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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q59-Q64):

NEW QUESTION # 59
A provider documents that he spent 20 minutes with a patient. Based on this, an E/M can be chosen solely based on time.

A. False
B. True

Answer: B

Explanation:
The statement is true. According to AMA time documented is considered the minimum time the physician or other qualified health care professional spent on face-to-face and non-face-to-face services. This includes time spent reviewing the patient's medical record, consulting other healthcare professionals, or ordering prescriptions, tests, and/or other services.

NEW QUESTION # 60
A mammogram is done on a patient who has a lump on her right breast at 4 0'clock and a lump in her left breast at 6 0'clock. What CPT and ICD-IO-CM code(s) should be reported?

A. 77065-50, N63.13, N63.20
B. 77066, N63.14, N63.25
C. 77067, D49.3
D. 77067, D48.61, D48.62

Answer: B

Explanation:
CPT code 77067 is a screening mammogram. In this case, the mammogram would be diagnostic because the purpose is to rule out and/or make a diagnosis based on physical exam findings. Code 77065-50 is an inappropriate use of the modifier because there exists a bilateral procedure code. A breast lump should only be coded to "mass" and not as a neoplasm unless specifically stated in the diagnosis. When deciphering the location of the mass, 12 0'clock is at the top of each breast, and the point of movement is clockwise. Therefore, 4 0'clock in the right breast is equivalent to the lower-inner quadrant, and 6 0'clock in the left breast is in the middle ofthe t".vo lower quadrants.

NEW QUESTION # 61
What would be considered a sequela to an injury?

A. Foreign body removal from a laceration
B. Chronic pain persisting after an injury has healed
C. Prescription drug management
D. Removal of an external fixation device

Answer: B

Explanation:
Per ICD-IO-CM, a sequela describes "complications or conditions that arise as a direct result of a condition." In this case, the chronic pain would be a condition that resulted from a prior injury.
Removal of a foreign body is active treatment of a laceration. Removal of a fixation device and prescription drug management are both considered routine and subsequent care.

NEW QUESTION # 62
The CPT code 76805 requires that multiple elements of the exam be documented, such as the evaluation of the amniotic fluid, umbilical cord insertion site, and placental location. If the provider documents most elements, he/she can bill the CPT code 76805.

A. True
B. False

Answer: B

Explanation:
The statement is false. Per ICD-IO-CM, "Results must be documented in the report for each of the elements described in the code description." If the provider does not document a given element, they must include a reason for non-visualization for the CPT to be reported.

NEW QUESTION # 63
Code the following physician's note:
A 14-year-old established patient is seen with mother to evaluate five 2 cm superficial lacerations to the left wrist. Patient admits to suicidal thoughts.
Lacerations were treated with Steri-Strips. Patient and mother counseled on suicide prevention and told to follow up with psych.

A. 12004, S61.512A, T14.91XA
B. 12004, S61.512A, R45.851
C. 99214, S61.512A, T14.91XA
D. 99213, S61.512A, R45.8S1

Answer: D

Explanation:
When the injury is treated with Steri-Strips or bandages, it should be reported with an E/M code and not a procedure code. Within the medical decision making, the number and complexity of problems addressed is low, the amount of data reviewed or analyzed is straightforward, and the risk of complications and/or morbidity or mortality of patient management from the injuries is low.
Therefore, the E/M is a 99213 because the medical decision-making is low. A suicide attempt would not be coded because the documentation is not specific as to whether the lacerations were an attempt at suicide.

NEW QUESTION # 64
......

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