1. Indications: 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient’s burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with xenograft (skin substitute graft), and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient’s face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with xenograft. Finally a split thickness skin graft of 0.015 inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service?

2. The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9 o’clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be approximately 1.5 - 2 cm in maximum dimension.  Hemostasis was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished, the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the procedure and diagnosis codes.

3. Indications:55-year-old female had a sizeable 1.5 cm basal cell carcinoma on the right upper lip. She had a 2 cm defect. After excision, it was reconstructed in a first stage with a nasolabial cheek flap. The margins were clear and she is planned for the second stage.  Operative Procedure:Under intravenous sedation, patient in supine position, the face was prepped and draped. Division performed to the bridge between the base of the flap of the upper lip. Unfurled the base of the flap that was excised until it was soft and pliable. It is defatted and laid back onto the cheek with interrupted 5-0 Monocryl and running 6-0 plain catgut. Similar procedure was performed on the redundant portion of the flap and permanently set into the upper lip. Steri-strips applied. Which CPT® should be used?

4. 25-year-old male has a ruptured distal bicep tendon. An incision is made overlying the antecubital fossa. The biceps tendon was retrieved and tagged using #1 Vicryl-suture. The second incision made on the superior border of the ulna. The supinator was incised deep to expose the radial tuberosity. Threaded suture from the anterior incision through to the posterolateral incison and brought the biceps up to the radial tuberosity. A drill hole was made followed by a tap and seated 5mm corkscrew into the radial tuberosity. Two sutures placed in the biceps tendon in horizontal mattress type fashion separately to tie down the suture. Closure was then accomplished with sutures and staples. What is the correct code for this procedure?

5. Patient complains of chronic/acute arm and shoulder pain following bilateral carpal tunnel surgery. Patient is followed by pain management for over a year. Physician finally diagnoses patient with reflex dystrophy syndrome (RSD). Physician performs six trigger point injections into four muscle groups. Code the procedure(s).

6. A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure?

7. This 25-year-old male presents with deviated nasal septum. After intubation, a left hemitransfixion incision was made with elevation of the mucoperichondrium. Cartilage from the bony septum was detached and the nasoseptum was realigned and removed in a piecemeal fashion from the obstructed perpendicular plate of the ethmoid. Thereafter, 4-0 chronic was used to approximate mucous membranes. Next, submucous resection of the middle and inferior turbinates was handled in the usual fashion by removing the anterior third of the bony turbinate and lateral mucosal followed by bipolar cauterization of the posterior enlarged tip of the inferior turbinate as well as outfracturing. A small amount of silver nitrate cautery was used to achieve hemostasis. A dressing consisted of a fold of Telfa with a ventilating tube for nasal airway on each side achieved good hemostasis, patient went to recovery in good condition. What is the correct code for this procedure?

8. A 67-year-old female has CAD, atrial fibrillation, claudication and several chronic conditions that have been marginally controlled with medication. The doctor decided that the benefits outweigh the risks for her having a single vessel cardiopulmonary bypass using an arterial graft. Her medication Heparin has been stopped for several days. She was admitted in the hospital a day before the surgery. In the operating room, general anesthesia was administered. After the chest is opened the patient begins to hemorrhage and drops in blood pressure. The decision is made to stop the procedure and close the chest. How should this service be coded?

9. Mr. Y presents to outpatient surgery for placement of a dual chamber pacemaker after multiple attempts to manage his bradycardia medically. Atrial and ventricular leads were placed under fluoroscopic guidance via the subclavian vein. Testing confirmed appropriate placement and conduction. The left chest was then infiltrated with Epinephrine and a pocket was opened for placement of the generator. The leads were attached to the generator and the generator was programmed. Appropriate pacing was confirmed. The skin pocket was closed in layers and dressing placed. Select the appropriate CPT® codes.

10. A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was once beating on its own again, we attempted to induce an arrhythmia and this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for this service.

11. A patient comes in for surgery today to address complications from his previous partial enterectomy performed 5 months ago. Upon reopening the patient’s previous incision the surgeon resected the ileum and a portion of the colon. An ileocolostomy was performed to complete the procedure with no complications. The appropriate CPT® code to report is:

12. PREOPERATIVE DIAGNOSIS:History of prior colon polyps POSTOPERATIVE DIAGNOSIS:Colon polyps, diverticulosis, hemorrhoids PROCEDURE: A rectal exam was performed and revealed small external hemorrhoids. The video colonoscope was passed without difficulty from anus to cecum. The colon was well prepped. The instrument was slowly withdrawn with good views obtained throughout. There was a 3 mm polyp in the proximal ascending colon. This polyp was removed with hot biopsy forceps and retrieved. There was a 4 mm rectal polyp located 10 cm from the anus in the proximal rectum. The polyp was removed by hot biopsy forceps. There was also moderate diverticulosis extending from the hepatic flexure to the distal sigmoid colon. Code the CPT® procedure(s).

13. A patient with esophageal cancer is brought to the OR for subtotal esophagectomy. A thoracotomy incision is made and the esophagus is identified. The tumor is carefully dissected free of the surrounding structures. No invasion of the aorta or IVC is identified. The cervical esophagus is controlled with pursestring sutures and then transected above the sternal notch. The esophagus is then dissected free of the stomach and the entire specimen is removed from the chest cavity and sent to pathology. The stomach is then pulled into the chest cavity and anastomosed to the remaining cervical esophageal stump. The anastomosis is tested for patency and no leaks are found. Hemostasis is assured. The chest is examined for any signs of additional disease but is grossly free of cancer. The chest is closed in layers and a chest tube is place through a separate stab incision. The patient tolerated the procedure well and was taken to the PACU in stable condition.

14. Patient with RUQ pain and nausea suspected of having a stone or other obstruction in the biliary tract is brought in for ERCP under radiologic guidance. Procedure:The patient was brought to the outpatient endoscopy suite and placed supine on the table. The mouth and throat were anesthetized. Under radiologic guidance, the scope was inserted through the oropharynx, esophagus, stomach, and into the small intestine. The ampulla of Vater was cannulated and filled with contrast. It was clear that there was an obstruction in the common bile duct. The endoscope was advanced retrograde to the point of the obstruction, which was found to be a stone that was removed with a stone basket. The rest of the biliary tract was visualized and no other obstructions or anomalies were found. The scope was removed without difficulty. The patient tolerated the procedure well.

15. Newborn male is scheduled for a circumcision. He is sterilely prepped and draped; a penile nerve block is performed. The circumcision is performed by a ring device. Hemostasis is achieved. Vaseline Gauze dressing applied. Patient tolerated the procedure well. How would this encounter be coded?

16. A laparoscopic assisted total hysterectomy is planned for a patient who has severe intramural fibroids. After inserting the laparoscope, extensive adhesions are noted to the extent that the ligaments supporting the uterus cannot be visualized. The physician decides to convert the procedure to an open abdominal hysterectomy in which the uterus and cervix are removed. What CPT® code(s) should be reported?

17. Patient has consented for further testing to determine the extent of her cervical dysplasia. A cervical cone biopsy of endocervical tissue was cut using a laser. It was tagged with a single stitch. Dilation and curettage was performed. Small amount of tissue was obtained and sent to pathology.  Which procedure code(s) should be used?

18. 58-year-old female has lumbar degenerative spondylolisthesis with severe stenosis and instability. The spinous process of L4 and L5 are decompressed bilaterally by performing a laminectomies, right-sided forminotomies and then left-sided facetectomy completely decompressing the nerve roots as well as the dura. How is this procedure reported?

19. Operation:Replacement of shunt valve with medium pressure ventriculo-peritoneal shunt assembly with in-line 0-25 Aesculap Shunt Assistant Implant ICP Monitor. Procedure:After obtaining general anesthesia, patient prepped and draped. Right parietal scalp incision was reopened and shunt catheter identified. The shunt reservoir was delivered from the wound and the distal catheter freed from it. Abdominal incision reopened, shunt passer was used to bring the distal catheter from the head wound to the abdominal wound. The old ventricular catheter was removed. A new ventricular-catheter was inserted into the tract of the old catheter and fed, good flow seen. It was then attached to the shunt reservoir that was then seated after attaching a 0-25 shunt assistant valve to it. The distal catheter was then fed into the peritoneal cavity. Subcutaneous tissues were closed in multi-layer fashion and skin with staples. Patient tolerated the procedure well and taken to PICU in stable condition. Code this procedure.

20. Physician is performing an intracapsular cataract extraction. The anterior chamber of the eye is entered performing an anterior capsulotomy using forceps. The lens nucleus was hydrodissected and loosened. Using phacoemulsification unit, the lens nucleus was divided and emulsified. Cortical and capsular fragments were removed. The anterior chamber and capsule bag inflated. Using lens inserter an intraocular lens prosthesis, Cystalens, was inserted and rotated to the horizontal position. Topical solution applied, conjunctiva repositioned over the wound with wet field cautery and patch applied. Which CPT® code(s) should be reported?

21. Physician performs a medical review and documentation on an 83-year-old patient who has been in the hospital for the last two days with confusion. Problem focused exam where she is alert and oriented x 3 today. Low medical decision making by ordering an echocardiogram and to continue IV fluids. Patient is not safe to return home. What CPT® code should be reported for this visit?

22. A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that arrived with multiple facial fractures that may need surgery. Patient was in an automobile accident and an opinion is needed for reconstructive surgery. The plastic surgeon arrives at the ED, obtains detailed history and performs a detailed exam. The plastic surgeon performs a moderate medical decision making, in deciding that the patient needs major surgery to repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with findings in the ED chart. The E/M service reported by the plastic surgeon is:

23. At the request of the mother’s obstetrician, a neonatologist is called to attend the birth of an infant being delivered at 29 weeks gestation. During delivery, the neonate was pale and bradycardic needing resuscitation. Neonatologist performs the suctioning and bag ventilation on this 1000 gram neonate was performed with 100 percent oxygen. Brachycardia worsened; endotracheal intubation was performed and insertion of an umbilical line for fluid resuscitation. Later this critically ill neonate was moved from the delivery room and admitted to the NICU with severe respiratory distress and continued hypotension. What are the appropriate procedure codes reported by the neonatologist?

24. Patient is admitted in labor for delivery. She received a labor neuraxial epidural for a vaginal delivery. The baby goes into fetal distress and a cesarean section is performed. Following delivery the patient starts to hemorrhage. The physician decides, with family approval, to perform a hysterectomy. Code the anesthesia services.

25. Angiograms reveal three artery blockages. The patient has COPD, which is a severe systemic disease. The patient undergoes a CABG X 3 venous grafts on cardiopulmonary bypass and cell saver. Code the anesthesia service.

26. A healthy 11-month-old patient with bilateral cleft lip and palate undergoes surgery. The surgeon performs a bilateral cleft lip repair, single stage. Code the anesthesia service.

27. A 78-year-old with lower back pain and leg pain is scheduled for a MRI of lumbar spine without contrast. Following the MRI, the patient is diagnosed with spinal stenosis of the lumbar region. What are the procedure and diagnosis codes?

28. 22-year-old driver loss control of her car and crashed into a light pole on the highway.  She arrived to the hospital by ambulance in an unconscious state. She had CT scans without contrast of the brain and chest. She had X-rays of AP and PA views of her left ribs and AP and PA views of her right ribs with a posterioanterior view of the chest. The CT scan of the brain showed a fracture of the skull base with no hemorrhage of the brain. The CT of the lung showed no puncture of the lungs. The X-ray showed fractures in her second, third, and fifth ribs. What CPT® and ICD-9-CM codes should be reported.

29. The physician orders an ultrasound on a patient 25 weeks pregnant with twins to access fetal heart rate and fetal position. Select the code(s).

30. A patient presents to the ED with crushing chest pain radiating down the left arm and up under the chin. There are elevated S-T segments on EKG. The cardiologist sees and admits the patient to CCU. He orders three serial CPK enzymes levels with instructions that the tests are also to be done with isoenzymes if the initial tests are elevated for that date of service. The CPK enzyme levels were elevated, the lab codes would be:

31. 22-year-old has had no prenatal care. Fundal height indicates a term fetus and by dates it is determined she is 38 weeks pregnant. Few hours prior to admission to Labor and Delivery her membranes ruptured spontaneously. She does not have fever, but the physician performs a rapid antigen test for group B strep. An enzyme immunoassay method is performed. Physician obtains a lower vaginal swab, then observes that it visually shows the patient is negative for the antigen. If clinical risk factors appear, intrapartum antibiotics will be initiated. Which lab test is reported?

32. The patient presents with burning urination and frequency. The physician performs a UA dipstick, which shows elevated WBC. He orders a urine culture with identification for each isolate to determine which antibiotic to give to the patient for the infection. What are the appropriate lab codes?

33. Which of the following coding combinations is an example of unbundling?

34. 69-year-old female has been having chest tightness. Cardiologist orders percutaneous transluminal coronary angioplasty (PCTA) of the right coronary artery and left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel of the left anterior descending coronary artery and right coronary artery. Stents were inserted in both arteries to keep the arteries opened. Patient was placed under moderate conscious sedation during the procedure for a total of 30 minutes. What CPT® codes should be reported for this procedure?

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

36. 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:

37. While playing softball a 12-year-old boy sustains a blowout fracture. What is the anatomical location of a blowout fracture?

38. A pediatrician examines an adolescent that has a thoracic curvature of the spine which is called:

39. The root metr/o means:

40. According to the CPT® Appendix L, when performing a selective vascular catheterization, which vessels would you pass through to place the catheter into the right middle cerebral artery?

41. 42-year-old male was previously treated with external fixation of a trimalleolar fracture. He is now presenting with a nonunion fracture of the medial and lateral malleoulus.  What are the ICD-9-CM codes to report?

42. Mr. Jones is here today to receive an intercostal nerve block to mitigate the debilitating pain of his malignancy. His cancer has metastasized to his lungs. Select the appropriate ICD-9-CM codes.

43. 55-year-old female presents to the office with ongoing history of diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetes on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe.

44. 32-year-old delivered a baby girl one week ago via cesarean section. She is in the obstetrician’s office with complaint of her cesarean wound bleeding. The wound is cleaned, the edges pulled with steri-strips, and a clean dressing is applied. What ICD-9-CM code(s) should be reported?

45. 70-year-old had fallen breaking her jaw. She has had difficulty eating after having her jaw wired. Her doctor ordered a stationary parenteral nutrition infusion pump for her TPN. A seven day supply of a parenteral home mix nutrition supply kit was also given. What HCPCS Level II codes are reported?

46. A patient has an insulin pump of 100 units. The pump is filled. Which code reports the supply?

47. When coding for a patient who has had a primary malignancy of the thyroid cartilage that was completely excised a year ago, which of the following statements is TRUE?

48. In order to use the critical care codes, which of the following statements is TRUE?

49. Which of the following statements regarding advanced beneficiary notices (ABN) is TRUE?

50. Which of the following services are covered by Medicare Part B?