met with her psychiatrist in his office for 45 minutes for the purpose of evaluating her potential to return to work.

A patient with long-time stress urinary incontinence underwent biofeedback training for improvement of urine leakage.

An inpatient with ESRD was placed on a regular schedule of haemodialysis treatments. The patient received dialysis at the hospital and was re-evaluated once by the physician for possible revision of the prescribed treatments. On re-evaluation, the physician determined no change in regimen was needed. Code for the dialysis and physician re-evaluation.

The patient is admitted to the hospital for an eight channel EEG to determine the focus of her cerebral seizures. The EEG is performed for 24 hours. Select the appropriate code for the set up and take down.

An 18-year-old ESRD patient is receiving dialysis services and has had two face-to-face visits with her physician within 25 days. On the 26th day, she was admitted to the hospital for inpatient management without a complete assessment. She remained in the hospital until the end of the month. Code for the physician services for the 25 days.

A patient with renal failure needs to begin dialysis treatments. He and his daughter both underwent complete training for managing dialysis at home.

A patient with obvious swelling in her left foot visited her physician. There was no known injury. The physician evaluated for possible blood clot before considering treatment. The physician ordered a stat duplex scan of the arteries of left leg and foot. The scan indicated no evidence of a clot.

A dialysis patient underwent a duplex scan of his hemodialysis access site to determine the pattern and blood flow in the arteries and veins.

A patient with chronic gastrointestinal disturbances underwent complete ultrasonic scanning of the intestinal vascular structure to determine if blood flow was adequate.

A patient with chronic skin rashes on the hands visits an allergist for evaluation and receives 12 percutaneous scratch tests with various household products.

A patient suffers from nasal congestion, rhinitis, and facial swelling after being stung by honeybees and undergoes allergen immunotherapy. The physician provides a single injection of bee venom.

A patient exhibits severe allergic reaction to peanuts. An allergist prepares and provides four vials of single dose antigens for the patient to inject if he accidently ingests peanut products.

A nurse practitioner who is trained genetic counsellor met with a couple and their child who has Duchenne’s muscular dystrophy. The couple us considering another child but wants to know the potential risk of the disorder in other children. The session lasted 1.5 hours.

A patient needs a renal transplant. The patient has been on dialysis and is awaiting a suitable donor. A clinical psychologist meets with the patient to assess the patient’s ability to comply with the requirements and drug regimen if a donor match is found. The session lasts 2 hours.

A 4-year-old has not reached the expected development milestones for her age group. She was referred by her paediatrician for extensive developmental testing. The psychologist initiated multiple function studies, using standardized instruments and reported the results to her paediatrician.