Medical Coding Certification Exam Preparation 2nd Edition By Stewart – Exam Bank

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Medical Coding Certification Exam Preparation 2nd Edition By Stewart – Exam Bank

 

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Medical Coding, 2e (Stewart)

Chapter 3   ICD-10-CM Chapter-Specific Guidelines

 

1) Not all chapters have guidelines for coding conditions within the chapters because:

  1. A) guidelines for some of the chapters have not yet been developed
  2. B) guidelines have been developed but are not yet published
  3. C) some guidelines conflict with those provided in the general guidelines and are not published to reduce confusion
  4. D) guidelines are not necessary for some chapters

 

2) The Chapter Specific Coding Guidelines are found in:

  1. A) Section I, A
  2. B) Section I, B
  3. C) Section I, C
  4. D) Section I, D

 

3) Select the best answer for the following: The guidelines at the ________ level(s) supersede the chapter-specific guidelines.

  1. A) chapter
  2. B) section
  3. C) chapter, section, and code
  4. D) code and section

 

4) Guidelines for Chapter 1, Infectious and Parasitic Diseases, include correct coding guidelines for:

  1. A) HIV, SIRS, and cellulitis
  2. B) HIV, septicemia, and SIRS only
  3. C) HIV, sepsis, and severe sepsis only
  4. D) HIV, sepsis, severe sepsis, septic shock, MRSA and ZIKA virus

 

5) Guidelines for correct coding of Admission/encounter for therapy of neoplasms are found in Section, Subsection:

  1. A) I, C, 2, e
  2. B) I, C, 2, d
  3. C) I, C, 2, h
  4. D) I, C, 2, i

 

6) Section, Subsection I, C, 2, a provides a specific guideline for:

  1. A) Coding and sequencing of complications
  2. B) Treatment directed at the malignancy
  3. C) Treatment of secondary site
  4. D) Determining extent of malignancy

 

 

7) Correct coding guidelines regarding Treatment of secondary neoplasm site are outlined in Section, Subsection:

  1. A) I, C, 2, g
  2. B) I, C, 2, e
  3. C) I, C, 2, b
  4. D) I, C, 2, a

 

8) Guidelines regarding correct Coding and sequencing of complications associated with malignancies or with therapy are found in Section, Subsection:

  1. A) I, C, 2, c
  2. B) I, C, 2, d
  3. C) I, C, 2, h
  4. D) I, C, 2, i

 

9) Section, Subsection I, C, 2, d provides correct coding guidelines for:

  1. A) Admission/encounter for therapy
  2. B) Symptoms, signs, and ill-defined conditions associated with neoplasms
  3. C) Coding and sequencing of complications
  4. D) Primary malignancy previously excised

 

10) Coding guidelines for determining the extent of the malignancy are found in Section, Subsection:

  1. A) I, C, 2, g
  2. B) I, C, 2, h
  3. C) I, C, 2, e
  4. D) I, C, 2, f

 

11) Section, Subsection I, C, 2, g covers guidelines regarding:

  1. A) Treatment directed at the malignancy
  2. B) Admission/encounter for therapy
  3. C) Symptoms, signs, and ill-defined conditions associated with neoplasms
  4. D) Malignant neoplasm associated with transplanted organ

 

12) Admission/encounter for pain management is discussed in Section, Subsection:

  1. A) I, C, 2, h
  2. B) I, C, 2, i
  3. C) I, C, 6, b
  4. D) I, C, 2, e

 

13) Section, Subsection I, C, 2, i provides correct coding guidelines for:

  1. A) Admission/encounter for pain management
  2. B) Malignancy in two or more contiguous sites
  3. C) Coding and sequencing of complications
  4. D) Primary malignancy previously excised

 

 

14) When coding for human immunodeficiency virus (HIV) and HIV-related conditions, the coder must understand the current state of the ________ in relation to the condition of HIV.

  1. A) treatment
  2. B) medication
  3. C) patient
  4. D) physician

 

15) Only if the condition is ________ can a coder select a code from category B20, human immunodeficiency virus (HIV) disease.

  1. A) suspected
  2. B) probable
  3. C) confirmed by test results as stated in a laboratory report
  4. D) confirmed by a statement by the provider in the documentation

 

16) A coder reviews a patient’s medical chart and reads a laboratory report of blood work ordered by the physician after the patient’s last visit. The patient presented with a chief complaint of general weakness and persistent cough as documented in the medical record and no further definitive diagnosis is documented. The coder sees that presence of HIV is confirmed in the laboratory report. The coder should:

  1. A) Code HIV only
  2. B) Code HIV, general weakness, and persistent cough
  3. C) Code general weakness only
  4. D) Code general weakness and persistent cough

 

17) Which of the following is not required to select an HIV code?

  1. A) confirmed diagnosis in the documentation
  2. B) provider’s documentation of an HIV diagnosis
  3. C) a positive test result confirming an HIV diagnosis
  4. D) a provider’s statement regarding HIV diagnosis

 

18) The presence of ________ signifies a progression of HIV disease from asymptomatic to symptomatic and shifts a patient’s diagnosis from HIV to AIDS.

  1. A) opportunistic infections
  2. B) bacterial infections
  3. C) viral infections
  4. D) generalized weakness

 

19) When an opportunistic infection, such as Kaposi’s sarcoma of the lung, is documented in an HIV-positive patient’s record, how may the coder report this diagnosis?

  1. A) Z21
  2. B) C46.50
  3. C) B20
  4. D) B20, C46.50

 

 

20) All of the following are HIV-related opportunistic infections except:

  1. A) Tuberculosis
  2. B) Gonorrhea
  3. C) Syphilis
  4. D) Candidiasis

 

21) All of the following are HIV-related opportunistic infections except:

  1. A) Molluscum contagiosum
  2. B) Microsporidiosis
  3. C) Toxoplasmosis
  4. D) Rickettsioses

 

22) All of the following are HIV-related opportunistic infections except:

  1. A) Isosporiasis
  2. B) Psoriasis
  3. C) Cytomegalovirus
  4. D) Cryptosporidiosis

 

23) All of the following are HIV-related opportunistic infections except:

  1. A) Cryptococcal meningitis
  2. B) Aspergillosis
  3. C) Peripheral neuropathy
  4. D) Lordosis

 

24) All of the following are HIV-related opportunistic infections except:

  1. A) Lymphomas
  2. B) Herpes simplex or zoster virus
  3. C) Molluscum contagiosum
  4. D) Leukemia

 

25) When an opportunistic infection is present, which of the following is true regarding code selection?

  1. A) An HIV code only is required
  2. B) An AIDS code only is required
  3. C) An HIV code and a code identifying the opportunistic infection are required; the HIV code is always sequenced first
  4. D) An AIDS code and a code identifying the opportunistic infection are required; the sequencing is dependent upon the reason for the visit and if other conditions are present

 

 

26) A 35-year-old male patient presents to the Emergency Room with a chief complaint of severe pain in the right hand after sustaining a fall down a flight of concrete steps at his apartment complex. Upon examination, the patient sustained multiple closed fractures to the hand. The patient is also HIV positive and suffers from peripheral neuropathy. Select the appropriate code selection and sequence to report for this patient:

  1. A) S62.91XA, B20, G99.0
  2. B) Z21, G99.0, S62.91XA
  3. C) S62.91XA, Z21, G99.0
  4. D) B20, S62.91XA, G99.0

 

27) Diagnosis code Z11.4 represents:

  1. A) Encounter for screening for human immunodeficiency virus (HIV)
  2. B) High-risk lifestyle
  3. C) Screening for other specified viral disease
  4. D) Inconclusive serologic test for human immunodeficiency virus

 

28) Counseling for human immunodeficiency virus (HIV), when a patient returns for test results and the test result is negative, is described by which ICD-10-CM code?

  1. A) Z11.59
  2. B) Z72.89
  3. C) Z71.7
  4. D) R75

 

29) Which ICD-10-CM code describes “Inconclusive laboratory evidence of human immunodeficiency virus?”

  1. A) R75
  2. B) Z72.89
  3. C) Z11.59
  4. D) Z21

 

30) Patient is being seen to determine their HIV status and they suspect they have been exposed to the HIV virus, select the appropriate code(s).

  1. A) Z72.9
  2. B) Z11.4, Z72.9
  3. C) Z11.4
  4. D) Z21

 

31) The body’s response to septicemia, trauma, or cancer is:

  1. A) septic shock
  2. B) severe sepsis
  3. C) sepsis
  4. D) systemic inflammatory response syndrome

 

 

32) Severe sepsis is:

  1. A) sepsis with organ failure
  2. B) a form of organ failure of the vascular system
  3. C) the presence of toxins or disease in the blood
  4. D) a response specifically to an infection

 

33) Septicemia is:

  1. A) sepsis with organ failure
  2. B) a form of organ failure of the vascular system
  3. C) the presence of toxins or disease in the blood
  4. D) a response specifically to an infection

 

34) A progressive condition that may or may not begin with an infectious process but may result in organ failure and loss of life is:

  1. A) systemic inflammatory response syndrome
  2. B) septicemia
  3. C) sepsis
  4. D) severe sepsis

 

35) A response specifically to an infection is:

  1. A) systemic inflammatory response syndrome
  2. B) septicemia
  3. C) sepsis
  4. D) severe sepsis

 

36) A form of organ failure of the vascular system is:

  1. A) septic shock
  2. B) severe sepsis
  3. C) sepsis
  4. D) systemic inflammatory response syndrome

 

37) As septic shock is organ failure due to sepsis, documentation of septic shock alone indicates the presence of ________, and coding this condition requires two codes.

  1. A) septic shock
  2. B) severe sepsis
  3. C) sepsis
  4. D) systemic inflammatory response syndrome

 

38) Coding of sepsis requires a minimum of ________ code(s).

  1. A) one
  2. B) two
  3. C) three
  4. D) four

 

 

39) Documentation of all of the following could result in a diagnosis of SIRS except:

  1. A) Brachycardia
  2. B) Tachypnea
  3. C) Body Temperature
  4. D) White Blood Count

 

40) Regarding SIRS, tachycardia is defined as:

  1. A) Heart rate greater than 80 beats per minute
  2. B) Heart rate greater than 90 beats per minute
  3. C) Heart rate greater than 100 beats per minute
  4. D) Heart rate greater than 110 beats per minute

 

41) Regarding SIRS, hypothermia is defined as:

  1. A) Body temperature less than 98.6 degrees Fahrenheit
  2. B) Body temperature less than 98.0 degrees Fahrenheit
  3. C) Body temperature less than 97.8 degrees Fahrenheit
  4. D) Body temperature less than 97.6 degrees Fahrenheit

 

42) Regarding SIRS, tachypnea is defined as:

  1. A) Respiratory rate greater than 40 breaths per minute
  2. B) Respiratory rate greater than 30 breaths per minute
  3. C) Respiratory rate greater than 20 breaths per minute
  4. D) Respiratory rate greater than 10 breaths per minute

 

43) Aside from infection, under what circumstance can the body develop SIRS?

  1. A) age
  2. B) trauma
  3. C) contagion
  4. D) mutation

 

44) Which of the following is an antibiotic resistant staph infection?

  1. A) MSSA
  2. B) MRA
  3. C) MRSA
  4. D) MSA

 

 

45) A 27-year-old pregnant female in her second trimester presents with MSSA. Select the appropriate code selection and sequence:

 

A41.01 Sepsis due to Methicillin susceptible staphylococcus aureus

B95.61 Methicillin susceptible staphylococcus aureus as the cause of diseases classified elsewhere

O98.812 Other maternal infectious and parasitic diseases complicating pregnancy, second trimester

 

  1. A) O98.812, A41.01
  2. B) O98.812, A41.01, B95.61
  3. C) A41.01, B95.61, O98.812
  4. D) O98.819, A41.01

 

46) Chapter 2, Neoplasms, contains most, but not all, codes for benign and malignant neoplasms. Some neoplasm codes are located in:

  1. A) Injury and Poisoning
  2. B) Signs, Symptoms, and Ill-Defined Conditions
  3. C) the chapters specific to the neoplasms’ anatomical sites
  4. D) the Neoplasm table only

 

47) When locating a code for a neoplasm, begin by:

  1. A) referencing the Table of Neoplasms
  2. B) indexing the histologic term
  3. C) indexing the anatomical site
  4. D) indexing “benign” or “malignant”

 

48) If a coder has reviewed the subterms listed and cannot find the condition documented, the coder should return to the main term and look for a note stating:

  1. A) See
  2. B) Code first
  3. C) See also
  4. D) Code first underlying condition

 

49) The site of origin of the malignancy is referred to as:

  1. A) benign
  2. B) secondary neoplasm
  3. C) malignant
  4. D) primary neoplasm

 

50) An invasive tumor that spreads beyond the tumor site is said to be:

  1. A) malignant
  2. B) benign
  3. C) primary neoplasm
  4. D) secondary neoplasm

 

51) The spread or metastases of a malignancy is the:

  1. A) secondary neoplasm
  2. B) primary neoplasm
  3. C) malignant
  4. D) benign

 

52) If a primary site, due to excision or therapy, no longer exists and the patient is receiving treatment for a secondary site, the primary site is coded with:

  1. A) family history Z code
  2. B) personal history Z code
  3. C) Signs, Symptoms, and Ill-Defined Conditions code
  4. D) no code is assigned

 

53) A patient presents with a primary neoplasm of the left femur (C40.22) and is admitted for chemotherapy treatment (Z51.11). During the course of treatment, the patient experiences severe nausea and is treated for the nausea in this encounter (R11.0). Select the appropriate code assignment and sequence for this scenario:

  1. A) R11.0, Z51.11
  2. B) R11.0, Z51.11, C40.22
  3. C) C40.22, Z51.11, R11.0
  4. D) Z51.11,C40.22, R11.0

 

54) Select the true statement regarding ICD-10-CM guidelines for the Neoplasms chapter:

  1. A) sequencing of anemia and neoplasms is dependent on the type of malignancy of the neoplasm
  2. B) If anemia is due to neoplasm, sequence the code for the neoplasm before the appropriate code for the type of anemia
  3. C) For advanced metastatic disease, coders are directed to select a “Disseminated malignant neoplasm, unspecified” from the Signs, Symptoms, and Ill-Defined Conditions chapter
  4. D) admissions for chemotherapy are no longer described by one ICD-10-CM code

 

55) Diabetes due to an underlying condition or cause is referred to as:

  1. A) insulin-dependent diabetes
  2. B) severe diabetes
  3. C) autonomous diabetes
  4. D) secondary diabetes

 

56) The categories E10, E11, E13 for diabetes reflect what specificity?

  1. A) the type of complications
  2. B) the status of control of the condition
  3. C) whether daily insulin is needed for control of the condition
  4. D) the type of diabetes

 

 

57) ICD guidelines state that if the type of diabetes is not documented:

  1. A) the coder may not assign a code until the physician is queried
  2. B) the coder may not assign a code for diabetes
  3. C) type I diabetes is coded
  4. D) type II diabetes is coded

 

58) Select the false statement regarding use of code Z79.4:

  1. A) it is not appropriate to use in conjunction with a code for type I diabetes
  2. B) it is possible that this code will not be used with a code for type II diabetes
  3. C) it is appropriate to use in conjunction with a code for type II diabetes when applicable
  4. D) it is appropriate to use in conjunction with a code for type I diabetes when applicable

 

59) When an insulin pump malfunctions leading to underdosing, select the appropriate reporting and sequencing of resulting conditions:

  1. A) code first the reason for the pump’s presence, then the mechanical complication due to the insulin pump, the appropriate diabetes code, and any additional codes for conditions resulting from the underdosing
  2. B) code first conditions resulting from the underdosing, then the mechanical complication due to the insulin pump, then the reason for the pump’s presence, followed by the appropriate diabetes code
  3. C) code first the mechanical complication due to the insulin pump, then the underdosing of insulin, the appropriate diabetes code, and any additional codes for conditions resulting from the underdosing
  4. D) code first the appropriate diabetes code, then the mechanical complication due to the insulin pump, then the reason for the pump’s presence, and any additional codes for conditions resulting from the underdosing

 

60) Categories E08 through E13 are subdivided first by the type or cause of diabetes, then by:

  1. A) duration of the diabetes
  2. B) the insulin dependence of the patient
  3. C) affected body system or manifestation of diabetes
  4. D) the status of control and the type of diabetes

 

61) Most of the codes listed in Categories E08 through E13 are:

  1. A) stand-alone
  2. B) combination
  3. C) sequenced
  4. D) secondary

 

62) When a diabetes-related complication is associated with an organ system, how many codes are typically needed to completely describe the diagnostic statement?

  1. A) two
  2. B) three
  3. C) one
  4. D) four

 

63) When an insulin pump malfunctions leading to overdosing, select the appropriate reporting and sequencing of resulting conditions:

  1. A) code first the mechanical complication due to the insulin pump, then poisoning by insulin, the appropriate diabetes code, and any additional codes for conditions resulting from the overdosing
  2. B) code first conditions resulting from the overdosing, then the mechanical complication due to the insulin pump, then the reason for the pump’s presence, then poisoning by insulin, followed by the appropriate diabetes code
  3. C) code first the reason for the pump’s presence, then poisoning by insulin, then the mechanical complication due to the insulin pump, the appropriate diabetes code, and any additional codes for conditions resulting from the overdosing
  4. D) code first the appropriate diabetes code, then the mechanical complication due to the insulin pump, then poisoning by insulin, then the reason for the pump’s presence, and any additional codes for conditions resulting from the overdosing

 

64) Select the correct sequencing of codes when the reason for a patient’s encounter is treatment of a condition resulting from diabetes when the diabetic condition is due to malnutrition:

  1. A) code the reason for the encounter (underlying condition) only
  2. B) code the diabetes only
  3. C) code the diabetes first, followed by the reason for the encounter (underlying condition)
  4. D) code underlying cause of the diabetes, then the diabetes, followed by the diabetic manifestation

 

65) Patient presents with postpancreatectomy diabetes mellitus following partial removal of the pancreas. Select the appropriate code(s).

  1. A) Z90.410
  2. B) E89.1
  3. C) E89.1, E13.-, Z90.411
  4. D) Z90.411Medical Coding, 2e (Stewart)

    Chapter 5   Evaluation and Management

     

    1) The Evaluation and Management (E/M) section of the CPT manual contains the codes ranging from:

    1. A) 99101-99499
    2. B) 99201-99999
    3. C) 99201-99499
    4. D) 99101-99999

     

    2) All of the following are categories included in the E/M section of the CPT manual except:

    1. A) preventive medicine services
    2. B) care management services
    3. C) psychiatric services
    4. D) emergency services

     

    3) All of the following are categories included in the E/M section of the CPT manual except:

    1. A) office services
    2. B) hospital services
    3. C) critical care services
    4. D) palliative services

     

    4) The E/M section is used to tell the story of the services provided to the patient in a(n):

    1. A) outpatient setting
    2. B) inpatient setting
    3. C) laboratory encounter
    4. D) Both outpatient setting and inpatient setting

     

    5) The E/M section is often the most difficult for coders to understand and use correctly because:

    1. A) no guidelines are provided for this section
    2. B) this section is based on applying measurements to the provider’s work
    3. C) conflicting guidelines are provided for this section and its subsections
    4. D) this section is newly developed and unfamiliar to coders

     

    6) To select the appropriate code from this section:

    1. A) The provider must dictate the appropriate CPT code in the documentation
    2. B) The coder must be able to abstract necessary information from the provider’s dictation
    3. C) The coder must be able to accurately compare services provided by several providers
    4. D) The provider must document time, counseling, and coordination of care for each visit

     

    7) Codes 99201-99215 contain:

    1. A) outpatient services
    2. B) inpatient services
    3. C) counseling services
    4. D) screening services

     

    8) The actual time the provider or qualified healthcare professional spends with the patient and/or family in the office or outpatient setting is called:

    1. A) counseling time
    2. B) review of systems
    3. C) face-to-face time
    4. D) personal, family, and social history

     

    9) Face-to-face time is:

    1. A) the hours a provider works each day
    2. B) the amount of time a patient spends in the office
    3. C) the actual time a provider or qualified healthcare professional spends with the patient and/or family
    4. D) the amount of time a coder and provider speak about a patient’s case

     

    10) In the hospital, face-to-face time is calculated by:

    1. A) the amount of time the physician spends on the floor or unit that is related to the care given to the patient
    2. B) the amount of time the physician spends speaking with the patient and/or family in the hospital room
    3. C) the amount of time the nurse and provider spend speaking about the patient’s case
    4. D) the amount of time the physician spends in that hospital on the date of service

     

    11) It is required that ________ key component(s) are met when selecting a code from 99201-99205:

    1. A) Four
    2. B) Three
    3. C) Two
    4. D) One

     

    12) Established patient office visit codes are included in the range:

    1. A) 99211-99215
    2. B) 99201-99205
    3. C) 99401-99405
    4. D) 99311-99315

     

    13) How many key components must be met in order to select a code from the Established Patient 99211-99215 code range?

    1. A) one
    2. B) two
    3. C) three
    4. D) four

     

     

    14) The only code in the 99211-99215 range that does not need to meet key component requirements is:

    1. A) 99215
    2. B) 99214
    3. C) 99212
    4. D) 99211

     

    15) Hospital Observation Services codes describe examinations provided in:

    1. A) the Emergency Room
    2. B) an outpatient, provider’s office
    3. C) a designated observation status room in a hospital
    4. D) an inpatient hospital room

     

    16) Code 99217 describes:

    1. A) Subsequent Observation Care
    2. B) Observation or Inpatient Care Services (Including Admission and Discharge Services)
    3. C) Initial Observation Care
    4. D) Observation Care Discharge Services

     

    17) Select the statement that is not true regarding code 99217, Observation Care Discharge Services:

    1. A) there is no key component requirement
    2. B) there is no time requirement
    3. C) this code may be reported with an inpatient initial service
    4. D) instructions for post-discharge care may occur during this service

     

    18) Code 99217, Observation Care Discharge Services, may describe which of the following services:

    1. A) final examination, instructions for post-discharge care, and preparation of discharge forms
    2. B) initiation of observation status, final examination, and preparation of discharge forms
    3. C) services provided during observation status after the initial-observation care has occurred
    4. D) services provided when a patient is admitted and discharged on the same day

     

    19) If a patient is admitted into observation status and then is admitted to inpatient status on the same day, the coder may:

    1. A) assign an Initial Observation Care code and an Initial Hospital Care code
    2. B) assign only an Initial Observation Care code
    3. C) assign only an Initial Hospital Care code
    4. D) assign either an Initial Observation Care code or an Initial Hospital Care code depending on the amount of time the provider spent with the patient in each status

     

     

    20) Patient Sally by Dr. Lane in the office on January 11. Upon examination, Dr. Lane recommended that Sally be transferred to the hospital for observation of her increasing heart palpitations. Dr. Lane followed up with Sally later that day in the observation room to monitor her progress. Select the appropriate code ranges and sequencing to describe these services:

    1. A) Initial Observation Care (99218-99220), followed by (99241-99245) Office or Other Outpatient Consultations
    2. B) Inpatient Consultations (99251-99255), followed by Initial Observation Care (99218-99220)
    3. C) Initial Observation Care (99218-99220), followed by Established Patients Office or Other Outpatient Services (99211-99215)
    4. D) Initial Observation Care (99218-99220)

     

    21) Subsequent Observation Care (99224-99226) is used for:

    1. A) observation or inpatient care if the patient is admitted and discharged on the same day
    2. B) final examination, instructions for post-discharge care, and preparation of discharge forms
    3. C) services provided during observation status after the initial-observation care has occurred
    4. D) the first encounter a physician has with an observation status patient

     

    22) All of the following are true of Initial Hospital Care (99221-99223) codes except:

    1. A) Time must be documented in order to select a code
    2. B) All three key components must be met
    3. C) These codes are used for the attending physician’s initial encounter with the inpatient
    4. D) These may be referred to as the admission versus initial encounter

     

    23) To obtain a level 99222 or 99223 code, a(n) ________ exam must have been performed and documented.

    1. A) problem-focused
    2. B) expanded problem-focused
    3. C) detailed
    4. D) comprehensive

     

    24) The “three R’s” regarding consultations are:

    1. A) request, refer, and render
    2. B) request, render, and report
    3. C) refer, recommend, and report
    4. D) refer, render, and report

     

    25) The major factor for using the consultation range of codes is the ________ of the service:

    1. A) extent
    2. B) intent
    3. C) length
    4. D) significance

     

     

    26) A visit that is requested in writing and that involves the rendering of an opinion and the compilation of a written report is:

    1. A) referral
    2. B) transfer or care
    3. C) consultation
    4. D) specialty office visit

     

    27) The transferring of care for the patient’s present illness is:

    1. A) specialty consultation
    2. B) consultation
    3. C) routine office visit
    4. D) referral

     

    28) A patient presents to the provider’s office with swelling of the face and hands after beginning an amoxicillin treatment three days ago. The patient has no current known drug allergies; the physician requests in writing that an allergist evaluate the patient, render an opinion, and supply a written report stating the opinion. This is an example of a(n):

    1. A) Expert request
    2. B) Consultation
    3. C) Referral
    4. D) Request of opinion

     

    29) Select the true statement regarding consultations:

    1. A) Inpatient consultations distinguish between new and established patients; office or other outpatient consultations do not distinguish between new and established patients
    2. B) Inpatient consultations require that two of the three key components be met for the level of service; office or other outpatient consultations require that all three key components must be met for the level of service
    3. C) Both inpatient and office or other outpatient consultations require that all three key components must be met for the level of service
    4. D) Inpatient consultations do not distinguish between new and established patients; office or other outpatient consultations distinguish between new and established patients

     

    30) Services provided in a 24-hour facility to an unscheduled patient with an immediate concern are provided in:

    1. A) emergency department
    2. B) critical care department
    3. C) intensive care unit
    4. D) urgent care facility

     

     

    31) Code range 99291-99292 is used to describe:

    1. A) Critical Care services
    2. B) Emergency Department services
    3. C) Office or Other Outpatient Consultations
    4. D) Nursing Facility Services

     

    32) Code 99291 represents this time frame of Critical Care services:

    1. A) an additional 30 minutes
    2. B) the first 20-60 minutes
    3. C) the first 30-74 minutes
    4. D) an additional 70 minutes

     

    33) All of the following are true about critical illness/injury except:

    1. A) a patient must be in a critical care unit to be categorized as having a critical illness
    2. B) a critical illness impairs one or more vital organ systems
    3. C) a critical injury presents a high probability of life-threatening deterioration
    4. D) a patient can be in a setting other than a critical care unit and be designated as critically ill

     

    34) Select the statement that is not true regarding critical care code selection:

    1. A) If less than 30 minutes is documented as time spent with the critically ill patient, code 99291 may not be reported
    2. B) Time spent on the floor but not directly at the bedside is counted as long as it pertains to the critical condition of the patient
    3. C) Time spent outside the unit may be considered in the time documentation
    4. D) Total time spent does not have to be continuous but must be documented

     

    35) All of the following are included in CPT critical care codes except:

    1. A) gastric intubation
    2. B) pulse oximetry
    3. C) vascular access procedures
    4. D) pulmonary function testing

     

    36) If a patient is discharged from inpatient care on the same day as a nursing facility admit, the coder may select:

    1. A) an Initial Nursing Facility Care code and a hospital discharge code
    2. B) an Initial Nursing Facility Care code only
    3. C) a hospital discharge code and a Subsequent Nursing Facility Care code
    4. D) an observation status discharge code and an Initial Nursing Facility Care code

     

    37) Code range 99341-99350 represents:

    1. A) Prolonged Services
    2. B) Home Services
    3. C) Critical Care Services
    4. D) Nursing Facility Discharge Services

     

     

    38) Codes in this range are reported when services are provided that are outside the normal services provided for the condition or injury of the present encounter:

    1. A) Prolonged Services
    2. B) Home Services
    3. C) Critical Care Services
    4. D) Preventive Services

     

    39) Services provided to a patient in order to maintain health and prevent disease are called:

    1. A) Well services
    2. B) Home services
    3. C) Preventive services
    4. D) Palliative services

     

    40) Preventive Services code selection is dependent on all but which of the following:

    1. A) Type of patient
    2. B) Age of the patient
    3. C) New or established patient
    4. D) Gender of the patient

     

    41) Code 99450 Basic Life and/or Disability Evaluation Services includes all of the following except:

    1. A) documentation of height, weight, and blood pressure
    2. B) performance of electrocardiogram
    3. C) collection of blood sample and urinalysis
    4. D) completion of appropriate forms

     

    42) The code range 99455-99456 Work-Related or Medical Disability Evaluation Services has a designation indicating:

    1. A) new or established patient
    2. B) whether the examination is performed by the treating or nontreating physician
    3. C) whether the service was mandated by the employer
    4. D) treatment plan or consultative service

     

    43) Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services (99466-99486) include all of the following except:

    1. A) transportation services for critical care pediatric patients
    2. B) outpatient neonatal care
    3. C) initial intensive care services
    4. D) continuing intensive care services

     

    44) Inpatient Neonatal and Pediatric Critical Care services are:

    1. A) designated by new or established and by age (0 days – 5 years of age)
    2. B) designated by initial and subsequent and by age (0 days – 5 years of age)
    3. C) designated by new or established and by age (28 days – 5 years of age)
    4. D) designated by initial and subsequent and by age (28 days and younger)

     

    45) A chief complaint is:

    1. A) the reason for the present encounter, usually in the patient’s own words
    2. B) the confirmed diagnosis in the provider’s documentation
    3. C) the diagnosis used to support further laboratory procedures
    4. D) the sign observed and documented by the provider

     

    46) One who has been formally admitted to a healthcare facility is:

    1. A) observation status
    2. B) inpatient
    3. C) outpatient
    4. D) critical care

     

    47) One who has not been formally admitted to inpatient status is:

    1. A) inmate status
    2. B) inpatient
    3. C) outpatient
    4. D) emergency services

     

    48) Select the correct steps to determining a code for an E/M service, listed in correct order:

    1. A) identify the status of the patient, determine the patient’s chief complaint, identify the place of service, identify the type of service.
    2. B) identify the place of service, identify the type of service, identify the status of the patient, determine the patient’s chief complaint
    3. C) determine the patient’s chief complaint, identify the status of the patient, identify the place of service, identify the type of service.
    4. D) determine the patient’s chief complaint, identify the place of service, identify the type of service, identify the status of the patient

     

    49) An established patient presents to the outpatient provider’s office with a chief complaint of sore throat. Which piece of information represents the first step in determining a code for an E/M service?

    1. A) established patient
    2. B) outpatient
    3. C) provider’s office
    4. D) sore throat

     

    50) A patient who has not received face-to-face services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past three years is a(n):

    1. A) consult
    2. B) new patient
    3. C) established patient
    4. D) existing patient

     

     

    51) Stacy is being seen by Dr. Randall for the first time for tingling in her wrist and lower arm. Dr. Randall is part of a multi-physician orthopedic practice. Stacy saw Dr. Furman, another orthopedist in the practice, one year ago for treatment of a broken pinkie finger. Stacy will be a(n) ________ for Dr. Randall:

    1. A) established patient
    2. B) new patient
    3. C) consult
    4. D) referral

     

    52) One who has received face-to-face services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past three years is a(n):

    1. A) new patient
    2. B) referral
    3. C) consult
    4. D) established patient

     

    53) Which of the following is not a true statement?

    1. A) No distinction is made between new and established patient for the emergency department
    2. B) No distinction is made between new and established patient for critical care codes
    3. C) No distinction is made between new and established patient for care management codes
    4. D) No distinction is made between new and established patient in the outpatient and inpatient setting

     

    54) The E/M section guidelines regarding new and established patients uses the terminology “same practice.” Payers consider providers to be in the “same practice” when they use:

    1. A) the same facilities
    2. B) the same tax ID
    3. C) the same Social Security number
    4. D) the same billing company

     

    55) In the E/M section, a 0 in the fourth place identifies:

    1. A) a new patient service in the office
    2. B) an established patient service in the office
    3. C) an initial inpatient service
    4. D) a subsequent inpatient service

     

    56) An established patient service in the office is indicated by a ________ fourth place digit:

    1. A) 2
    2. B) 3
    3. C) 1
    4. D) 4

     

     

    57) In the E/M section, a 2 in the fourth place identifies:

    1. A) an emergency service
    2. B) a critical care service
    3. C) a subsequent inpatient service
    4. D) an initial inpatient service

     

    58) A subsequent inpatient service is identified by a ________ fourth digit:

    1. A) 2
    2. B) 3
    3. C) 4
    4. D) 5

     

    59) In the E/M section, a 4 in the fourth place identifies:

    1. A) an emergency service
    2. B) a critical care service
    3. C) a consultation service in the office
    4. D) a consultation service in the hospital

     

    60) A consultation service in the hospital is represented by a ________ fourth digit:

    1. A) 4
    2. B) 5
    3. C) 8
    4. D) 9

     

    61) In the E/M section, an 8 in the fourth place identifies:

    1. A) a consultation service in the office
    2. B) a consultation service in the hospital
    3. C) an emergency service
    4. D) a critical care service

     

    62) A critical care service is identified by a ________ fourth digit:

    1. A) 0
    2. B) 9
    3. C) 2
    4. D) 8

     

    63) All of the following are components of an E/M service except:

    1. A) history
    2. B) coordination of care
    3. C) nature of presenting problem
    4. D) vital signs

     

     

    64) All of the following are components of an E/M service except:

    1. A) medical decision making
    2. B) dictation time
    3. C) counseling
    4. D) time

     

    65) The three key components used to select an appropriate E/M code are:

    1. A) Counseling, coordination of care, and time
    2. B) History, medical decision making, and time
    3. C) Counseling, history, and examination
    4. D) History, examination, and medical decision making

     

    66) Time can be a key ________ for the codes within the E/M section requiring either two or three key components.

    1. A) factor
    2. B) component
    3. C) issue
    4. D) consideration

     

    67) A patient is seen by a provider today for 80 minutes. Based on the E/M guideline regarding time as a key factor, how many minutes at a minimum must the provider document spending in face-to-face counseling and coordination of care with the patient?

    1. A) 20 minutes
    2. B) 30 minutes
    3. C) 40 minutes
    4. D) 50 minutes

     

    68) The key component which includes the number of management options or diagnoses is:

    1. A) coordination of care
    2. B) medical decision making
    3. C) examination
    4. D) history

     

    69) The elements of the History component in E/M code selection are:

    1. A) history of present illness, body areas, and past, family, and social history
    2. B) amount and complexity of data, history of present illness, and number of diagnoses and management options
    3. C) history of present illness, review of systems, and past, family, and social history
    4. D) body areas, review of systems, and amount and complexity of data

     

    70) Location, duration, quality, and severity are all subelements of which element?

    1. A) organ system
    2. B) amount and complexity of data
    3. C) number of diagnosis and treatment options
    4. D) history of present illness

     

    71) The descriptive words “gait, range of motion, inspect nails, and digits” are used to describe which subelement?

    1. A) cardiovascular
    2. B) constitutional
    3. C) eyes
    4. D) musculoskeletal

     

    72) The ________ documentation guidelines are followed for the CPC exam:

    1. A) 1991
    2. B) 1997
    3. C) 1995
    4. D) 1998

     

    73) How many subelements are needed to achieve an Extended history of present illness?

    1. A) four
    2. B) three
    3. C) two
    4. D) one

     

    74) PFSH stands for:

    1. A) personal, family, and social history
    2. B) past, former, and surgical history
    3. C) personal, family, and surgical history
    4. D) past, family, and social history

     

    75) A series of questions presented to the patient which identify any signs and symptoms or contributing factors relevant to the present encounter is a(n):

    1. A) examination
    2. B) review of systems
    3. C) history of present illness
    4. D) past, family, and social history

     

    76) Past, family, and social history (PFSH) encompasses which of the following:

    1. A) family’s past surgeries, allergies, and illnesses
    2. B) patient’s past surgeries, allergies, and family illnesses
    3. C) family’s marital status and allergies
    4. D) spouse’s risk factors, marital status, allergies, and family illnesses

     

    77) In the table of risk, the highest level in any one ________ determines the overall risk:

    1. A) element
    2. B) subcategory
    3. C) subelement
    4. D) subsection

     

     

    78) In the Exam component, organ system element, a detailed exam is made up of ________ body areas and/or organ systems:

    1. A) 4-6
    2. B) 5-7
    3. C) 4-7
    4. D) 5-8

     

    79) In the History component, review of systems element, how many subelements must be documented for an extended ROS?

    1. A) 2-5
    2. B) 3-7
    3. C) 2-9
    4. D) 3-8

     

    80) The description of the illness or injury which precipitated the present encounter is the:

    1. A) chief complaint
    2. B) past history
    3. C) history of present illness
    4. D) review of systems

     

    81) Which of the following is not included in the Moderate decision making subelement of the Medical decision making element?

    1. A) high risk of complications
    2. B) multiple diagnosis and management options
    3. C) moderate amount of data reviewed
    4. D) moderate risk of complications

     

    82) In the SOAP note format, the assessment contains which key component in E/M selection:

    1. A) history of present illness
    2. B) exam
    3. C) medical decision making
    4. D) no key component is located here

     

    83) In the SOAP note format, the objective section contains which key component in E/M selection:

    1. A) no key component is located here
    2. B) exam
    3. C) history of present illness
    4. D) medical decision making

     

    84) Modifier 57 signifies:

    1. A) Unrelated E/M service by the same physician during a postoperative period
    2. B) Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
    3. C) Mandated services
    4. D) Decision for surgery

     

    85) A patient presents with worsening lower back pain after receiving an epidural injection intended to provide relief just one week ago. Upon examination, the provider determines the patient is a candidate for laminectomy at the L5-S1 facet. The provider discusses the procedure, including preoperative instructions and performs a complete physical examination to clear the patient for surgery. Which modifier will be appended to this E/M service?

    1. A) 57
    2. B) 24
    3. C) 32
    4. D) 25

     

    86) An unrelated E/M service by the same physician during a postoperative period is described by modifier:

    1. A) 24
    2. B) 25
    3. C) 32
    4. D) 57

     

    87) Which E/M modifier is appropriate to use with this scenario: A patient presents to the orthopedist’s office with a complaint of severely sore knee while in the post-operative period for a carpal tunnel decompression performed by the same provider.

    1. A) 24
    2. B) 25
    3. C) 57
    4. D) 32

     

    88) Modifier 25 signifies:

    1. A) Unrelated E/M service by the same physician during a postoperative period
    2. B) Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
    3. C) Mandated services
    4. D) Decision for surgery

     

    89) Modifier 32, Mandated services, is used when:

    1. A) Patient presents to the office with a cough and while in the office shows the provider a wart on her foot and the provider removes the wart
    2. B) Third-party payer requires a second opinion
    3. C) Surgeon is asked to see a patient in the ED for severe abdominal pain. He diagnoses the patient with appendicitis and decides to perform an appendectomy that evening.
    4. D) Surgeon performs appendectomy, and the patient returns to the office during the 90 day global period with abdominal pain that is diagnosed as gallstones

     

     

    90) Gerald fell 6 feet from a ladder while running wire at work today. He presents to the provider’s office with complaints of low back pain and left knee pain. He arrives with a paper copy of the notes from a visit with his primary care physician about these problems. His employer requested Gerald receive a second opinion from another provider to confirm the diagnosis. What E/M modifier would be appended to the code for today’s service?

    1. A) 24
    2. B) 25
    3. C) 32
    4. D) 57
  5. Medical Coding, 2e (Stewart)

    Chapter 7   Surgery Section

     

    1) Guidelines and instructional notes appear in all of the following locations throughout the Surgery section except:

    1. A) beginning of each subsection
    2. B) beginning of the section
    3. C) beginning of each subcategory
    4. D) throughout the entire section

     

    2) When deciding on a code, a coder should be sure to look at ________ for the symbols that appear there relating to the codes above.

    1. A) the last code of the page
    2. B) the bottom of each CPT page
    3. C) the modifier list on the inside cover of the manual
    4. D) the first code of the page

     

    3) How many subsections are there in the Surgery section of CPT?

    1. A) six
    2. B) seven
    3. C) five
    4. D) four

     

    4) The Surgery section is divided into subsections based on:

    1. A) fee schedule
    2. B) surgical approach
    3. C) organ system or body area
    4. D) complexity of procedure

     

    5) Code range 10021-69990 encompasses what Section or Subsection of CPT?

    1. A) Musculoskeletal
    2. B) Eye and Ocular Adnexa
    3. C) Surgery
    4. D) Mediastinum and Diaphragm

     

    6) In what code range could a coder find the Integumentary subsection?

    1. A) 10030-19499
    2. B) 20100-29999
    3. C) 30000-32999
    4. D) 33010-37799

     

    7) What subsection does code range 20005-29999 contain?

    1. A) Respiratory
    2. B) Cardiovascular
    3. C) Musculoskeletal
    4. D) Hemic and Lymphatic

     

    8) Which code range contains the Respiratory subsection?

    1. A) 10021-10022
    2. B) 20100-29999
    3. C) 30000-32999
    4. D) 38100-38999

     

    9) The Cardiovascular subsection of the Surgery section of CPT is located in which code range?

    1. A) 50010-53899
    2. B) 30000-32999
    3. C) 33010-37799
    4. D) 40490-49999

     

    10) Code range 38100-38999 encompasses which subsection of the Surgery section of CPT?

    1. A) Mediastinum and Diaphragm
    2. B) Hemic and Lymphatic
    3. C) Female Genital
    4. D) Endocrine

     

    11) Select the appropriate subsection found in code range 39000-39599:

    1. A) Maternity Care and Delivery
    2. B) Integumentary
    3. C) Hemic and Lymphatic
    4. D) Mediastinum and Diaphragm

     

    12) In what code range is the Digestive subsection located?

    1. A) 50010-53899
    2. B) 59000-59899
    3. C) 59001-53899
    4. D) 40490-49999

     

    13) Code range 50010-53899 contains codes for which subsection?

    1. A) Eye and Ocular Adnexa
    2. B) Urinary System
    3. C) Endocrine
    4. D) Nervous System

     

    14) The Reproductive and Intersex Surgery; Male Genital subsections is found in which of the following code ranges?

    1. A) 56405-58999
    2. B) 65091-68899
    3. C) 30000-32999
    4. D) 54000–55899

     

     

    15) Code range 56405-58999 contains which subsection of the Surgery section of CPT?

    1. A) Auditory System
    2. B) Maternity Care and Delivery
    3. C) Eye and Ocular Adnexa
    4. D) Female Genital

     

    16) Maternity Care and Delivery is located in which of the following code ranges in CPT?

    1. A) 50010-53899
    2. B) 59000-59899
    3. C) 50001-53899
    4. D) 40490-49999

     

    17) The Endocrine subsection of the Surgery section of CPT is found in code range:

    1. A) 60000-60300
    2. B) 60500-60699
    3. C) 61000-64999
    4. D) 69000-69990

     

    18) The subsection Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body is found in which code range of CPT?

    1. A) 60000-60300
    2. B) 60500-60699
    3. C) 61000-64999
    4. D) 69000-69990

     

    19) Codes 61000-64999 cover which subsection of the Surgery section of CPT?

    1. A) Integumentary
    2. B) Musculoskeletal
    3. C) Nervous System
    4. D) Respiratory

     

    20) The Eye and Ocular Adnexa subsection of the Surgery section is located in which code range?

    1. A) 60000-60300
    2. B) 60500-60699
    3. C) 61000-64999
    4. D) 65091-68899

     

    21) Codes 69000-69990 contain procedures performed on which of the following body systems?

    1. A) Auditory System
    2. B) Reproductive and Intersex Surgery; Male Genital
    3. C) Endocrine
    4. D) Respiratory

     

     

    22) Select the correct definition of a “separate procedure” in the Surgery section:

    1. A) a procedure that is performed in the same anatomical area as the primary procedure and may be billed separately with the appropriate modifier
    2. B) a procedure that is performed on a separate anatomical site as the primary procedure and may be billed separately with the appropriate modifier
    3. C) a procedure that, when performed with another procedure at the same anatomical site at the same time, is bundled into the other procedure and may not be billed separately
    4. D) a procedure that is performed at a different time from a primary procedure and may be billable if the documentation identifies it as a planned, staged procedure

     

    23) A procedure that may be billed for when performed alone, but may not be billed for when performed with a more extensive procedure of the same site is called a(n):

    1. A) independent procedure
    2. B) separate procedure
    3. C) nonessential procedure
    4. D) minor procedure

     

    24) Documentation states a surgical case includes an excision of an ileoanal reservoir via ileostomy with enterolysis. The coder identifies the following CPT codes to report these services:

    44005 – Enterolysis (freeing of intestinal adhesion) (separate procedure)

    45136 – Excision of ileoanal reservoir with ileostomy

    How should the coder accurately report this procedure within CPT guidelines?

    1. A) 45136
    2. B) 45136, 44005-51
    3. C) 45136, 44005-59
    4. D) 44005

     

    25) What are the appropriate options for reporting a procedure when there is no specific Level I CPT code to describe it?

    1. A) the procedure cannot be reported
    2. B) a Category III code may be used
    3. C) a Category III code or an unlisted code may be used
    4. D) an unlisted code may be used

     

    26) Temporary codes for services, procedures, or emerging technology for which there is no CPT code available are called:

    1. A) annex codes
    2. B) category III codes
    3. C) unlisted codes
    4. D) category II codes

     

     

    27) Which codes allow for data tracking, and the service or procedure indicated by the code may or may not become a CPT code in the future?

    1. A) category I codes
    2. B) category IV codes
    3. C) category III codes
    4. D) category II codes

     

    28) Choose the appropriate order in which codes are expected to be used when available to describe a service or procedure:

    1. A) category I, category II, category III
    2. B) category III, category I, unlisted
    3. C) category I, category III, unlisted
    4. D) category I, category II, category III, unlisted

     

    29) Which type of codes are known as the “codes of last resort?”

    1. A) add-on codes
    2. B) annex codes
    3. C) temporary codes
    4. D) unlisted codes

     

    30) With only a few exceptions, unlisted service or procedure codes end in:

    1. A) -00
    2. B) -99
    3. C) -98
    4. D) -09

     

    31) What do Category III codes always end in?

    1. A) -99
    2. B) -C
    3. C) -T
    4. D) -00

     

    32) What does the ending -T signify on a Category III code?

    1. A) emerging technology
    2. B) temporary code
    3. C) third-party payer recognized
    4. D) test code

     

    33) What is the means by which the provider gains access to the body to complete a service or procedure?

    1. A) access point
    2. B) incisional site
    3. C) approach
    4. D) direction

     

     

    34) When a diagnostic scope procedure is performed in the same surgical session as a surgical scope procedure, which of the following is true?

    1. A) the coder must determine whether the diagnostic or surgical scope procedure was more extensive and report the most extensive procedure
    2. B) the surgical scope procedure is bundled into the reimbursement for the diagnostic scope procedure
    3. C) both the diagnostic and the surgical scope procedures may be reported, with a -59 modifier appended to the diagnostic scope CPT code
    4. D) the diagnostic scope procedure is bundled into the reimbursement for the surgical scope procedure

     

    35) A procedure completed through the skin is called a(n) ________ procedure:

    1. A) open
    2. B) percutaneous
    3. C) traction
    4. D) closed

     

    36) A procedure performed through an incision in the skin or other membranes in which the provider has full view of the organs or structures as needed is called a(n) ________ procedure:

    1. A) closed
    2. B) open
    3. C) critical
    4. D) operational

     

    37) Documentation states “Diagnostic proctosigmoidoscopy performed with balloon dilation.” CPT codes available to report these procedures are:

    45300 – Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

    45303 – Proctosigmoidoscopy, rigid; with dilation (e.g. balloon, guide wire, bougie)

    How would the coder accurately report these procedures?

    1. A) 45300
    2. B) 45303
    3. C) 45300, 45303-51
    4. D) 45303, 45300-59

     

    38) When a diagnostic scope procedure is performed in the same surgical session as an open procedure, which of the following is true?

    1. A) the coder must determine whether the diagnostic scope procedure or the open procedure was more extensive and report the most extensive procedure
    2. B) the open procedure is bundled into the reimbursement for the diagnostic scope procedure
    3. C) both the diagnostic and the open procedures may be reported, with a -59 modifier appended to the diagnostic scope CPT code
    4. D) the diagnostic scope procedure is bundled into the reimbursement for the open procedure

     

     

    39) A 53-year-old male patient presents to the OR for a planned arthroscopic acetabuloplasty. The physician inserts the scope and visualizes the repair site. Upon visualization, the surgeon determines the acetabuloplasty will require more extensive repair than initially expected. The surgeon removes the arthroscope and makes an arthrotomy into the hip joint. The surgeon completes a cup-type acetabuloplasty and concludes with layered closure of the skin and subcutaneous tissues. How should the coder appropriately report these procedures?

    27120 – Acetabuloplasty: (e.g. Whitman, Colonna, Haygroves, or cup type)

    29860 – Arthroscopy hip, diagnostic with or without synovial biopsy (separate procedure)

    1. A) 27120, 29860-51
    2. B) 27120, 29860-59
    3. C) 29860, 27120-59
    4. D) 27120

     

    40) A prescribed period of time surrounding the surgical procedure is called the:

    1. A) global surgical package
    2. B) major surgical recovery time
    3. C) rest period
    4. D) maximum reimbursement package

     

    41) All surgical procedure codes, with the exception of ________, are divided into two categories: minor procedures and major procedures.

    1. A) modifier -63 exempt codes
    2. B) recycled/reinstated codes
    3. C) codes pending FDA approval
    4. D) modifier -51 exempt codes

     

    42) What is the usual post-operative period for a minor procedure?

    1. A) 1-90 days
    2. B) 1-10 days
    3. C) 5-10 days
    4. D) 0-10 days

     

    43) What is the usual post-operative period for a major procedure?

    1. A) 0-60 days
    2. B) 90 days or more
    3. C) 30-90 days
    4. D) 15-60 days

     

    44) Select the service that is not considered to be part of the global surgical package by most third-party payers:

    1. A) treatment of complications related to the surgery
    2. B) history and physical exam on the day of or day prior to surgery
    3. C) anesthesia needed to perform the procedure, such as local anesthesia
    4. D) postoperative care including documenting operative notes, written orders, and providing typical follow-up care

     

    45) Which modifier is required to be appended to an E/M service when a decision for surgery is made the day of or the day prior to surgery?

    1. A) -58
    2. B) -63
    3. C) -57
    4. D) -79

     

    46) This component of CPT is used to tell the rest of the surgical story by adding the details that are not or cannot be expressed in the CPT or ICD code:

    1. A) add-on codes
    2. B) category III codes
    3. C) modifiers
    4. D) category II codes

     

    47) Which of the following is not information typically relayed by a modifier?

    1. A) laterality
    2. B) age of patient
    3. C) multiple procedures
    4. D) staged procedures

     

    48) When a coder responds “yes” to the question: “Was the procedure more difficult or time-consuming or did it require extra work on the part of the surgeon?” which modifier should be used?

    1. A) -32
    2. B) -79
    3. C) -22
    4. D) -52

     

    49) Which of the following questions would lead a coder to select modifier -52?

    1. A) Was the procedure performed on an anatomical site that has laterality?
    2. B) Was the procedure more difficult or time-consuming or did it require extra work on the part of the surgeon?
    3. C) Was the procedure discontinued after anesthesia but prior to completion?
    4. D) Did the procedure performed involve less than the procedure described by the code?

     

    50) Select the modifier(s) that are appropriate to select when answering the question, “Was the procedure performed as described by the nomenclature of the code?”

    1. A) -25, -57
    2. B) -51, -52, -53
    3. C) -22, -52, -53
    4. D) -47, -32

     

     

    51) When a procedure is performed in the global period of another procedure, the procedure is reported using the same CPT code as the previous procedure, and it is performed by the same physician, which modifier should be used?

    1. A) -78
    2. B) -77
    3. C) -76
    4. D) -58

     

    52) When a procedure is performed in the global period of another procedure and was performed as the result of a complication of the previous procedure, which modifier should be used?

    1. A) -78
    2. B) -79
    3. C) -76
    4. D) -58

     

    53) Which modifier should be used when a procedure is performed in the global period of another procedure and the procedure was performed by a different surgeon?

    1. A) -80
    2. B) -77
    3. C) -91
    4. D) -57

     

    54) A planned, more extensive procedure is performed in the global period for another procedure. Select the appropriate modifier for use:

    1. A) -59
    2. B) -80
    3. C) -77
    4. D) -58

     

    55) When an additional procedure is performed through a separate incision, which normally would not be reportable but is appropriate to report in the particular circumstance, the coder should append modifier:

    1. A) -59
    2. B) -62
    3. C) -51
    4. D) -52

     

    56) Modifier -51 should be used when:

    1. A) two surgeons performed integral parts of the same procedure
    2. B) a procedure performed by a different surgeon occurs during the global period of another procedure
    3. C) an additional procedure that is not normally separately reportable with the primary surgical code is performed through a separate incision
    4. D) an additional procedure is performed that is normally reportable in addition to the primary procedure

     

    57) The following scenario would require use of modifier 47, Anesthesia by surgeon:

    1. A) During an anterior thoracic spine procedure, the neurosurgeon requests that a thoracic surgeon create the approach to the spine
    2. B) While in the postoperative period of a tonsillectomy, the patient falls from a slide and fractures the left ulna, requiring surgical repair
    3. C) Surgeon performs a neuroplasty procedure and administers a nerve block
    4. D) A neurosurgeon requests the assistance of a nonresident surgeon for a difficult and extensive procedure for which no available residents are qualified to assist

     

    58) Bilateral procedure is the description for which modifier?

    1. A) 58
    2. B) 66
    3. C) 80
    4. D) 50

     

    59) Multiple procedures is represented by modifier:

    1. A) 58
    2. B) 59
    3. C) 51
    4. D) 50

     

    60) Modifier 54 communicates:

    1. A) Postoperative care only
    2. B) Surgical care only
    3. C) Preoperative care only
    4. D) Distinct procedural service

     

    61) When a local orthopedist follows up on a patient after his return home, following surgery while on vacation out of state, the following modifier would be applied to the service:

    1. A) 55
    2. B) 25
    3. C) 80
    4. D) 81

     

    62) Staged or related procedure or service by the same physician during the postoperative period is modifier:

    1. A) 58
    2. B) 79
    3. C) 80
    4. D) 91

     

    63) Distinct procedural service is represented by modifier:

    1. A) 78
    2. B) 79
    3. C) 58
    4. D) 59

     

    64) What is the description of Modifier 66?

    1. A) Minimum assistant surgeon
    2. B) Assistant surgeon
    3. C) Surgical team
    4. D) Two surgeons

     

    65) What is the description of Modifier 76?

    1. A) Repeat procedure by same physician
    2. B) Return to operating room for a related procedure during postoperative period
    3. C) Repeat procedure by another physician
    4. D) Unrelated procedure or service by the same physician during postoperative period

     

    66) Modifier 81 is used to describe:

    1. A) Assistant surgeon
    2. B) Multiple modifiers
    3. C) Assistant surgeon, when a qualified resident is not available
    4. D) Minimum assistant surgeon

     

    67) Preoperative management only is described by which modifier?

    1. A) -55
    2. B) -56
    3. C) -58
    4. D) -59

     

    68) Which modifier describes a procedure performed on an infant less than 4 kg?

    1. A) -78
    2. B) -79
    3. C) -63
    4. D) -66

     

    69) What is the term for the removal of all or part of a lesion for pathologic examination?

    1. A) excision
    2. B) biopsy
    3. C) incision
    4. D) -ectomy

     

    70) When a coder sees the words “cautery, cryo, or laser,” what term used in CPT is the physician referring to?

    1. A) biopsy
    2. B) harvest
    3. C) repair
    4. D) destruction

     

     

    71) The term “procurement” is another term for:

    1. A) -plasty
    2. B) repair
    3. C) incision
    4. D) harvest

     

    72) Restoration of diseased or damaged tissue, organ, or bone is called:

    1. A) repair
    2. B) excision
    3. C) response
    4. D) restoration

     

    73) The suffix used to describe an incision is:

    1. A) -otomy
    2. B) – ectomy
    3. C) -plasty
    4. D) -ostomy

     

    74) The process of using a scope inserted through a natural opening or stoma to examine the inside of an organ or system is:

    1. A) laparoscopy
    2. B) arthroscopy
    3. C) endoscopy
    4. D) cystoscopy

     

    75) The suffix -oscopy means:

    1. A) visually examining through a scope
    2. B) surgically creating an artificial opening
    3. C) surgically removing by cutting
    4. D) reshaping or replacing by surgical means

     

    76) The key to coding surgical cases is:

    1. A) being able to understand and manipulate medical data
    2. B) being adept at cross-referencing medical terminology with the physician-based relative value system
    3. C) comparing and contrasting documentation styles among several providers
    4. D) knowing and understanding what to identify during the review of documentation for services provided and conditions supporting the need for those services

     

    77) What are the three separate processes of coding an operative report?

    1. A) procedural, diagnostic, and HCPCS coding
    2. B) diagnostic, services, and supplies
    3. C) procedural, diagnostic, and addition of modifiers
    4. D) inpatient, outpatient, and urgent care

     

     

    78) When coding an operative report, what is the first question a coder should ask himself/herself when performing procedural coding?

    1. A) What is the primary procedure?
    2. B) Where is the main term?
    3. C) What are the differences in the code choices available?
    4. D) Do any modifiers apply to this case?

     

    79) Select the true statement regarding diagnostic coding of an operative report?

    1. A) The coder may select the pre-operative diagnostic statement in the operative report for use as the definitive diagnosis
    2. B) The coder should read through the entire operative report before assigning a diagnostic code
    3. C) The coder may select the post-operative diagnostic statement in the operative report for use as the definitive diagnosis
    4. D) The coder should always query the physician to receive the definitive diagnostic statement

     

    80) When a working condition is identified and the condition does not affect patient care treatment or management, the condition is said to be a(n) ________ diagnosis:

    1. A) secondary
    2. B) nonessential
    3. C) unrelated
    4. D) supportingMedical Coding, 2e (Stewart)

      Chapter 9   Surgery Section: Musculoskeletal System

       

      1) Which Surgery subsection of the CPT manual contains the largest number of codes?

      1. A) Musculoskeletal
      2. B) Integumentary
      3. C) Cardiovascular
      4. D) Nervous System

       

      2) All of the following are means of organization within the Musculoskeletal subsection except:

      1. A) anatomical site
      2. B) approach or technique
      3. C) type of tissue
      4. D) treatment or condition

       

      3) Select the one function that is not a function of the muscular system:

      1. A) generate body heat
      2. B) move blood through the body
      3. C) hold the body erect
      4. D) move food through the digestive system

       

      4) Select the muscle that is not part of the Quadriceps femoris:

      1. A) Vastus lateralis
      2. B) Vastus intermedius
      3. C) Vastus medialis
      4. D) Fibularis

       

      5) What are groups of fibers that are held together by connective tissue and enclosed in a fibrous sheath?

      1. A) muscle fibers
      2. B) fascia
      3. C) skeletal muscles
      4. D) smooth muscles

       

      6) Select the definition of the term “myofascial”:

      1. A) group of fibers that are held together by connective tissue
      2. B) striated muscle
      3. C) pertaining to fascia and muscle
      4. D) narrow band of nonelastic, dense, fibrous connective tissue

       

      7) Deep fascia lies beneath the ________ layer of subcutaneous tissue:

      1. A) first
      2. B) second
      3. C) third
      4. D) fourth

       

       

      8) Select the correct definition of a tendon:

      1. A) bands of fibrous tissue that connect two or more bones or cartilage
      2. B) narrow band of non-elastic, dense, fibrous connective tissue which attaches muscle to a bone
      3. C) striated, voluntary muscles
      4. D) located in walls of internal organs; unstriated and involuntary muscles

       

      9) A ligament is:

      1. A) bands of fibrous tissue that connect two or more bones or cartilage
      2. B) narrow band of non-elastic, dense, fibrous connective tissue which attaches muscle to a bone
      3. C) striated, voluntary muscles
      4. D) located in walls of internal organs; unstriated and involuntary muscles

       

      10) Which type of muscle is a voluntary muscle?

      1. A) ligament
      2. B) myocardial
      3. C) smooth
      4. D) skeletal

       

      11) Select the muscle that is located in the walls of internal organs:

      1. A) ligament
      2. B) tendon
      3. C) smooth
      4. D) skeletal

       

      12) Which type of muscles form the muscular wall of the heart?

      1. A) ligament
      2. B) myocardial
      3. C) smooth
      4. D) skeletal

       

      13) All of the following are functions of the skeletal system except:

      1. A) support and shape the body
      2. B) facilitate passage of blood through the body
      3. C) make blood cells
      4. D) protect internal organs

       

      14) What is the hardest tissue in the body?

      1. A) diaphysis
      2. B) bone
      3. C) epiphyses
      4. D) articulation

       

      15) Where is spongy bone located?

      1. A) outermost covering of bone
      2. B) outer layer of the bones
      3. C) shaft of the bone
      4. D) ends and inner portions of long bones

       

      16) Which part of the bone contains yellow bone marrow?

      1. A) cartilage
      2. B) spongy bone
      3. C) medullary cavity
      4. D) compact bone

       

      17) Select the correct definition of the diaphysis:

      1. A) immovable joint
      2. B) shaft of a long bone
      3. C) acts as a shock absorber between bones
      4. D) forms outermost covering of bone

       

      18) What is the name for the place where two or more bones meet?

      1. A) periosteum
      2. B) medullary cavity
      3. C) joint
      4. D) axial skeleton

       

      19) The medical term arthr/o signifies:

      1. A) forehead
      2. B) cartilage
      3. C) joint
      4. D) axis

       

      20) Which of the following is a true statement about the temporal bone in the skull?

      1. A) it comprises the sides and base of the cranium
      2. B) it forms part of the nose, orbit, and floor of the cranium
      3. C) it comprises the roof and upper sides of the cranium
      4. D) it forms the forehead

       

      21) The axial skeleton is made up of all of the following bone structures except:

      1. A) skull
      2. B) femur
      3. C) spinal column
      4. D) sternum

       

      22) The skull bone that forms the roof and upper sides of the cranium is called the:

      1. A) frontal
      2. B) sphenoid
      3. C) ethomoid
      4. D) parietal

       

       

      23) The bone of the face that is the base for the nasal septum is the:

      1. A) vomer
      2. B) mandible
      3. C) palatine
      4. D) maxillary

       

      24) The maxillary bone:

      1. A) forms the cheekbones
      2. B) comprises most of the upper jaw
      3. C) forms part of the orbit at the inner angle of the eye
      4. D) comprises the lower jaw bone

       

      25) The word root cervic/o signifies:

      1. A) lumbar
      2. B) thorax
      3. C) axis
      4. D) neck

       

      26) The bone of the face that makes up part of the orbit at the inner angle of the eye is the:

      1. A) lacrimal
      2. B) vomer
      3. C) mandible
      4. D) palatine

       

      27) What type of bone are vertebrae?

      1. A) flat
      2. B) irregular
      3. C) long
      4. D) spongy

       

      28) Which bone is located in the upper arm?

      1. A) ulna
      2. B) humerus
      3. C) radius
      4. D) olecranon process

       

      29) This bone forms the point of the shoulder:

      1. A) acromion
      2. B) clavicle
      3. C) scapula
      4. D) olecranon process

       

      30) The radius is:

      1. A) the long bone of the finger
      2. B) the larger bone in the forearm
      3. C) the smaller bone in the forearm
      4. D) the upper arm

       

      31) The palms of the hands are made up of:

      1. A) phalanges
      2. B) metacarpals
      3. C) patellas
      4. D) ulnas

       

      32) Select the term that is used to describe the collar bone:

      1. A) femur
      2. B) scapula
      3. C) ulna
      4. D) clavicle

       

      33) The large projection on the upper end of the ulna that forms the point of the elbow is the:

      1. A) olecranon process
      2. B) humerus
      3. C) scapula
      4. D) acromion

       

      34) The upper portion of the hip bone is the:

      1. A) pubis
      2. B) ilium
      3. C) ischium
      4. D) tibia

       

      35) The pubis is the:

      1. A) upper portion of each hip bone
      2. B) front arch of the pelvis
      3. C) lower portion of each hip bone
      4. D) back section of the hip bone

       

      36) What is the fibula?

      1. A) upper leg bone
      2. B) kneecap
      3. C) large, anterior lower leg bone
      4. D) small lateral bone of the lower leg

       

      37) The bone embedded in the tendon near the first digit of each foot is the:

      1. A) tarsal
      2. B) sesamoid
      3. C) phalanges
      4. D) metatarsal

       

       

      38) Which bone forms the part of the foot to which the bones are attached?

      1. A) tarsal
      2. B) sesamoid
      3. C) phalanges
      4. D) metatarsal

       

      39) What is the main difference between the bones of the hands and the bones of the wrist?

      1. A) The bones of the hands are irregular and the bones of the wrist are long
      2. B) The bones of the hands are long and the bones of the wrist are irregular
      3. C) The bones of the hands are short and the bones of the wrist are long
      4. D) The bones of the hands are long and the bones of the wrist are short

       

      40) Which of the following consists of the upper and lower extremities and makes body movement possible?

      1. A) axial skeleton
      2. B) appendicular skeleton
      3. C) frontal skeleton
      4. D) perpendicular skeleton

       

      41) All of the following are common conditions of the musculoskeletal system except:

      1. A) stenosis
      2. B) arthropathy
      3. C) diseases of the connective tissue
      4. D) derangement joint disorders

       

      42) In which code range can a coder find Diseases of the musculoskeletal system and connective tissues in the ICD-10-CM manual?

      1. A) S00-T88
      2. B) M00-M99
      3. C) V00-Y99
      4. D) L00-L99

       

      43) In what chapter are Diseases of the Musculoskeletal System and Connective Tissue found in the ICD-10-CM manual?

      1. A) 10
      2. B) 11
      3. C) 12
      4. D) 13

       

      44) The subheading “Arthropathies ” is further subdivided in ICD-10-CM. Select the subheading that is not a subdivision in ICD-10-CM:

      1. A) Disorders of Bone Density and Structure
      2. B) Infectious Arthropathies
      3. C) Other Joint Disorders
      4. D) Osteoarthritis

       

       

      45) The subheading “Arthropathies” in ICD-10-CM is inclusive of all body areas with the exception of the:

      1. A) wrist
      2. B) spine
      3. C) hips
      4. D) feet

       

      46) Select the disorder that is not considered to be a disorder of the connective tissue and, therefore, is not found in the subheading Systemic connective tissue disorders (M30-M36) in ICD-10-CM:

      1. A) poliomyelitis
      2. B) polyarteritis
      3. C) systemic lupus erythematosus
      4. D) systemic sclerosis

       

      47) Per the ICD-10-CM Manual infectious arthropathies (M00-M09) are due to microbiological agents and code selection distinction is made between which of the types of etiological relationship?

      1. A) Direct infection
      2. B) Indirect infection
      3. C) Direct infection, reactive arthropathy, and postinfective arthropathy
      4. D) Reactive arthropathy

       

      48) Conditions of what body area are reported using codes M40-M54 Dorsopathies, in ICD-10-CM?

      1. A) skull
      2. B) joints
      3. C) axial skeleton
      4. D) spine

       

      49) The subheading “Inflammatory polyarthropathies” (M05-M14) contains all of the following conditions except:

      1. A) rheumatoid arthritis with or without rheumatoid factor
      2. B) rheumatoid bursitis
      3. C) juvenile arthritis
      4. D) osteoarthritis

       

      50) A patient presents with an acute, traumatic tear of the rotator cuff. The coder will:

      1. A) select a code from subheading “Arthropathies”
      2. B) select a code from subheading “Dorsopathies
      3. C) select a code from Symptoms, Signs, and Ill Defined Conditions chapter
      4. D) select a code from Injury and Poisoning chapter

       

       

      51) What is the correct arrangement of the Musculoskeletal subsection of the CPT manual?

      1. A) organized by treatment or condition, further subdivided by anatomical site and approach or technique
      2. B) organized by approach or technique, further subdivided by anatomical site
      3. C) organized by approach or technique, further subdivided by anatomical site and treatment or condition
      4. D) organized by anatomical site, further subdivided by approach or technique and treatment or condition

       

      52) Select the first question that a coder must ask himself/herself when the code selection process begins.

      1. A) Was the procedure performed on muscle, soft tissue, or bone?
      2. B) What approach or technique was used (open, scope, or percutaneous)?
      3. C) What is the most specific anatomical site?
      4. D) Was the treatment for a traumatic injury (acute) or a medical condition (chronic)?

       

      53) In which code range can a coder find endoscopic and arthroscopic procedures performed on the Musculoskeletal system?

      1. A) 27301-27599
      2. B) 28001-28899
      3. C) 29800-29999
      4. D) 26990-27299

       

      54) Select the list of anatomical headings in the Musculoskeletal subheading that include subsection-specific notes:

      1. A) Skull, Shoulder, Elbow, Pelvis and Hip Joint
      2. B) Head, Spine, Shoulder, Humerus and Elbow, Forearm and Wrist, Pelvis and Hip Joint, and Femur and Knee Joint
      3. C) Spine, Shoulder, Wrist, Pelvis and Hip Joint, Arthrodesis, Hands and Feet
      4. D) Skull, Shoulder and Elbow, Wrist and Fingers, Pelvis and Hip Joint, Spine

       

      55) All of the following are subheadings found in each anatomical heading in the Musculoskeletal subsection of CPT except:

      1. A) Introduction or Removal
      2. B) Manipulation
      3. C) Repair, Revision, and/or Reconstruction
      4. D) Arthrocentesis

       

      56) Procedure codes involving the body area Back and Flank are found in which code range?

      1. A) 21010-21499
      2. B) 21920-21936
      3. C) 22010-22899
      4. D) 22900-22999

       

       

      57) Code range 26010-26989 contains procedure codes on which body area?

      1. A) Head
      2. B) Shoulder
      3. C) Spine
      4. D) Hands and Fingers

       

      58) In the General subsection of the CPT manual, in which subheading can a coder find biopsies performed on muscle or bone?

      1. A) Incision
      2. B) Wound Exploration – Trauma
      3. C) Excision
      4. D) Introduction or Removal

       

      59) Select the documentation terminology that would not support selecting a code from subheading Wound Exploration – Trauma:

      1. A) superficial
      2. B) penetrating
      3. C) stab
      4. D) trauma

       

      60) How are arthrocentesis, aspiration, and/or injection of a joint or bursa codes further subdivided?

      1. A) treatment or condition
      2. B) anatomical site
      3. C) size of joint or bursa
      4. D) one or multiple injections/aspirations

       

      61) A patient presents for surgical removal of the hardware inserted to treat a previous bimalleolar fracture. Some scar tissue must be removed in order to access the hardware. Three incisions were made to complete this procedure. How should the coder appropriately assign codes to report this procedure?

      1. A) Code for the scar tissue removal, and one code for the hardware removal
      2. B) Code for the scar tissue removal, and three codes for the hardware removal
      3. C) Assign one code for the hardware removal
      4. D) Assign three codes for the hardware removal

       

      62) Which type of graft is not included in the subsection Grafts (or Implants)?

      1. A) bone
      2. B) skin
      3. C) cartilage
      4. D) tendon

       

      63) Identify the correct subdivision of the Excision subheading regarding cysts:

      1. A) location and size
      2. B) benign vs. malignant
      3. C) size and type (benign vs. malignant)
      4. D) anatomic site

       

      64) An excision of a soft tissue or bone tumor that requires excision of surrounding soft tissue is called a:

      1. A) subcutaneous
      2. B) fascial
      3. C) subfascial
      4. D) radical resection

       

      65) When wires, pins, screws, etc., are placed through or within the fracture site in order to stabilize the fracture, this is called:

      1. A) closed fracture
      2. B) skeletal manipulation
      3. C) external fixation
      4. D) internal fixation

       

      66) The application of force to a limb through a wire, pin, screw, or clamp that is attached to a bone is:

      1. A) manipulation
      2. B) skeletal traction
      3. C) skin traction
      4. D) external fixation

       

      67) What is manipulation?

      1. A) the application of force to a limb through a wire, pin, screw, or clamp that is attached to a bone
      2. B) attempted reduction or restoration of a fracture or joint to its normal anatomic alignment by the application of manually applied force
      3. C) use of wires, pins, screws, etc., which are placed through or within the fracture site in order to stabilize the fracture
      4. D) skeletal pins attached to an external mechanism

       

      68) What is another word for arthrodesis?

      1. A) fusion
      2. B) grafting
      3. C) harvesting
      4. D) reduction

       

      69) When a device (rod) is attached by hooks or screws to the spine only at each end of the device, this is called:

      1. A) internal fixation
      2. B) external fixation
      3. C) nonsegmental instrumentation
      4. D) segmental instrumentation

       

       

      70) When a device (rod) is attached by hooks or screws to the spine at each end of the device and to at least one other point of the spine along the device, this is called:

      1. A) internal fixation
      2. B) external fixation
      3. C) nonsegmental instrumentation
      4. D) segmental instrumentation

       

      71) When an arthroscopy is performed at the same time as an arthrotomy, what modifier would be appropriate to append to the second code?

      1. A) 50
      2. B) 51
      3. C) 52
      4. D) 59

       

      72) When a replantation of an incomplete amputation is performed, which modifier is appropriate to append to the code to accurately report the extent of the service?

      1. A) 50
      2. B) 51
      3. C) 52
      4. D) 59

       

      73) The terms “incisional, excisional, needle aspiration, punch, and shave” can be used to describe what type of procedure?

      1. A) destruction
      2. B) repair
      3. C) biopsy
      4. D) graft

       

      74) During an excisional procedure, when no tissue remains to send to pathology, this procedure is said to be a(n):

      1. A) biopsy
      2. B) destruction
      3. C) annihilation
      4. D) excision

       

      75) The degeneration, decline of tissue or organs, or wasting of tissue or organs is referred to as:

      1. A) scarring
      2. B) impingement syndrome
      3. C) fascioplasty
      4. D) atrophy

       

      76) What is impingement syndrome?

      1. A) an incorrectly healing fracture
      2. B) the thinning of bone tissue and loss of bone density over time
      3. C) fracture caused by disease, not trauma
      4. D) condition of inflamed and swollen tendons caught in the narrow space between the bones within the shoulder joint

       

      77) What is the thinning of bone tissue and loss of bone density over time?

      1. A) pathologic fracture
      2. B) malunion
      3. C) osteoarthritis
      4. D) osteoporosis

       

      78) Which injury usually involves a stretched or torn ligament?

      1. A) sprain
      2. B) strain
      3. C) shin splint
      4. D) hamstring injury

       

      79) An injury to the body of the muscle or the attachment of a tendon is a:

      1. A) sprain
      2. B) strain
      3. C) shin splint
      4. D) hamstring injuryMedical Coding, 2e (Stewart)

        Chapter 10   Surgery Section: Respiratory System

         

        1) The respiratory system’s primary function is to:

        1. A) supply oxygen to the blood
        2. B) allow for exchange of gases
        3. C) expel carbon dioxide from the blood
        4. D) control exchange of gases

         

        2) Alveoli are responsible for:

        1. A) contracting the diaphragm and intercostal muscles
        2. B) relaxing the diaphragm and intercostal muscles
        3. C) exchanging oxygen and carbon dioxide
        4. D) drawing air into the lungs

         

        3) The lower respiratory system includes:

        1. A) trachea, bronchial tubes, and lungs
        2. B) nose and sinuses
        3. C) trachea, pharynx, and larynx
        4. D) nose, sinuses, pharynx, and larynx

         

        4) The partition of cartilage that divides the left and right nasal cavities is the:

        1. A) nose
        2. B) paranasal sinus
        3. C) nasal cavity
        4. D) nasal septum

         

        5) The sphenoid sinus is:

        1. A) cavity in the skull which opens into the nasal cavity located between the nose and eyes
        2. B) cavity in the skull which opens into the nasal cavity located in the center of the skull base
        3. C) small flap of cartilage that closes over the trachea preventing food from entering the larynx and thus the lungs
        4. D) tubular structure which branches off the trachea

         

        6) The voice box is also known as the:

        1. A) pharynx
        2. B) larynx
        3. C) trachea
        4. D) bronchi

         

        7) The apex of the lung is also known as the:

        1. A) three right lobes
        2. B) lower part of lung
        3. C) membrane surrounding the lung
        4. D) upper part of lung

         

         

        8) The turbinates are located in which part of the respiratory system?

        1. A) paranasal sinuses
        2. B) nasal cavities
        3. C) nostrils
        4. D) nares

         

        9) How many skull cavities open into the nasal cavity?

        1. A) three
        2. B) four
        3. C) two
        4. D) five

         

        10) Which of the following is a passage through which both air and food pass?

        1. A) pharynx
        2. B) larynx
        3. C) trachea
        4. D) bronchi

         

        11) The trachea is also referred to as the:

        1. A) throat
        2. B) voice box
        3. C) windpipe
        4. D) nares

         

        12) How many lobes does the right lung contain?

        1. A) one
        2. B) two
        3. C) three
        4. D) four

         

        13) The lung containing two lobes is the ________:

        1. A) right
        2. B) left
        3. C) upper
        4. D) lower

         

        14) Select the correct definition of the diaphragm:

        1. A) connects the nose and the mouth to the larynx
        2. B) membrane surrounding the lung
        3. C) separates the thoracic and abdominal cavities
        4. D) houses the vocal cords

         

        15) The largest sinus cavity, under the eyes, is the:

        1. A) ethmoid
        2. B) maxillary
        3. C) sphenoid
        4. D) epiglottis

         

        16) Some common diseases coded to the Respiratory Subsection of ICD-10-CM include all of the following except

        1. A) asthma
        2. B) chronic obstructive pulmonary disease
        3. C) pneumonia
        4. D) laceration of the larynx

         

        17) In ICD-10-CM, the Respiratory section is Chapter:

        1. A) 7
        2. B) 8
        3. C) 9
        4. D) 10

         

        18) Bronchitis, influenza, and pneumonia are all found in the ________ section of ICD-10:

        1. A) Diseases of the Respiratory System
        2. B) Infectious and Parasitic Diseases
        3. C) Symptoms, Signs, and Ill-Defined Conditions
        4. D) Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

         

        19) The code range for the Respiratory section in ICD-10-CM is:

        1. A) L00-L99
        2. B) S00-T88
        3. C) J00-J99
        4. D) K00-K95

         

        20) In ICD-10-CM, code range J60-J65 contains codes for which conditions?

        1. A) Acute Respiratory Infections
        2. B) Pneumoconioses and Other Lung Diseases due to External Agents
        3. C) Pneumonia and Influenza
        4. D) Other Diseases of the Upper Respiratory Tract

         

        21) Chronic Obstructive Pulmonary Disease is found in which category and code range:

        1. A) Category J40-J47 chronic lower respiratory diseases
        2. B) Category J00-J06, acute upper respiratory infections
        3. C) Category J20, other acute lower respiratory infections
        4. D) Category J30, other diseases of upper respiratory tract

         

        22) Code range J30-J39 contains codes describing which conditions?

        1. A) Acute Respiratory Infections
        2. B) Pneumoconioses and Other Lung Diseases due to External Agents
        3. C) Pneumonia and Influenza
        4. D) Other Diseases of Upper Respiratory Tract

         

         

        23) In ICD-10-CM the subheading “Other Diseases of the Respiratory System” includes all of the following conditions except:

        1. A) acute respiratory failure
        2. B) acute bronchitis with acute bronchospasm
        3. C) chronic respiratory failure
        4. D) acute bronchospasm

         

        24) “The common cold” is also known as:

        1. A) acute tonsillitis
        2. B) acute nasopharyngitis
        3. C) acute sinusitis
        4. D) acute pharyngitis

         

        25) Acute pharyngitis may also be documented as:

        1. A) the common cold
        2. B) acute upper respiratory infection
        3. C) sore throat
        4. D) strep throat

         

        26) Category J06 includes codes describing:

        1. A) acute bronchitis
        2. B) acute upper respiratory infection of multiple or unspecified sites
        3. C) acute tonsillitis
        4. D) acute laryngitis

         

        27) An inflammation, due to an infectious organism or irritant, of the bronchus, is also known as:

        1. A) acute bronchiolitis
        2. B) acute upper respiratory infection
        3. C) acute tracheitis
        4. D) acute bronchitis

         

        28) The component of the respiratory system that is the dividing line between the upper and lower respiratory tracts is:

        1. A) larynx
        2. B) pharynx
        3. C) trachea
        4. D) bronchus

         

        29) Select the true statement concerning code selection for sinusitis and tonsillitis in ICD-10-CM:

        1. A) In ICD-10-CM, sinusitis and tonsillitis are reported by the same code
        2. B) In ICD-10-CM, the organism causing the sinusitis or tonsillitis needs to be identified
        3. C) In ICD-10-CM, tonsillitis has been moved to the Diseases of the Digestive System chapter
        4. D) In ICD-10-CM, sinusitis must be chronic before it may be coded

         

         

        30) A persistent inflammatory condition of the sinuses is also known as:

        1. A) nasal polyps
        2. B) chronic pharyngitis
        3. C) chronic sinusitis
        4. D) chronic nasopharyngitis

         

        31) “Hay fever,” or ________, is coded to category J30.

        1. A) chronic laryngotracheitis
        2. B) chronic rhinitis
        3. C) peritonsillar abscess
        4. D) allergic rhinitis

         

        32) All of the following are categories of pneumonia in the ICD-10-CM manual for Diseases of the Respiratory System except:

        1. A) Meconium aspiration pneumonia
        2. B) Pneumonia due to other infectious organisms, not elsewhere classified
        3. C) Bacterial pneumonia, not elsewhere classified
        4. D) Viral pneumonia

         

        33) Patient Mary Smith presents to the physician’s office today with a chief complaint of upper respiratory symptoms. Upon examination and discussion, the provider discovers that Mary recently returned from overseas and may have been exposed to the avian influenza virus. The provider orders further testing for Mary and documents “possible avian influenza virus” in her chart. The coder may select:

        1. A) a code from category J10, influenza due to other identified influenza virus
        2. B) a code from category J09 influenza due to certain identified influenza virus
        3. C) a code from category J11.1, influenza due to unidentified influenza virus with other respiratory manifestations
        4. D) code J11.00, influenza due unidentified influenza with unspecified type of pneumonia

         

        34) Select the statement that is false regarding the condition hypoxia:

        1. A) hypoxia would not be reported in addition to acute respiratory failure
        2. B) hypoxia is considered to be inherent to acute respiratory failure
        3. C) hypoxia is considered to be inherent to chronic obstructive pulmonary disease
        4. D) hypoxia may be reported as an additional code if documented with chronic obstructive pulmonary disease

         

        35) What is the primary difference between pneumonia and pneumonitis?

        1. A) Pneumonitis is only acquired by coal workers
        2. B) Pneumonia is an infectious inflammation while pneumonitis is noninfectious
        3. C) Pneumonia can be caused by exposure to toxic solids and liquids; pneumonitis can be caused by exposure to toxic fumes or gases
        4. D) Inflammation is inherent in pneumonitis and is not inherent in pneumonia

         

         

        36) Coal workers’ pneumoconiosis and asbestosis are found in which subheading of the Respiratory System in ICD-10-CM?

        1. A) Other Diseases of the Respiratory System
        2. B) Pneumonia and Influenza
        3. C) Lung Diseases due to External Agents
        4. D) Acute Respiratory Infections

         

        37) Necrotic or necrotizing pneumonia is also known as:

        1. A) empyema
        2. B) pleurisy
        3. C) abscess
        4. D) pneumothorax

         

        38) The abbreviation TRALI stands for:

        1. A) tracheostomy-related acute lung infection
        2. B) transfusion-related acute lung injury
        3. C) total refraction of alveoli, lungs, and interstitium
        4. D) transverse rejection of alveoli, lungs, and interstitium

         

        39) How is the Respiratory System subsection of the CPT manual formatted?

        1. A) by anatomical site, alphabetically
        2. B) by anatomical site, from lungs to nose
        3. C) by anatomical site, from nose to lungs
        4. D) by anatomical site, from largest organ to smallest

         

        40) Visualization using a mirror is referred to as:

        1. A) external approach
        2. B) indirect examination
        3. C) internal approach
        4. D) direct examination

         

        41) Visualization using a rigid or fiber-optic endoscope is also known as:

        1. A) external approach
        2. B) indirect examination
        3. C) internal approach
        4. D) direct examination

         

         

        42) A surgeon begins an endoscopic procedure intending to examine the patient’s maxillary and ethmoid sinuses only. Upon examination during this procedure, the surgeon determines the patient’s symptoms will be effectively treated by removing some inflamed tissue from the maxillary sinus. The surgeon removes the tissue from the maxillary sinus, removes the endoscope and the procedure concludes. The coder may select:

        1. A) 31267 “Nasal/sinus endoscopy, surgical, with maxillary antrostomy, with removal of tissue from maxillary sinus”
        2. B) 31231 “Nasal endoscopy, diagnostic, unilateral or bilateral”
        3. C) 31267 “Nasal/sinus endoscopy, surgical, with maxillary antrostomy, with removal of tissue from maxillary sinus” and 31231 “Nasal endoscopy, diagnostic, unilateral or bilateral”
        4. D) 31276 “Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus”

         

        43) When reviewing code selection from the Respiratory subsection of CPT, why is it important for a coder to identify the cause of the condition (i.e. a traumatic injury vs. a medical condition)?

        1. A) the provider will receive a higher reimbursement rate if treatment is provided for a traumatic injury
        2. B) modifier 22 may be appended to codes reporting treatment of a traumatic injury
        3. C) Medicare will only reimburse providers for treatment of medical conditions
        4. D) a traumatic injury is an acute condition and a medical condition is a chronic condition

         

        44) Which of the following is not a question a coder should ask when selecting codes from the Respiratory subsection of CPT?

        1. A) Was the approach internal or external?
        2. B) Was the procedure performed at a single site or multiple sites?
        3. C) Was the procedure performed in a single stage or multiple stages?
        4. D) At which anatomical site was the procedure performed?

         

        45) The Respiratory Subsection general heading “Lungs and Pleura” is found in what code range?

        1. A) 31000-31299
        2. B) 31300-31599
        3. C) 32035-32999
        4. D) 31600-31899

         

        46) All of the following are Respiratory Subsection General Headings except:

        1. A) Nose
        2. B) Larynx
        3. C) Pharynx
        4. D) Trachea and bronchi

         

        47) Excision of nasal polyps is divided by whether the procedure is:

        1. A) simple or extensive
        2. B) incisional or excisional
        3. C) performed in an office or in a hospital
        4. D) performed on the upper or lower turbinates

         

        48) A “septal button” is another term for a septal:

        1. A) plug
        2. B) prosthesis
        3. C) packing
        4. D) bandage

         

        49) Excision of a middle or superior turbinate is reported using this code:

        1. A) 30130
        2. B) 30115
        3. C) 30100
        4. D) 30999

         

        50) A procedure which often requires the use of nasal stents, balloon catheters, or posterior packing is:

        1. A) complex anterior nasal hemorrhage control
        2. B) posterior nasal hemorrhage control
        3. C) therapeutic fracture of a nasal inferior turbinate
        4. D) simple anterior nasal hemorrhage control

         

        51) Which of these is not a common subheading under the Respiratory Section general headings?

        1. A) Laparoscopy
        2. B) Removal/Removal of Foreign Body
        3. C) Incision
        4. D) Excision

         

        52) A rhinoplasty with intermediate revision includes:

        1. A) a primary rhinoplasty
        2. B) a primary rhinoplasty with nasal-tip work and osteotomies
        3. C) a secondary rhinoplasty with a small amount of nasal-tip work
        4. D) a secondary rhinoplasty with bony work with osteotomies

         

        53) Harry underwent a primary rhinoplasty two days ago, performed by Dr. Trent. Harry calls the office complaining of significant bleeding from the nose. Dr. Trent meets Harry at the hospital and performs an anterior simple nasal hemorrhage control. What modifier would the coder append to 30901?

        1. A) 58
        2. B) 59
        3. C) 78
        4. D) 79

         

         

        54) Surgical sinus endoscopy includes:

        1. A) bilateral procedures
        2. B) sinusotomy
        3. C) polyp removal
        4. D) sinusotomy and diagnostic endoscopy

         

        55) A partial laryngectomy antero-latero-vertical includes:

        1. A) resection of the vocal cords, thyroid, and a portion of the arytenoids
        2. B) resection of the thyroid cartilage and portions of both vocal cords
        3. C) resection of vocal cord and adjacent cartilage
        4. D) radical neck dissection

         

        56) Modifier 50 signifies:

        1. A) Multiple procedures
        2. B) Bilateral procedure
        3. C) Reduced Service
        4. D) Staged or Related Procedure

         

        57) Bilateral procedure is communicated to third-party payers by modifier:

        1. A) 50
        2. B) 51
        3. C) 58
        4. D) 59

         

        58) Modifier 51 communicates:

        1. A) Multiple procedures
        2. B) Bilateral procedure
        3. C) Reduced Service
        4. D) Staged or Related Procedure

         

        59) Reduced service is communicated to third-party payers by using modifier:

        1. A) 50
        2. B) 51
        3. C) 58
        4. D) 52

         

        60) Provider’s documentation states “performed lavage by cannulation in the bilateral maxillary sinuses.” The description for CPT code 31000 reads “Lavage by cannulation, maxillary sinus (antrum puncture or other natural ostium.)” How would the coder report the procedure performed?

        1. A) 31000-58
        2. B) 31000-52
        3. C) 31000-51
        4. D) 31000-50

         

         

        61) Visualization of the larynx by means of a mirror positioned at the back of the throat is called:

        1. A) oximetry
        2. B) bronchoscopy
        3. C) indirect laryngoscopy
        4. D) laparoscopy

         

        62) Abbreviation ABG stands for:

        1. A) arterial blood gas
        2. B) artery blockage group
        3. C) adult bronchoscopy
        4. D) asthma-blocked grouping

         

        63) An examination of arterial blood for levels of oxygen, carbon dioxide, or other gases is called:

        1. A) carboxyhemoglobin measurement
        2. B) arterial blood gas
        3. C) aspirate
        4. D) oximetry

         

        64) The following procedure can be performed by using incisional, excisional, needle aspiration, punch, or shave technique:

        1. A) biopsy
        2. B) incision
        3. C) repair
        4. D) pneumonectomy

         

        65) To complete this procedure, foreign material is drawn into the lungs or withdrawn from the lungs for diagnostic or therapeutic reasons:

        1. A) oximetry
        2. B) aspirate
        3. C) carboxyhemoglobin measurement
        4. D) laryngoscopy

         

        66) A biopsy is a(n):

        1. A) examination of arterial blood for levels of oxygen, carbon dioxide, or other gases
        2. B) creation of an opening by surgically cutting into the skin or other tissue
        3. C) restoration of diseased or damaged tissue
        4. D) removal of all or part of a lesion for pathologic examination

         

        67) The creation of an opening by surgically cutting into the skin or other tissue is:

        1. A) bronchoscopy
        2. B) excision
        3. C) incision
        4. D) biopsy

         

         

        68) The measurement of oxygen saturation of the blood is called:

        1. A) carboxyhemoglobin measurement
        2. B) oximetry
        3. C) arterial blood gas
        4. D) spirometry

         

        69) The measurement of breathing or lung volume is known as:

        1. A) carboxyhemoglobin measurement
        2. B) oximetry
        3. C) arterial blood gas
        4. D) spirometry

         

        70) Pneumonectomy is:

        1. A) reshaping or replacing by surgical means
        2. B) restoration of diseased or damaged tissue
        3. C) surgical removal of a lung
        4. D) measurement of breathing or lung volume

         

        71) A ventilation/perfusion scan is:

        1. A) measurement of breathing or lung volume
        2. B) nuclear medicine study pertaining to air and blood flow to the lungs
        3. C) test that measures the amount of carbon monoxide and hemoglobin in blood
        4. D) examination of arterial blood for levels of oxygen, carbon dioxide, or other gases

         

        72) A condition in which the airways are hypersensitive and react to inhaled irritants by narrowing or obstructing is:

        1. A) dyspnea
        2. B) atelectasis
        3. C) asthma
        4. D) chronic obstructive pulmonary disorder

         

        73) The condition “rales” is:

        1. A) abnormal chest sounds
        2. B) discharge of blood from the nose
        3. C) several viral infection of the lungs
        4. D) inflammation of the lungs caused by an organism

         

        74) Another word for nosebleed or rhinorrhagia is:

        1. A) rales
        2. B) atelectasis
        3. C) dyspnea
        4. D) epistaxis

         

         

        75) A severe viral infection of the lungs is:

        1. A) epistaxis
        2. B) severe acute respiratory syndrome
        3. C) pneumonia
        4. D) chronic obstructive pulmonary disorderMedical Coding, 2e (Stewart)

          Chapter 11   Surgery Section: Cardiovascular and Lymphatic Systems

           

          1) All of the following are primary functions of the cardiovascular system except:

          1. A) transporting nutrients and oxygen to cells
          2. B) assisting the digestive system in removing waste products from the body
          3. C) removing carbon dioxide from cells
          4. D) removing waste products from cells

           

          2) When coding for the cardiovascular system, coders may need to select codes from all of the following sections:

          1. A) Evaluation and Management; Surgery
          2. B) Surgery; Radiology; Pathology and Laboratory
          3. C) Surgery; Medicine; Pathology and Laboratory
          4. D) Surgery; Evaluation and Management; Radiology; Medicine

           

          3) All of the following are main functions of the lymphatic system except:

          1. A) maintain body temperature
          2. B) defend the body against disease
          3. C) absorb and transport liquids from blood vessels
          4. D) maintain fluid balance

           

          4) Which of the following structures is not a main part of the cardiovascular system?

          1. A) heart
          2. B) marrow
          3. C) blood
          4. D) blood vessels

           

          5) Blood is pumped away from the heart by the pulmonary artery to the lungs via the ________ system:

          1. A) cardiovascular
          2. B) systemic
          3. C) peripheral
          4. D) pulmonary

           

          6) The ________ circulation system transports oxygenated blood away from the heart, to the rest of the body, and returns oxygen-depleted blood back to the heart:

          1. A) cardiovascular
          2. B) systemic
          3. C) peripheral
          4. D) pulmonary

           

           

          7) The muscular, cone-shaped organ whose main function is to pump blood is the:

          1. A) septum
          2. B) aorta
          3. C) heart
          4. D) superior vena cava

           

          8) How many chambers does the heart contain?

          1. A) two
          2. B) three
          3. C) four
          4. D) five

           

          9) Into which chambers does oxygenated blood flow back to the heart from the lungs?

          1. A) right and left atria
          2. B) right and left ventricle
          3. C) right atrium and right ventricle
          4. D) left atrium and left ventricle

           

          10) What is the outer layer of the heart-wall tissue?

          1. A) aorta
          2. B) epicardium
          3. C) septum
          4. D) endocardium

           

          11) Which of the following is the wall dividing the right and left sides of the heart?

          1. A) aorta
          2. B) epicardium
          3. C) septum
          4. D) endocardium

           

          12) The pericardium is:

          1. A) the outer layer of heart-wall tissue
          2. B) the inner layer of heart-wall tissue
          3. C) the membrane sac that encases the heart
          4. D) the wall dividing the right and left sides of the heart

           

          13) What is the superior vena cava?

          1. A) the largest vein which carries de-oxygenated blood from the upper body to the heart
          2. B) the largest artery that takes oxygenated blood from the left ventricle to the body
          3. C) takes oxygenated blood from the lungs to the left atrium
          4. D) the largest vein which carries de-oxygenated blood from the lower body to the heart

           

           

          14) Select the middle layer of the artery wall:

          1. A) tunica externa
          2. B) capillaries
          3. C) tunica media
          4. D) tunica intima

           

          15) Smaller bunches of arteries are called:

          1. A) aorta
          2. B) arterioles
          3. C) capillaries
          4. D) superficial arteries

           

          16) The largest vein that carries de-oxygenated blood from the back, abdomen, and pelvis, and lower extremities of the body back to heart is the:

          1. A) tunica externa
          2. B) superior vena cava
          3. C) deep vein
          4. D) inferior vena cava

           

          17) Veins that are located close to the arteries are called:

          1. A) arterioles
          2. B) deep veins
          3. C) superficial veins
          4. D) capillaries

           

          18) All of the following are components of the electrical system of the heart except:

          1. A) aorta
          2. B) SA node
          3. C) His-Purkinje system
          4. D) AV node

           

          19) What is the start of the His-Purkinje system?

          1. A) Bundle of His
          2. B) Purkinje fibers
          3. C) Sinoatrial (SA) node
          4. D) Atrioventricular (AV) node

           

          20) The heart’s natural pacemaker, where the electrical impulses begin, is called the:

          1. A) Sinoatrial (SA) node
          2. B) Atrioventricular (AV) node
          3. C) Bundle of His
          4. D) Purkinje fibers

           

           

          21) What is the bridge between the atria and the ventricles that allows the electrical signals to pass to the bundle of His?

          1. A) Sinoatrial (SA) node
          2. B) Atrioventricular (AV) node
          3. C) Bundle of His
          4. D) Purkinje fibers

           

          22) The tricuspid valve is:

          1. A) located on the right side of the heart between the atrium and the ventricle
          2. B) the bicuspid valve
          3. C) located between the left ventricle and the aorta
          4. D) a semilunar valve located between the right ventricle and the pulmonary artery

           

          23) This valve allows blood to flow from the left atrium into the left ventricle:

          1. A) tricuspid
          2. B) pulmonary
          3. C) aortic
          4. D) mitral

           

          24) The aortic valve:

          1. A) opens to allow blood to exit the left ventricle and flow into the aorta when the pressure in the left ventricle rises above the pressure in the aorta
          2. B) stops the backflow of blood between the right atrium and right ventricle
          3. C) allows blood to flow from the left atrium into the left ventricle
          4. D) prevents the flow of blood back into the right ventricle and opens to allow deoxygenated blood to flow through the pulmonary artery into the lungs

           

          25) The pulmonary valve:

          1. A) opens to allow blood to exit the left ventricle and flow into the aorta when the pressure in the left ventricle rises above the pressure in the aorta
          2. B) stops the backflow of blood between the right atrium and right ventricle
          3. C) allows blood to flow from the left atrium into the left ventricle
          4. D) prevents the flow of blood back into the right ventricle and opens to allow deoxygenated blood to flow through the pulmonary artery into the lungs

           

          26) When de-oxygenated blood is returned to the heart, the blood is brought into the center of the cardiovascular system by the ________.

          1. A) SA node
          2. B) bundle of HIS
          3. C) inferior vena cava
          4. D) pulmonary valve

           

           

          27) Select the structure that is not a main part of the lymphatic system:

          1. A) spleen
          2. B) liver
          3. C) lymph nodes
          4. D) thymus

           

          28) Select the structure that filters blood and is the largest lymph organ:

          1. A) thymus
          2. B) spleen
          3. C) lymph nodes
          4. D) lymph vessels

           

          29) This contains nutrients, fats, electrolytes, and cellular waste:

          1. A) lymph fluid
          2. B) lymph vessels
          3. C) lymph nodes
          4. D) lymph waste

           

          30) Lymph vessels:

          1. A) transport lymph fluids and merge into lymphatic ducts
          2. B) contain nutrients, fats, electrolytes, and cellular waste
          3. C) are collections of tissue located along the lymph vessels
          4. D) produce T cells

           

          31) Which structure in the lymphatic system produces T cells?

          1. A) lymph vessels
          2. B) lymph nodes
          3. C) spleen
          4. D) thymus

           

          32) All of the following are common problems patients present with concerning the cardiovascular system except:

          1. A) congestive heart failure
          2. B) bursitis
          3. C) hypertension
          4. D) edema

           

          33) Where can a coder find the correct codes for the diagnosis ischemic heart disease?

          1. A) Chapter 6, ICD-10-CM
          2. B) Chapter 3, CPT
          3. C) Chapter 9, ICD-10-CM
          4. D) Chapter 4, CPT

           

           

          34) In which code range can a coder find Chapter 9 codes in ICD-10-CM?

          1. A) E00-E89
          2. B) L00-L99
          3. C) J00-J99
          4. D) I00-I99-

           

          35) Where could a coder locate codes for acute rheumatic fever in the ICD-10-CM manual?

          1. A) Chapter 7
          2. B) Chapter 8
          3. C) Chapter 9
          4. D) Chapter 10

           

          36) A patient presents with a hyperactive thymus. A coder will select a code from range:

          1. A) E23, hypofunction and other disorders of the pituitary gland
          2. B) I10, essential hypertension
          3. C) E34, other endocrine disorders
          4. D) E32, diseases of thymus

           

          37) Which of the following is not true regarding rheumatic fever?

          1. A) if left untreated, it can lead to complications such as liver failure
          2. B) it commonly occurs after a throat infection
          3. C) it commonly occurs after suffering an infection from group A streptococci
          4. D) if not treated properly, it can lead to complications including inflammation of the heart

           

          38) Which of the following is not a further subdivision of the subcategory “Rheumatic fever with heart involvement”?

          1. A) acute rheumatic myocarditis
          2. B) acute rheumatic angiocarditis
          3. C) acute rheumatic endocarditis
          4. D) acute rheumatic pericarditis

           

          39) In the category Chronic Rheumatic Heart Disease (I05-I09) which of the following is not a true statement?

          1. A) There is not a subdivision for rheumatic disorders of both aortic and tricuspid valves
          2. B) There is a subvision for tricuspid valve only
          3. C) There is a subvision for mitral valve only
          4. D) There is a subvision for mitral and aortic valve involvement

           

          40) What is valve insufficiency?

          1. A) narrowing of the valve
          2. B) contracture of the valve
          3. C) improper closure or functioning of the valve
          4. D) rupture of the valve

           

           

          41) All of the following are components of malignant hypertension except:

          1. A) severely elevated arterial pressure
          2. B) possible necrosis of organs such as eyes, heart, and kidneys
          3. C) arterial pressure that is mildly elevated
          4. D) possible hemorrhage of vessels

           

          42) Select the correct description for code I10 in ICD-10-CM:

          1. A) benign hypertension
          2. B) unspecified hypertension
          3. C) malignant hypertension
          4. D) essential primary hypertension

           

          43) What is the primary difference between codes from Category I11, I15, and I16 in ICD-10-CM?

          1. A) Each category represents a different specificity of hypertension
          2. B) Category I11 represents hypertensive heart disease; I15 represents secondary hypertension; and I16 represents hypertensive crisis
          3. C) Each category represents a different specificity of hypertension and Category I11 represents hypertensive heart disease; I15 represents secondary hypertension; and I16 represents hypertensive crisis
          4. D) They each represent different categories of CKD

           

          44) What is a common medical abbreviation for the condition “heart attack”?

          1. A) CVA
          2. B) BMI
          3. C) ITA
          4. D) AMI

           

          45) Of the following, select the answer that is not a known section of the heart that can be involved in an acute myocardial infarction:

          1. A) supralateral wall
          2. B) inferoposterior wall
          3. C) anterolateral wall
          4. D) subendocardial wall

           

          46) A coder will no longer document subsequent care of an acute myocardial infarction using codes from the category “Acute Myocardial Infarction” (I21) after what time period?

          1. A) 4 weeks
          2. B) 3 weeks
          3. C) 7 weeks
          4. D) 8 weeks

           

           

          47) A disturbance in the electrical impulse of the heart is:

          1. A) congestive heart failure
          2. B) dysrhythmia
          3. C) conduction disorder
          4. D) systolic heart failure

           

          48) Select the correct definition of diastolic heart failure:

          1. A) the heart is unable to pump blood to the extremities and lungs, resulting in edema of these areas
          2. B) the left side of the heart fails
          3. C) contraction of the heart muscle does not pump blood adequately
          4. D) the heart does not relax properly after contraction, resulting in decreased blood flow through the heart

           

          49) In systolic heart failure:

          1. A) the heart is unable to pump blood to the extremities and lungs, resulting in edema of these areas
          2. B) the left side of the heart fails
          3. C) contraction of the heart muscle does not pump blood adequately
          4. D) the heart does not relax properly after contraction, resulting in decreased blood flow through the heart

           

          50) What is the medical term for bleeding within the brain?

          1. A) cerebrovascular disease
          2. B) subarachnoid hemorrhage
          3. C) transient ischemic attack
          4. D) intracranial hemorrhage

           

          51) What is deep vein thrombosis?

          1. A) inflammation of a vein with development of a clot in a deep vein
          2. B) an acute condition characterized by arterial swelling and embolism
          3. C) hemorrhage following rupture of a vein
          4. D) raised, painful veins, typically in the upper back leg

           

          52) In which code range can a coder find procedure codes for services rendered on the heart and pericardium?

          1. A) 33202-33622
          2. B) 33510-33622
          3. C) 33010-33999
          4. D) 33010-33507

           

          53) What is an electrical device inserted into the body to shock the heart into regular rhythm?

          1. A) defibrillator
          2. B) shunt
          3. C) lead
          4. D) catheter

           

          54) All of the following are potential questions a coder would ask himself/herself when selecting a code in subheading “Pacemaker or Implantable Defibrillator” in the CPT manual except:

          1. A) Was this an initial insertion, a replacement, or a repositioning?
          2. B) Has the patient suffered an acute myocardial infarction prior to placement?
          3. C) Was the approach transvenous or epicardial?
          4. D) Was the device permanent or temporary?

           

          55) Through what means does ablation assist in the treatment of abnormal heart arrhythmia?

          1. A) ablation provides a “jump start” of new electrical conduction from the Bundle of His, stopping the previous rhythm and enabling the heart to begin a new, consistent rhythm
          2. B) ablation destroys cardiac tissue, preventing abnormal electrical signals from traveling through the heart, stopping an arrhythmia
          3. C) ablation promotes inflammation in the epicardial tissue, preventing abnormal electrical signals from traveling through the heart, stopping an arrhythmia
          4. D) ablation destroys the Purkinje fibers that are sending an abnormal electrical impulse, allowing the His-Purkinje system to effectively reset and begin a new, consistent rhythm

           

          56) The subheading “Heart (Including Valves) and Great Vessels” (33300-33340) includes all of the following procedures except:

          1. A) suture repair of aorta or great vessels
          2. B) insertion of graft aorta or great vessels
          3. C) exploratory cardiotomy
          4. D) percutaneous transluminal balloon angioplasty

           

          57) What is the backflow of blood due to valve prolapse?

          1. A) insufficiency
          2. B) stenosis
          3. C) regurgitation
          4. D) rupture

           

          58) Select the true statement regarding correct coding of Coronary Artery Bypass Grafting:

          1. A) Codes 33510-33516, Venous grafting only for coronary artery, are to be used as primary procedure codes any time a combined arterial and venous grafting procedure is performed
          2. B) Combined codes for arterial-venus grafting are always sequenced first when this procedure is performed
          3. C) Codes 33533-33548, Arterial grafting for coronary bypass, require use of modifier -51 when used with combined codes for arterial-venus grafting
          4. D) Codes 33517-33530, Combined arterial-venus grafting for coronary bypass, are add-on codes and may not be used alone or as a primary procedure

           

          59) An atrial septal defect occurs when:

          1. A) there is a hole in the aorta
          2. B) there is a hole in the septum between the two lower chambers of the heart
          3. C) there is a hole in the septum between the two upper chambers of the heart
          4. D) there is a hole in the inferior vena cava

           

          60) Subsection Cardiac Assist, (33967-33993) include all of the following procedures except:

          1. A) percutaneous insertion of a ventricular assist device
          2. B) replacement of a ventricular assist device
          3. C) abdominal insertion of a ventricular assist device
          4. D) transthoracic insertion of a ventricular assist device

           

          61) Which of the following is true regarding selective placement of a catheter in subsection Vascular Injection Procedures, (36000-36522)?

          1. A) the catheter is left in the access vessel
          2. B) the catheter is not advanced beyond the aorta
          3. C) the catheter is placed into the third, fourth, or fifth order of the vascular family
          4. D) the catheter is placed into the first, second, or third order of the vascular family

           

          62) A central venous access device is used for all of the following except:

          1. A) administration of oral antibiotics
          2. B) administration of chemotherapy
          3. C) blood transfusions
          4. D) multiple blood draws

           

          63) Select the indication for which removal of the spleen is not typically performed:

          1. A) spontaneous rupture
          2. B) dialysis
          3. C) enlargement that becomes destructive to platelets
          4. D) means of diagnosing certain conditions

           

          64) Dr. Sellers actively assists in the identification of an optimal bone marrow donor for his patient. Cells from the donor are acquired and proper procedure is followed to transfer these cells to the patient. However, after receiving the first donation, it is evident the patient requires a second donation and transplant in another operative session on the same date of service. Dr. Sellers returns to the original donor and harvests an additional donation of cells. Select the appropriate code(s) to report Dr. Sellers’ second set of harvesting services:

          1. A) 38204, Management of recipient hematopoietic progenitor cell donor search and cell acquisition
          2. B) None – the second set of harvesting services is included in the first reporting of 38204
          3. C) 38204-51, Management of recipient hematopoietic progenitor cell donor search and cell acquisition, Multiple Procedures
          4. D) 38204-78, Management of recipient hematopoietic progenitor cell donor search and cell acquisition, Unplanned return to the operating/procedure room by the same physician or another qualified health care professional following the initial procedure for a related procedure during the postoperative period

           

           

          65) A patient presents for bilateral lymphangiography to determine presence or absence of neoplasms in the lymph nodes. CPT code 38790, Injection procedure, lymphangiography, is available for use. What modifier should be appended to describe this procedure?

          1. A) 50
          2. B) 51
          3. C) 59
          4. D) 79

           

          66) Modifier 53 signifies:

          1. A) Discontinued Procedure
          2. B) Decision for Surgery
          3. C) Distinct Procedural Service
          4. D) Bilateral Procedure

           

          67) A right internal carotid angiography and a left vertebral angiography were performed on the same patient during the same session. Which modifier is appropriate to accurately report these services?

          1. A) 50
          2. B) 51
          3. C) 59
          4. D) 78

           

          68) Select the procedure that means to surgically connect two vessels:

          1. A) percutaneous transluminal coronary angioplasty
          2. B) endartectomy
          3. C) anastomosis
          4. D) lymphadenectomy

           

          69) An x-ray exam of the arteries or veins is a(n):

          1. A) cardioversion
          2. B) angiography
          3. C) endartectomy
          4. D) percutaneous transluminal coronary angioplasty

           

          70) What is the name of the procedure in which electrodes are placed directly on the chest to deliver a shock, in an effort to treat a cardiac arrhythmia:

          1. A) external cardioversion
          2. B) angiography
          3. C) endartectomy
          4. D) percutaneous transluminal coronary angioplasty

           

           

          71) An endartectomy is:

          1. A) a device used to hold open a blood vessel
          2. B) the surgical connection of two vessels
          3. C) a procedure used to improve blood flow to the heart by bypassing a blockage of a vessel with a grafted vessel
          4. D) surgical removal of plaque from within a blocked or occluded artery

           

          72) What is the inflammation of large blood vessels?

          1. A) temporal arteritis
          2. B) bruits
          3. C) portal vein thrombosis
          4. D) thrombus

           

          73) When a coder sees the terminology “Sydenham’s” or “St. Vitus’ dance,” to what condition is the provider referring?

          1. A) hypertension
          2. B) rheumatic chorea
          3. C) lymphedema
          4. D) sick sinus syndrome

           

          74) Symptoms including bradycardia, fatigue, syncope, shortness of breath, confusion, and palpitations are all indications of what cardiac condition?

          1. A) hypertension
          2. B) thrombus
          3. C) sick sinus syndrome
          4. D) arrhythmia

           

          75) Which of the following conditions is characterized by fluid build-up in the stomach, enlarged spleen, and severe esophageal hemorrhaging?

          1. A) portal vein thrombosis
          2. B) sick sinus syndrome
          3. C) embolus
          4. D) hypertension

           

          76) What is a collection of excess fluid in the lymph tissue?

          1. A) hypertension
          2. B) rheumatic chorea
          3. C) lymphedema
          4. D) sick sinus syndromeMedical Coding, 2e (Stewart)

            Chapter 13   Surgery Section: Urinary System and Male Reproductive System

             

            1) Select the organ that is not a major organ of the urinary system:

            1. A) kidney
            2. B) liver
            3. C) urinary bladder
            4. D) ureter

             

            2) All of the following are functions of the urinary system except:

            1. A) filter the blood
            2. B) create the balance of water and chemicals in the body
            3. C) remove excess fluids from the body
            4. D) transport water to cells

             

            3) Which of the following is not a major organ in the male reproductive system?

            1. A) thymus gland
            2. B) Cowper’s gland
            3. C) prostate gland
            4. D) urethra

             

            4) Which organ system contains the seminal vesicle, vas deferens, and epididymis?

            1. A) urinary system
            2. B) lymphatic system
            3. C) respiratory system
            4. D) male reproductive system

             

            5) What function is identified as the primary function of the urinary system?

            1. A) excrete waste products and foreign substances
            2. B) produce red blood cells
            3. C) filter the blood and produce urine
            4. D) regulate the pH of the blood

             

            6) What is the glomerulus?

            1. A) the outer layer of the kidney
            2. B) a collection of kidney cells whose function is to filter blood and form urine
            3. C) the inner layer of the kidney
            4. D) the region through which blood passes as it enters the kidney

             

            7) What is the outer layer of the kidney?

            1. A) ureter
            2. B) cortex
            3. C) medulla
            4. D) glomerulus

             

             

            8) Which of the following is not a function of the kidney organ?

            1. A) produce white blood cells
            2. B) regulate the pH of blood
            3. C) filter the blood and produce urine
            4. D) regulate blood pressure and blood volume

             

            9) Which structure within the kidney captures water and waste products to form urine?

            1. A) renal pelvis
            2. B) nephrons
            3. C) glomerulus
            4. D) renal tubules

             

            10) What are the ureters’ primary functions?

            1. A) transport urine from the kidney to the urinary bladder
            2. B) store urine as a result of the bladder walls relaxing and expanding
            3. C) assist in keeping urine from leaking
            4. D) passageways through which urine passes from the urinary bladder to the outside of the body

             

            11) Which structure is a passageway, or tube, through which urine passes from the urinary bladder to the outside of the body?

            1. A) urethra
            2. B) nephrons
            3. C) glomerulus
            4. D) renal tubules

             

            12) Select the correct flow of urine through the urinary system:

            1. A) urethra – kidneys – urinary bladder – ureters – exit from the body
            2. B) ureters – kidneys – urinary bladder – urethra – exit from the body
            3. C) kidneys – ureters – urinary bladder – urethra – exit from the body
            4. D) urinary bladder – urethra – kidneys – ureters – exit from the body

             

            13) What is erythropoiesis?

            1. A) production of urine
            2. B) production of red blood cells
            3. C) production of male growth hormone
            4. D) production of semen

             

            14) Select the correct listing of external structures in the male reproductive system:

            1. A) penis, vas deferens, ejaculatory ducts
            2. B) penis, urethra, scrotum
            3. C) penis, testes, vas deferens
            4. D) penis, scrotum, testes

             

             

            15) What is the prepuce?

            1. A) a pouchlike sac that contains the testicles
            2. B) an oval organ located in the scrotum, secured by the spermatic cord
            3. C) a long, coiled tube located on the back of the testicle
            4. D) foreskin that surrounds and protects the head of the penis

             

            16) What is a long, coiled tube located on the back of the testicle called?

            1. A) epididymis
            2. B) vas deferens
            3. C) ejaculatory duct
            4. D) urethra

             

            17) Select the correct name for coiled masses of tubes that are responsible for producing sperm cells:

            1. A) vas deferens
            2. B) seminal vesicle
            3. C) spermatic cord
            4. D) seminiferous tubules

             

            18) What is the vas deferens?

            1. A) a pouchlike sac that contains the testicles
            2. B) an oval organ located in the scrotum, secured by the spermatic cord
            3. C) a long, coiled tube located on the back of the testicle
            4. D) a tube from the epididymis to the pelvic cavity that transports mature sperm to the urethra

             

            19) The oval organs located in the scrotum, secured by the spermatic cord, are:

            1. A) testes
            2. B) seminal vesicle
            3. C) spermatic cord
            4. D) seminiferous tubules

             

            20) The vas deferens and the seminal vesicles fuse to form the ________, which empty into the urethra.

            1. A) testes
            2. B) epididymis
            3. C) spermatic cord
            4. D) ejaculatory ducts

             

            21) The function of the ________ is production of fluid that empties into the urethra and acts as a lubricant for the urethra and as a neutralizer for urine:

            1. A) ejaculatory ducts
            2. B) seminal vesicles
            3. C) prostate glands
            4. D) Cowper’s glands

             

             

            22) One of the functions of the ________ is to produce additional fluid that aids in the nourishment of the sperm.

            1. A) epididymis
            2. B) prostate gland
            3. C) vas deferens
            4. D) Cowper’s gland

             

            23) Select the condition that is not a common disease affecting the urinary system:

            1. A) hematuria
            2. B) arthritis
            3. C) cystitis
            4. D) renal failure

             

            24) Which of the following conditions is not a common disease affecting the male genital system?

            1. A) prostate disease
            2. B) orchitis
            3. C) male infertility
            4. D) oophoritis

             

            25) A lesion of proliferative glomerulonephritis is a condition in which:

            1. A) the kidney function has been progressively and rapidly destroyed, and can result in ESRD
            2. B) there is unchecked growth of tissue, which affects the ability of the kidney to filter the blood
            3. C) the filtering system becomes inflamed and often scarred, and the ability to remove waste from the blood is comprised
            4. D) a noninflammatory condition affects functioning of the nephrons

             

            26) In which chapter of the ICD-10-CM manual will a coder find Diseases of the Genitourinary System?

            1. A) 11
            2. B) 12
            3. C) 13
            4. D) 14

             

            27) In which code range would a coder find Other Diseases of the Urinary System in ICD-10-CM?

            1. A) N25-N29
            2. B) N30 -N39
            3. C) N99
            4. D) N00-N23

             

             

            28) In which subheading and code range will a coder find Nephrotic Syndromes in ICD-10-CM?

            1. A) Glomerular diseases N00-N08
            2. B) Reno tubule-interstitial diseases N10-N16
            3. C) Other diseases of the kidney and ureter N25-N29
            4. D) Other diseases of the urinary system N30-N39

             

            29) Where are Diseases of Male Genital Organs found in the ICD-10-CM manual?

            1. A) N30-N39
            2. B) N80-N98
            3. C) N40-N53
            4. D) N70-N77

             

            30) Where are Glomerular Diseases found in the ICD-10-CM manual?

            1. A) N00-N08
            2. B) N10-N16
            3. C) N20-N23
            4. D) N25-N29

             

            31) In what code range will a coder locate codes for Renal Tubulointerstitial Disease in the ICD-10-CM manual?

            1. A) N00-N08
            2. B) N10-N16
            3. C) N20-N23
            4. D) N25-N29

             

            32) Where will a coder find codes for Urolithiasis in ICD-10-CM?

            1. A) N00-N08
            2. B) N10-N16
            3. C) N20-N23
            4. D) N25-N29

             

            33) What is the most common form of acute nephritis?

            1. A) nephrotic syndrome
            2. B) nephrosis
            3. C) glomerulonephritis
            4. D) primary nephritic syndrome

             

             

            34) What is the primary difference between primary nephritic syndrome and secondary nephritic syndrome?

            1. A) primary nephritic syndrome is an acute condition while secondary nephritic syndrome is a chronic condition
            2. B) primary nephritic syndrome is limited to the kidney while secondary nephritic syndrome affects the kidney and other parts of the body
            3. C) primary nephritic syndrome is a noninflammatory condition of the kidneys, while secondary nephritic syndrome is inflammatory
            4. D) primary nephritic syndrome is an acute condition affecting the renal tubes, while secondary nephritic syndrome is a degenerative disease of the renal tubules

             

            35) What is a noninflammatory condition of the kidneys that results in degenerative disease of the renal tubules, and kidney disease affecting function of the nephrons?

            1. A) nephritis
            2. B) glomerulonephritis
            3. C) nephrotic syndrome
            4. D) nephrosis

             

            36) Which of the following is not a common cause of acute kidney failure?

            1. A) calculi obstructing the flow of urine
            2. B) tumors
            3. C) congestive heart failure
            4. D) chronic obstructive pulmonary disease

             

            37) If renal function does not return after treatment of acute kidney failure, what does the condition typically progress into?

            1. A) chronic kidney disease
            2. B) renal medullary necrosis
            3. C) tubular necrosis
            4. D) renal cortical necrosis

             

            38) Select the correct sequence of codes to be selected when coding chronic kidney disease:

            1. A) code first the manifestation, use an additional code to identify kidney transplant status, use an additional code to identify the hypertensive chronic disease
            2. B) code first the manifestation, use an additional code to identify the hypertensive chronic disease
            3. C) code first the hypertensive chronic disease, use an additional code to identify the manifestation
            4. D) code first the hypertensive chronic disease, use an additional code to identify kidney transplant status, use an additional code to identify the manifestation

             

            39) How many stages are there of chronic kidney disease in the ICD-10-CM manual?

            1. A) 3
            2. B) 4
            3. C) 5
            4. D) 6

             

            40) To which Stage is a mild form of kidney disease classified in the Stages of chronic kidney disease in ICD-10-CM?

            1. A) Stage 1
            2. B) Stage 2
            3. C) Stage 3
            4. D) Stage 4

             

            41) To which Stage is a severe form of kidney disease, symptoms are progressively more pronounced, classified in the Stages of chronic kidney disease in ICD-10-CM?

            1. A) Stage 1
            2. B) Stage 2
            3. C) Stage 3
            4. D) Stage 4

             

            42) To which Stage is a moderate form of kidney disease, patient may be experiencing some anemia and bone loss, classified in the Stages of chronic kidney disease in ICD-10-CM?

            1. A) Stage 1
            2. B) Stage 2
            3. C) Stage 3
            4. D) Stage 4

             

            43) How is chronic kidney disease requiring chronic dialysis categorized in ICD-10-CM?

            1. A) Stage 4 CKD
            2. B) Severe CKD
            3. C) Renal failure
            4. D) End Stage Renal Disease

             

            44) A patient’s chart includes two diagnostic statements for services rendered today. The provider documents the patient has Stage 5 chronic kidney disease and End Stage Renal Disease. Which of the following is the appropriate reporting of ICD-10-CM codes to describe this patient’s condition?

            1. A) N18.5
            2. B) N18.6
            3. C) N18.5, N18.6
            4. D) N18.6, N18.5

             

            45) Which of the following would be coded to the Diseases of the Genitourinary System chapter of ICD?

            1. A) polyuria
            2. B) chronic kidney disease
            3. C) urinary frequency
            4. D) urinary incontinency

             

             

            46) When referring to conditions affecting the urinary bladder, the terms contracture or stenosis are often used to describe:

            1. A) irradiation cystitis
            2. B) diverticulum of the bladder
            3. C) overactive bladder
            4. D) bladder neck obstruction

             

            47) What is the abbreviation frequently used to describe the condition “benign prostatic hypertrophy”?

            1. A) BPH
            2. B) BPHT
            3. C) PHT
            4. D) PH

             

            48) Per CPT General Guidelines for the Urinary System subsection of CPT, insertion of a urinary bladder catheter:

            1. A) is never coded separately
            2. B) is considered to be part of the global surgical package
            3. C) is separately reportable
            4. D) is separately reportable with use of modifier -59

             

            49) Per CPT General Guidelines for the Urinary System subsection of CPT, placement of a catheter for postoperative drainage:

            1. A) is never coded separately
            2. B) is separately reportable with use of modifier -51
            3. C) is separately reportable
            4. D) is separately reportable with use of modifier -59

             

            50) Per CPT General Guidelines for the Urinary System subsection of CPT, when an endoscopic procedure is performed as part of an open procedure:

            1. A) only the open procedure is reported
            2. B) the endoscopy procedure is separately reportable with use of modifier -51
            3. C) the endoscopy procedure is separately reportable
            4. D) the endoscopy procedure is separately reportable with use of modifier -59

             

            51) Per CPT General Guidelines for the Urinary System subsection of CPT, when multiple endoscopic approaches are attempted:

            1. A) separate codes may be reported for the first attempt and the successful attempt
            2. B) only the first attempt is reported
            3. C) only the successful attempt is reported
            4. D) separate codes may be reported for each attempt

             

             

            52) All of the following are questions a coder should ask himself/herself when selecting codes from the Urinary subsection of CPT except:

            1. A) What approach was used?
            2. B) Does the documentation describe a procedure done at a single site or multiple sites?
            3. C) At which anatomical site was the procedure performed?
            4. D) What type of exam, office, other outpatient, or consultation, was performed?

             

            53) In what code range will a coder find procedure codes performed on the kidney in CPT?

            1. A) 50010-50593
            2. B) 50600-50980
            3. C) 51020-52700
            4. D) 53000-53899

             

            54) In what code range will a coder find procedure codes performed on the ureter in CPT?

            1. A) 50010-50135
            2. B) 50600-50980
            3. C) 51020-52700
            4. D) 53000-53899

             

            55) Which of the following is not a general heading in the Urinary subsection of CPT?

            1. A) Laparoscopy
            2. B) Introduction
            3. C) Revision
            4. D) Endoscopy

             

            56) How are the Incision codes used to report drainage of a perirenal or renal abscess further subdivided in CPT?

            1. A) primary or secondary
            2. B) unilateral or bilateral
            3. C) open or percutaneous
            4. D) minimal or invasive

             

            57) Provider documentation states a renal biopsy was performed via fine-needle aspiration. Select the appropriate code(s) used to report this procedure:

            1. A) 50200
            2. B) 50200, 10022
            3. C) 50205
            4. D) 10022

             

            58) A coder is assigning the correct procedure code to describe a nephrectomy. Which of the following questions is not necessary to answer during the code selection process?

            1. A) Did the procedure include a partial or total ureterectomy?
            2. B) Was the procedure complicated due to hypertensive chronic kidney disease?
            3. C) Was there vena caval resection with reconstruction?
            4. D) Was it an open or laparoscopic procedure?

             

            59) Which of the following is not a major physician component of a renal transplantation code?

            1. A) living donor nephrectomy
            2. B) backbench work
            3. C) recipient renal allotransplantation
            4. D) laparoscopic donor nephrectomy

             

            60) How are codes for ureterolithotomy further subdivided in CPT?

            1. A) location
            2. B) unilateral or bilateral
            3. C) primary or recurrent
            4. D) herniated or incarcerated

             

            61) Which of the following is not a subsection of Bladder (51020-52700) codes in CPT?

            1. A) Removal
            2. B) Excision
            3. C) Incision
            4. D) Biopsy

             

            62) What is another term commonly used to describe a partial cystectomy in CPT?

            1. A) incomplete
            2. B) revisional
            3. C) segmental
            4. D) radical

             

            63) In the Urodynamics (51725-51798) subsection of the Urinary system codes in CPT, what does an EMG document?

            1. A) pelvic muscle activity
            2. B) the resistance of the urethra to fluid flow
            3. C) how much fluid the bladder can hold
            4. D) how much pressure builds up in the bladder

             

            64) What is the correct abbreviation for a Cystometrogram?

            1. A) CM
            2. B) CG
            3. C) C
            4. D) CMG

             

            65) Per CPT General Guidelines for the Male Reproductive System subsection of CPT, exploration of the surgical field:

            1. A) is not reported separately
            2. B) is identified by a separate CPT add-on code
            3. C) is separately reportable by using modifier -22
            4. D) is separately reportable by using modifier -51

             

             

            66) In what code range will a coder find procedures performed on the prostate in CPT?

            1. A) 55200-55450
            2. B) 55500-55559
            3. C) 55600-55680
            4. D) 55700-55899

             

            67) In what code range will a coder find procedures performed on the spermatic cord in CPT?

            1. A) 55200-55450
            2. B) 55500-55559
            3. C) 55600-55680
            4. D) 55700-55899

             

            68) All of the following are general headings in the Male Reproductive subsection of CPT except:

            1. A) Endoscopy
            2. B) Repair
            3. C) Introduction
            4. D) Excision

             

            69) Under which general heading are circumcision procedures reported?

            1. A) Incision
            2. B) Revision
            3. C) Excision
            4. D) Repair

             

            70) CPT code 54150 states “Circumcision, using a clamp or another device, with a regional dorsal penile or ring block.” How should the coder report a circumcision procedure using a clamp without dorsal penile or ring block?

            1. A) Report 54150
            2. B) Report 54150-52
            3. C) Select a code from the Integumentary, Removal subsection
            4. D) Select a code from the Male Reproductive, Incision subsection

             

            71) All of the following are further subdivisions of urethroplasty procedures in the CPT manual except:

            1. A) first or second stage
            2. B) male urethra
            3. C) simple or complex
            4. D) female urethra

             

             

            72) For renal autotransplantation extracorporeal (bench) surgery, CPT directs the coder to use autotransplantation as the primary procedure and report secondary procedures such as partial nephrectomy or nephrolithotomy with modifier:

            1. A) 50
            2. B) 51
            3. C) 59
            4. D) 79

             

            73) Which modifier describes a staged or related procedure or service by the same physician during the postoperative period?

            1. A) 58
            2. B) 59
            3. C) 78
            4. D) 79

             

            74) A patient returns to the operating room while in the surgical global period for a transurethral fulguration of the prostate to treat postoperative bleeding from a procedure performed on that body area. Which modifier is appropriate to append to the code for this procedure?

            1. A) 51
            2. B) 58
            3. C) 78
            4. D) 79

             

            75) What is an x-ray of the urinary bladder?

            1. A) vasectomy
            2. B) pyelography
            3. C) cystography
            4. D) lithotripsy

             

            76) What is a lithotripsy?

            1. A) removal of kidney stones by a small puncture wound through the skin
            2. B) imaging of the renal pelvis and ureter
            3. C) surgical procedure in which the vas deferens is cut
            4. D) noninvasive treatment of calculi by crushing

             

            77) Select the correct definition of a nephrolithotomy:

            1. A) removal of kidney stones by a small puncture wound through the skin
            2. B) imaging of the renal pelvis and ureter
            3. C) surgical procedure in which the vas deferens is cut
            4. D) noninvasive treatment of calculi by crushing

             

             

            78) What is a procedure in which an undescended testicle is lowered into the scrotum and fixed in place?

            1. A) transurethral resection of the prostate
            2. B) urethroplasty
            3. C) orchiopexy
            4. D) pyelography

             

            79) Which of the following is a screening test for prostate cancer?

            1. A) PSA
            2. B) VCUG
            3. C) TURP
            4. D) pyelography

             

            80) What is a pyelography?

            1. A) removal of kidney stones by a small puncture wound through the skin
            2. B) imaging of the renal pelvis and ureter
            3. C) surgical procedure in which the vas deferens is cut
            4. D) noninvasive treatment of calculi by crushing

             

            81) Select the abbreviation that describes a surgical removal of all or part of the prostate gland:

            1. A) PSA
            2. B) VCUG
            3. C) TURP
            4. D) pyelography

             

            82) What is a VCUG?

            1. A) x-ray examination of the bladder and urethra performed while the bladder is emptying
            2. B) imaging of the renal pelvis and ureter
            3. C) surgical procedure in which the vas deferens is cut
            4. D) noninvasive treatment of calculi by crushing

             

            83) Select the correct definition of the term anorchism:

            1. A) condition in which the urethra opens on the underside of the penis
            2. B) enlargement of the prostate gland
            3. C) stones that can occur in any of the structures of the urinary system
            4. D) absence of one or both testes

             

            84) Enlargement of the prostate gland, which can interfere with urinary function, is called:

            1. A) micturition
            2. B) hypospadias
            3. C) cystocele
            4. D) benign prostatic hyperplasia

             

             

            85) What is the failure of one or both testes to descend into the scrotum?

            1. A) micturition
            2. B) hypospadias
            3. C) cystocele
            4. D) cryptorchidism

             

            86) What is hypospadias?

            1. A) condition in which the urethra opens on the underside of the penis
            2. B) enlargement of the prostate gland
            3. C) stones that can occur in any of the structures of the urinary system
            4. D) absence of one or both testes

             

            87) What is a hernia protrusion of the urinary bladder?

            1. A) micturition
            2. B) hypospadias
            3. C) cystocele
            4. D) cryptorchidism

             

            88) Select the correct term for the process in which the bladder contracts and expels urine:

            1. A) micturition
            2. B) hypospadias
            3. C) cystocele
            4. D) cryptorchidism

             

            89) When a coder sees provider documentation of a kidney stone or kidney calculus, which condition does this indicate?

            1. A) pyelonephritis
            2. B) proteinuria
            3. C) nephrolithiasis
            4. D) nephroptosis

             

            90) The downward displacement of the kidney is:

            1. A) pyelonephritis
            2. B) proteinuria
            3. C) nephrolithiasis
            4. D) nephroptosisMedical Coding, 2e (Stewart)

              Chapter 15   Surgery Section: Nervous System

               

              1) What is the primary function of the nervous system?

              1. A) to send and receive messages via nerve pathways made up of neurons
              2. B) to regulate involuntary functions, including breathing, metabolism and digestion
              3. C) to control internal and external bodily functions
              4. D) to regulate voluntary functions, including speech and movement

               

              2) Approximately how many neurons does the human body have?

              1. A) 100 million
              2. B) 1000 billion
              3. C) 1 trillion
              4. D) 100 billion

               

              3) Which two structures receive signals from the sensory organs, peripheral nerves, and endocrine system to process and are used to control and coordinate the body’s actions and reactions?

              1. A) central nervous system and somatic nervous system
              2. B) neurons and pathways
              3. C) brain and spinal cord
              4. D) nerve roots and spine

               

              4) What is the system that includes the brain and spinal cord and is responsible for coordination and communication within the entire body?

              1. A) peripheral nervous system
              2. B) somatic nervous system
              3. C) cerebellum
              4. D) central nervous system

               

              5) Which of the following is the system that consists of nerves only and connects the brain and spinal cord to the body?

              1. A) peripheral nervous system
              2. B) somatic nervous system
              3. C) cerebellum
              4. D) central nervous system

               

              6) Which system regulates body movement through control of skeletal or voluntary muscles?

              1. A) peripheral nervous system
              2. B) somatic nervous system
              3. C) cerebellum
              4. D) central nervous system

               

               

              7) The ________ is the brain structure that is located posterior to the brainstem and inferior to the cerebrum, responsible for fine motor coordination and movement, posture, and balance:

              1. A) hypothalamus
              2. B) cerebellum
              3. C) amygdala
              4. D) cerebrum

               

              8) The nervous system is divided into which two major systems?

              1. A) central nervous system and somatic nervous system
              2. B) peripheral nervous system and autonomic nervous system
              3. C) autonomic nervous system and somatic nervous system
              4. D) central nervous system and peripheral nervous system

               

              9) The autonomic and the somatic nervous systems are subdivisions of which component of the nervous system?

              1. A) central nervous system
              2. B) peripheral nervous system
              3. C) nerve roots
              4. D) sensory neuron

               

              10) Select the correct flow of the nervous system:

              1. A) nerve root – nerve pathway – sensory neuron – motor neuron – muscle or organ
              2. B) muscle or organ – nerve pathway – nerve root – motor neuron – sensory neuron – brain or spinal cord
              3. C) sensory neuron – nerve pathway – nerve root – brain or spinal cord – nerve root – motor neuron – muscle or organ
              4. D) brain or spinal cord – sensory neuron – nerve root – nerve pathway – motor neuron – muscle or organ

               

              11) The autonomic nervous system controls muscles of which type of organs?

              1. A) sympathetic
              2. B) internal
              3. C) major
              4. D) parasympathetic

               

              12) Which larger component of the nervous system are the sympathetic and parasympathetic nervous systems a part of?

              1. A) central nervous system
              2. B) peripheral nervous system
              3. C) autonomic nervous system
              4. D) somatic nervous system

               

               

              13) Which system is responsible for fight-or-flight response?

              1. A) sympathetic nervous system
              2. B) somatic nervous system
              3. C) peripheral nervous system
              4. D) parasympathetic nervous system

               

              14) Which system is responsible for relaxation, bringing all systems back to normal after a fight-or-flight response?

              1. A) sympathetic nervous system
              2. B) somatic nervous system
              3. C) peripheral nervous system
              4. D) parasympathetic nervous system

               

              15) Which system controls voluntary movement and carries sensory information?

              1. A) sympathetic nervous system
              2. B) somatic nervous system
              3. C) peripheral nervous system
              4. D) parasympathetic nervous system

               

              16) The amygdala is part of the:

              1. A) cerebellum
              2. B) brainstem
              3. C) cerebrum
              4. D) brain

               

              17) What is the corpus callosum?

              1. A) integrates sensory information from various parts of the body
              2. B) involved in auditory perception
              3. C) structure that divides the left and right hemispheres of the cerebrum
              4. D) largest lobe of the brain sitting just inside the front of the skull

               

              18) All of the following are components of the cerebrum except:

              1. A) parietal lobes
              2. B) temporal lobes
              3. C) occipital lobes
              4. D) frontal lobes

               

              19) What are the primary functions of the frontal lobes?

              1. A) planning, organizing, problem solving, memory, impulse control, speech, and language
              2. B) integrate sensory information from various parts of the body and map objects perceived visually into body coordinate positions
              3. C) auditory perception, processing of semantics in both speech and vision
              4. D) receive and process visual information such as color and motion

               

               

              20) What is the function of the amygdala?

              1. A) planning, organizing, problem solving, memory, impulse control, speech, and language
              2. B) processing and memory of emotions
              3. C) auditory perception, processing of semantics in both speech and vision
              4. D) receive and process visual information such as color and motion

               

              21) Which lobes are responsible for knowledge of numbers and their relations?

              1. A) parietal
              2. B) frontal
              3. C) temporal
              4. D) occipital

               

              22) Katie steps off the train into Grand Central Station and scans the crowd for her father, who is waiting to pick her up. After looking through a large crowd of faces, she recognizes her father and she smiles. Which lobes of the brain is Katie currently using to recognize her father’s face?

              1. A) parietal
              2. B) frontal
              3. C) temporal
              4. D) occipital

               

              23) Robbie is helping his mother break spaghetti in half to put it in a large pot of boiling water for cooking. Robbie decides to throw a handful of spaghetti into the pot and boiling water splashes up onto Robbie’s arm. Which lobes of the brain are telling Robbie that the water is very hot?

              1. A) parietal
              2. B) frontal
              3. C) temporal
              4. D) occipital

               

              24) Select the structure that is closest to the spinal cord and regulates breathing, heartbeat, and centers for reflexes:

              1. A) meninges
              2. B) Hippocampus
              3. C) thalamus
              4. D) medulla oblongata

               

              25) Select the correct function of the thalamus:

              1. A) carries sensory information from the peripheral nerves to the brain and from the brain to the peripheral nerves
              2. B) contains cerebrospinal fluid and protects the central nervous system
              3. C) is the control center for many autonomic functions of the peripheral nervous system and sleep-wake cycles
              4. D) acts as a central relay for incoming message to the nervous system

               

               

              26) Which structure is responsible for communication and coordination between the two hemispheres of the brain?

              1. A) dura mater
              2. B) pons
              3. C) Hippocampus
              4. D) arachnoid mater

               

              27) Which structure plays a key role in the formation of long-term memory?

              1. A) dura mater
              2. B) pons
              3. C) Hippocampus
              4. D) arachnoid mater

               

              28) How many pairs of cranial nerves make up the peripheral nervous system?

              1. A) 14
              2. B) 12
              3. C) 16
              4. D) 18

               

              29) How many pairs of spinal nerves make up the peripheral nervous system?

              1. A) 31
              2. B) 23
              3. C) 14
              4. D) 18

               

              30) Select the structure that is not part of the meninges:

              1. A) Pia mater
              2. B) Hippocampus
              3. C) Dura mater
              4. D) Arachnoid mater

               

              31) Which of the following is not a primary function of the ventricles?

              1. A) production of cerebrospinal fluid
              2. B) filtration of cerebrospinal fluid
              3. C) transport of cerebrospinal fluid
              4. D) regulation of cerebrospinal fluid pressure

               

              32) Select the condition that is not a common disease affecting the central nervous system:

              1. A) meningitis
              2. B) hydrocephalus
              3. C) multiple sclerosis
              4. D) cystic fibrosis

               

               

              33) All of the following are common diseases affecting the peripheral nervous system except:

              1. A) carpal tunnel syndrome
              2. B) Parkinson’s disease
              3. C) mononeuropathy
              4. D) Guillain-Barre syndrome

               

              34) In which chapter of the ICD-10-CM manual will a coder find Diseases of the Central Nervous System and Sense Organs?

              1. A) 5
              2. B) 6
              3. C) 8
              4. D) 9

               

              35) In Category G00-G09, “Inflammatory Diseases of the Central Nervous System” which condition does not require the use of an additional code to identify the organism?

              1. A) streptococcal meningitis
              2. B) pneumococcal meningitis
              3. C) staphylococcal meningitis
              4. D) other bacterial meningitis

               

              36) What is meningitis?

              1. A) inflammation of the brain tissue and spinal cord
              2. B) abscess within the spine or cranium
              3. C) inflammation of alveoli causing sleep disruption
              4. D) inflammation of the meninges of the brain and/or spinal cord

               

              37) What is the primary difference between encephalitis and meningitis?

              1. A) meningitis is synonymous with myelitis
              2. B) encephalitis is always caused by a spinal or cranial abscess while meningitis can be caused by several underlying conditions
              3. C) encephalitis requires inflammation to be present in both the meninges of the brain and the spinal cord while meningitis requires inflammation to be present in either the meninges of the brain or the spinal cord
              4. D) encephalitis requires inflammation in the brain tissue or spinal cord, while meningitis requires inflammation in the meninges of the brain or spinal cord

               

              38) To what category will a coder code conditions related to Sleep Disorders in ICD-10-CM?

              1. A) G51
              2. B) G31
              3. C) G25
              4. D) G47

               

               

              39) Codes for what condition are found in category G89 in ICD-10-CM?

              1. A) Hereditary and Degenerative Diseases of the Central Nervous System
              2. B) Other Headache Syndromes
              3. C) Disorders of the Peripheral Nervous System
              4. D) Pain

               

              40) In what code range will a coder locate codes to describe Episodic and Paroxysmal Disorders in ICD-10-CM?

              1. A) G00-G09
              2. B) G40-G47
              3. C) G35-G37
              4. D) G80-G83

               

              41) Where are Nerve, Nerve Root, and Plexus Disorders found in ICD-10-CM?

              1. A) G89-G99
              2. B) G35-G37
              3. C) G50-G59
              4. D) G60-G65

               

              42) Category G47, Sleep Disorders, in ICD-10-CM contain codes to describe sleep disorders that are a result of all of the following except:

              1. A) behavioral disorders
              2. B) physiologic abnormalities
              3. C) anatomical anomalies
              4. D) disease process

               

              43) What is a movement disorder that results in clenching of the jaw or grinding of the teeth?

              1. A) hypersomnolence
              2. B) organic insomnia
              3. C) circadian rhythm disorder
              4. D) bruxism

               

              44) Select the correct definition for hypersomnolence:

              1. A) difficulty falling asleep or staying asleep
              2. B) excessive sleepiness
              3. C) sleep apnea due to obesity
              4. D) circadian rhythm disruption

               

              45) Which disease is due to the degeneration of nigral neurons, which are responsible for creating dopamine?

              1. A) hydrocephalus
              2. B) Parkinson’s disease
              3. C) Alzheimer’s disease
              4. D) Addison’s disease

               

               

              46) How are codes for Parkinson’s diseases further specified (G20 and G21)?

              1. A) primary and secondary parkinsonism
              2. B) primary symptom and underlying cause
              3. C) primary, secondary with further specificity as to underlying cause
              4. D) stage of degeneration and primary symptom

               

              47) Select the disease that is caused by destruction of subcortical white matter of the brain:

              1. A) hydrocephalus
              2. B) Parkinson’s disease
              3. C) Alzheimer’s disease
              4. D) Addison’s disease

               

              48) Which of the following is a disorder of the ventricle and/or cerebrospinal fluid that leads to increased intracranial pressure?

              1. A) hydrocephalus
              2. B) Parkinson’s disease
              3. C) Alzheimer’s disease
              4. D) Addison’s disease

               

              49) Which of the following is not a type of hydrocephalus included in Chapter 6 of ICD-9-CM?

              1. A) idiopathic normal pressure
              2. B) obstructive
              3. C) degenerative
              4. D) communicating

               

              50) What is a syringomyelia?

              1. A) cyst of the spinal cord
              2. B) cyst of the spinal cord and brainstem area
              3. C) Werdnig-Hoffmann disease
              4. D) degeneration of the anterior horn cells

               

              51) What is the name for a syringomyelia that has extended into the brainstem area?

              1. A) syringobulbia
              2. B) status migrainous
              3. C) encephalitis
              4. D) hemiparesis

               

              52) Select the type of headache that is not listed under Other Headache Syndromes (G44) in ICD-10-CM:

              1. A) cluster
              2. B) tension
              3. C) migraine
              4. D) post-traumatic

               

               

              53) What is hemiplegia?

              1. A) loss of the ability to move one side of the body
              2. B) weakness on one side of the body
              3. C) loss of sensation on one side of the body
              4. D) periodic muscle spasms experienced on one side of the body

               

              54) What is hemiparesis?

              1. A) loss of the ability to move one side of the body
              2. B) weakness on one side of the body
              3. C) loss of sensation on one side of the body
              4. D) periodic muscle spasms experienced on one side of the body

               

              55) The category Other Disorders of the Central Nervous System (G89-G99) in ICD-10-CM contains codes for all of the following conditions except:

              1. A) Pain, not elsewhere classified
              2. B) Generalized pain
              3. C) Disorders of autonomic nervous system
              4. D) Cerebrospinal fluid leak

               

              56) An ambidextrous patient suffers a left side flaccid hemiplegia. Select the correct ICD-10-CM diagnosis code for this condition:

              G81.00 Flaccid hemiplegia affecting unspecified side

              G81.02 Flaccid hemiplegia affecting dominant side

              G81.03 Flaccid hemiplegia affecting nondominant side

              1. A) G81.02, G81.03
              2. B) G81.02
              3. C) G81.00
              4. D) G81.03

               

              57) Select the question that is not a typical question needed to determine the correct coding of procedures performed on the Nervous System:

              1. A) What was the approach?
              2. B) Were grafts and/or patches used during repair?
              3. C) Was the procedure primary or a reexploration of a surgical site?
              4. D) Was the treatment for a traumatic injury or a medical condition?

               

              58) How are the general headings of codes in the Nervous System subsection categorized in CPT?

              1. A) anatomic site
              2. B) approach
              3. C) type of procedure
              4. D) age of patient

               

               

              59) In what code range will a coder find procedures performed on the Skull, Meninges, and Brain in CPT?

              1. A) 60000-60099
              2. B) 61000-62258
              3. C) 62263-63746
              4. D) 64000-64999

               

              60) CPT codes for injection, drainage, or aspiration in the Skull, Meninges, and Brain general heading are divided first by anatomical site, then by:

              1. A) age of the patient and initial or subsequent
              2. B) body area and age of the patient
              3. C) initial or subsequent and whether a substance was injected
              4. D) body area and whether a substance was injected

               

              61) At what anatomic site is an intracerebral procedure performed?

              1. A) cerebellum
              2. B) brain
              3. C) cerebrum
              4. D) cranium

               

              62) At what anatomic site is an intracranial procedure performed?

              1. A) cerebellum
              2. B) brain
              3. C) cerebrum
              4. D) skull

               

              63) What is an excision of the cranium in which a bone flap is removed and not returned to the original site?

              1. A) corpectomy
              2. B) craniectomy
              3. C) facetectomy
              4. D) foraminotomy

               

              64) What is an incision into the cranium in which a bone flap is removed and then returned either immediately or at a later time to the original site?

              1. A) laminotomy
              2. B) neurorrhaphy
              3. C) craniotomy
              4. D) foraminotomy

               

              65) Why are multiple surgeons typically used to perform surgeries of the skull base?

              1. A) the nature and complexity of the procedure
              2. B) reimbursement is provided for several elements of the procedure
              3. C) reconstruction may not be performed by the same surgeon as the approach
              4. D) the surgery is typically long and surgeons need to be available to give one another reprieves

               

              66) All of the following are separate components of a skull base procedure in CPT except:

              1. A) Initial diagnostic procedures
              2. B) Approach procedures
              3. C) Definitive procedures
              4. D) Repair and/or reconstruction

               

              67) Codes in the Endovascular Therapy (61623-61642) subheading are divided into:

              1. A) Dilation, Insertion, Repair, Closure
              2. B) Occlusion/remobilization, Dilation, Repair
              3. C) Angioplasty/stent placement, Dilation, Closure
              4. D) Occlusion/remobilization, Angioplasty/stent placement, Dilation

               

              68) What is a medical imaging technique that creates a 3-D image of a specific anatomical site for therapeutic surgical or diagnostic interventions or localization of a tumor?

              1. A) stereotactic
              2. B) magnetic resonance imaging
              3. C) angiography
              4. D) CT scan

               

              69) Which of the following is not an available approach for selection in the Neurostimulators subheading in CPT?

              1. A) twist drill
              2. B) burr hole
              3. C) craniectomy
              4. D) craniotomy

               

              70) Select the true statement regarding coding in the Cerebrospinal Fluid (CSF) Shunt subheading:

              1. A) the codes for replacement/revision or removal are based on the location of the distal end of the shunt
              2. B) the codes for CSF removals are divided as to with or without contrast material
              3. C) procedures in this subheading include initial programming
              4. D) codes for insertions include one replacement/revision service per shunt

               

              71) Codes in the Injection, Drainage, or Aspiration subheading of the Spine and Spinal Cord subheading are further divided by all of the following except:

              1. A) age of the patient
              2. B) number of days on which the procedure is performed
              3. C) condition
              4. D) nature of the procedure

               

              72) What is the removal or resection of the anterior portion of the vertebra?

              1. A) foraminotomy
              2. B) craniectomy
              3. C) corpectomy
              4. D) facetectomy

               

              73) What is the enlargement of the foramen through which the nerve root exits the spinal canal?

              1. A) foraminotomy
              2. B) craniectomy
              3. C) corpectomy
              4. D) facetectomy

               

              74) What is a laminectomy?

              1. A) the removal of the facet or bony overgrowth on the facet that leads to compression of the nerve root
              2. B) the enlargement of the foramen through which the nerve root exits the spinal canal
              3. C) removal of the superior or inferior half of the lamina
              4. D) removal of the lamina of a vertebral segment

               

              75) What is the nonbony area between two vertebral segments?

              1. A) nucleus pulposus
              2. B) vertebral interspace
              3. C) annulus fibrosus
              4. D) cartilaginous end plate

               

              76) At what level(s) of the spine may a lateral extracavitary for extradural exploration/decompression be performed?

              1. A) thoracic or lumbar
              2. B) cervical
              3. C) lumbar
              4. D) cervical, thoracic, or lumbar

               

              77) How are codes for peripheral neurostimulators categorized?

              1. A) method of electrode placement
              2. B) primary or revision procedure
              3. C) simple or complex procedure
              4. D) level of intensity of shock delivered

               

              78) What is a repair of transected nerves by suturing?

              1. A) neurorrhaphy
              2. B) neuroplasty
              3. C) anastomosis
              4. D) denervation

               

              79) When hemilaminectomies are performed at both the right and left laminae of an interspace, which modifier is reported?

              1. A) 50
              2. B) 51
              3. C) 58
              4. D) 59

               

              80) When two related procedures are performed via separate incisions at two connecting interspaces, which modifier is appropriate to append to the code for the second procedure?

              1. A) 50
              2. B) 51
              3. C) 58
              4. D) 59

               

              81) To perform an anterior discectomy for decompression, it is common for a thoracic surgeon to perform the approach component of the procedure and a neurosurgeon to perform the decompression procedure. Because this procedure is reportable only by one CPT code, which modifier will each surgeon append to the code to report his/her portion of the service?

              1. A) 62
              2. B) 63
              3. C) 64
              4. D) 66

               

              82) A spinal tap is also referred to as:

              1. A) echoencephalography
              2. B) electroencephalography
              3. C) polysomnogram
              4. D) cerebrospinal fluid analysis

               

              83) A radiographic study of the intracranial structures of the brain is:

              1. A) echoencephalography
              2. B) electroencephalography
              3. C) polysomnogram
              4. D) cerebrospinal fluid analysis

               

              84) What is an electroencephalography?

              1. A) removal of a small amount of cerebrospinal fluid
              2. B) radiographic study of the intracranial structures
              3. C) recording that measures brain and body activity during sleep
              4. D) recording and analysis of the electrical activity in the brain

               

              85) What is a polysomnogram?

              1. A) removal of a small amount of cerebrospinal fluid
              2. B) radiographic study of the intracranial structures
              3. C) recording that measures brain and body activity during sleep
              4. D) recording and analysis of the electrical activity in the brain

               

              86) Another term for memory impairment is:

              1. A) ataxia
              2. B) dementia
              3. C) anterior horn cell disease
              4. D) syncope

               

              87) What are anterior horn cell diseases?

              1. A) primary, persistent unilateral headaches
              2. B) cognitive deficits
              3. C) lack of muscle coordination in the execution of voluntary movements
              4. D) a group of conditions that affect the anterior nerve root

               

              88) What is a temporary loss of consciousness due to the sudden decline of blood flow to the brain?

              1. A) ataxia
              2. B) dementia
              3. C) anterior horn cell disease
              4. D) syncopeMedical Coding, 2e (Stewart)

                Chapter 17   Radiology

                 

                1) Radiology involves all of the following except:

                1. A) treating diseases
                2. B) establishing diagnoses
                3. C) preventing diseases
                4. D) treating injuries

                 

                2) Which of the following services are not found in the Radiology section of CPT?

                1. A) x-rays
                2. B) Doppler imaging
                3. C) computed tomography
                4. D) magnetic resonance imaging

                 

                3) A patient presents to the radiology department with an order for a CT scan. The provider’s diagnostic statement supporting the scan is “severe cough, probable COPD.” Upon examination, the CT scan does not show evidence of abnormality with the lungs and surrounding structures. How should the coder appropriately code this patient’s diagnosis?

                1. A) code the severe cough only
                2. B) code the severe cough and COPD
                3. C) select code Z87.09, Personal history of other diseases of respiratory system
                4. D) select code Z87.898, Personal history of other specified disease

                 

                4) To locate a definitive or confirmed diagnosis within the provider documentation, coders should look for certain terms. These include all except which term listed below?

                1. A) impression
                2. B) conclusion
                3. C) probable
                4. D) finding

                 

                5) Select the scenario in which it is appropriate to use an ICD abnormal-findings code:

                1. A) when additional testing is required and the test results are negative
                2. B) when a patient presents with a chief complaint that is not evident following radiologic evaluation
                3. C) when two radiologic exams confirm the suspected condition
                4. D) when two radiologic exams demonstrate conflicting findings

                 

                6) Katie presents to the oncology suite for radiation therapy for primary malignancy in the right breast. She is also experiencing nausea as a result of the therapy. Select the accurate reporting of Katie’s diagnoses for today’s service:

                1. A) Primary malignancy right breast, admission for radiation therapy
                2. B) Primary malignancy right breast, nausea, admission for radiation therapy
                3. C) Admission for radiation therapy, nausea, primary malignancy right breast
                4. D) Nausea, primary malignancy right breast, admission for radiation therapy

                 

                7) In which code range will a coder find procedure codes classified as Bone/Joint Studies in CPT?

                1. A) 76506-76999
                2. B) 77001-77032
                3. C) 77051-77059
                4. D) 77071-77084

                 

                8) Where will one find codes for Radiation Oncology in CPT?

                1. A) 76506-76999
                2. B) 77001-77022
                3. C) 77261-77799
                4. D) 78012-79999

                 

                9) What type of Radiology codes are found in code range 70010-76499?

                1. A) Radiologic Guidance
                2. B) Breast, Mammography
                3. C) Diagnostic Radiology (Diagnostic Imaging)
                4. D) Diagnostic Ultrasound

                 

                10) What type of Radiology codes are found in code range 76506-76999?

                1. A) Breast, Mammography
                2. B) Diagnostic Ultrasound
                3. C) Radiation Oncology
                4. D) Nuclear Medicine

                 

                11) In which code range will a coder find procedure codes describing Radiologic Guidance in CPT?

                1. A) 77001-77022
                2. B) 77051-77059
                3. C) 77071-77084
                4. D) 77261-77799

                 

                12) Where are codes for procedures involving Breast, Mammography located in CPT?

                1. A) 77001-77022
                2. B) 77053-77067
                3. C) 77071-77084
                4. D) 77261-77799

                 

                13) Where are codes for Nuclear Medicine procedures located in CPT?

                1. A) 76506-76999
                2. B) 77001-77022
                3. C) 77261-77799
                4. D) 78012-79999

                 

                 

                14) How are multiple fractures coded per ICD guidelines?

                1. A) one code is assigned for the most severe fracture
                2. B) codes are assigned for each fracture, listing the least severe to the most severe
                3. C) codes are assigned for each fracture, listing the most severe to the least severe
                4. D) one code is assigned to describe the most severe fracture in each body area

                 

                15) Of the following common ICD categories used to report CPT codes, which is commonly used to bolster medical necessity for a radiologic procedure?

                1. A) aftercare
                2. B) history of (personal or family)
                3. C) screening
                4. D) signs/symptoms

                 

                16) Of the following common ICD categories used to report CPT codes, which is used when a radiologic exam is performed for early detection for a patient with no symptoms?

                1. A) aftercare
                2. B) history of (personal or family)
                3. C) screening
                4. D) signs/symptoms

                 

                17) If a testing is performed to rule out or confirm a suspected diagnosis and the patient presents with signs and symptoms, this is a ________:

                1. A) screening examination
                2. B) rule-out procedure
                3. C) routine procedure
                4. D) diagnostic examination

                 

                18) A 45-year-old female patient presents for a screening mammogram. Upon examination, the screening test shows evidence of a calcification in the left breast. How would the coder appropriately assign diagnosis codes for this service?

                1. A) list the screening code, then the breast mass code
                2. B) list the breast mass code only
                3. C) list the breast mass code, then the screening code
                4. D) list the screening code only

                 

                19) Of the following common ICD a category used to report CPT codes, which is used for encounters after the patient has finished active treatment for the fracture and is receiving care during healing or recovery?

                1. A) aftercare
                2. B) history of (personal or family)
                3. C) screening
                4. D) signs/symptoms

                 

                 

                20) What is contrast material?

                1. A) the background used, typically white, to provide contrast to the images of bones/tissues
                2. B) a dye or another substance that is being used to enhance the image of an organ or tissue being examined
                3. C) markers placed at the site of the radiologic examination to indicate the area to be examined
                4. D) aprons used to protect the patient and the radiology technician from harmful radiation exposure

                 

                21) How are many of the x-ray code descriptions in the Radiology section of CPT further subdivided?

                1. A) number of views
                2. B) use of contrast material
                3. C) placement of lead markers
                4. D) severity of injury

                 

                22) Select the correct term for a study that creates real-time or moving images that are useful for diagnostic procedures and for guidance in interventional procedures:

                1. A) x-ray
                2. B) CT scan
                3. C) fluoroscopy
                4. D) endoscopy

                 

                23) When a physician (radiologist) performs both the surgical component and the supervision and interpretation component of a procedure, how would the coder appropriately assign CPT codes to communicate this to a third-party payer?

                1. A) assign one code from the Surgery section with modifier 26
                2. B) assign one code from the Radiology section with modifier TC
                3. C) assign one code from the Radiology section with modifier 26
                4. D) assign one code from the Surgery section and one code from the Radiology section

                 

                24) All of the following are questions a coder will typically answer when assigning a CPT code from the Radiology section except:

                1. A) Was oral or IV contrast used?
                2. B) What was the number of views?
                3. C) Was the procedure for a traumatic injury or a medical condition?
                4. D) What was the approach?

                 

                25) How are codes in the Diagnostic Imaging subsection of CPT divided?

                1. A) length of procedure
                2. B) age of patient
                3. C) place of service
                4. D) anatomic site

                 

                 

                26) Codes for Diagnostic Imaging are divided by anatomic site; all of the following are subheadings in this subsection except:

                1. A) Spine and Pelvis
                2. B) Gastrointestinal tract
                3. C) Ears, Nose, and Throat
                4. D) Upper extremities

                 

                27) Which of these is a radiology imaging modality used to study structures in a body plane?

                1. A) magnetic resonance imaging
                2. B) computed tomography
                3. C) fluoroscopy
                4. D) brachytherapy

                 

                28) When used in the Radiology section of CPT, what does the acronym KUB stand for?

                1. A) potassium, ubiquinol, barium
                2. B) ubiquitin-protease system
                3. C) kidney, ureter, bladder
                4. D) karyolymph of the ulnar border

                 

                29) Select the radiology imaging modality that uses a magnetic field and radio waves to produce images of organs and tissues:

                1. A) magnetic resonance imaging
                2. B) computed tomography
                3. C) fluoroscopy
                4. D) brachytherapy

                 

                30) What is the difference between an MRI and an MRA?

                1. A) an MRA scan is always a more extensive procedure that requires more time
                2. B) an MRI scan is used to visualize bones, while an MRA scan is used to visualize organs
                3. C) an MRI does not use contrast material; an MRA uses contrast material
                4. D) an MRI scan is used to visualize organs, while an MRA scan is used to visualize vessels

                 

                31) How are codes for MRI and MRA further subdivided?

                1. A) anatomic site
                2. B) place of service
                3. C) with or without imaging markers
                4. D) condition

                 

                32) Where will a coder find guidelines regarding the reporting of diagnostic angiography and venography supervision and interpretation codes?

                1. A) the beginning of the Surgery section
                2. B) the beginning of the Cardiology subsection of the Surgery section
                3. C) the beginning of the Cardiology subsection of the Radiology section
                4. D) the beginning of the specific code ranges

                 

                 

                33) A noninvasive test that uses high-frequency sound waves to produce images that are captured in real time and show structure, movement, and the flow of blood through blood vessels is called:

                1. A) Doppler imaging
                2. B) fluoroscopy
                3. C) ultrasound
                4. D) computed tomography

                 

                34) What is another name for an ultrasound procedure?

                1. A) Doppler
                2. B) sonography
                3. C) mammogram
                4. D) fluoroscopy

                 

                35) Ultrasound procedures are defined as:

                1. A) A-mode, M-mode, B-scan, and real-time scan
                2. B) A-mode, B-mode, M-mode
                3. C) modular and scan
                4. D) abdominal, retroperitoneal, limited, and complete

                 

                36) Code 76700, Complete abdominal ultrasound, must include:

                1. A) images of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and upper abdominal aorta and inferior vena cava
                2. B) images of a single organ or quadrant of the abdomen
                3. C) images of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava
                4. D) images of the abdominal aorta and common iliac artery

                 

                37) Code 76705, Limited abdominal ultrasound is assigned when:

                1. A) the images include the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and upper abdominal aorta and inferior vena cava
                2. B) the images taken are less than the definition of a complete retroperitoneal ultrasound
                3. C) the images include the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava
                4. D) images taken are less than the definition of a complete abdominal ultrasound

                 

                38) Code 76770, Complete retroperitoneal ultrasound, is assigned when:

                1. A) the images include the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and upper abdominal aorta and inferior vena cava
                2. B) the images taken are less than the definition of a complete retroperitoneal ultrasound
                3. C) the images include the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava
                4. D) when less than the definition of a complete retroperitoneal ultrasound is documented

                 

                 

                39) The codes in the Obstetrical subheading of the Pelvis general heading are further subdivided by all of the following except:

                1. A) trimester
                2. B) weight of fetus
                3. C) number of gestational sacs
                4. D) approach

                 

                40) The general heading Bone/Joint Studies contains codes for all of the following radiologic procedures except:

                1. A) bone age studies
                2. B) bone length studies
                3. C) fracture assessments
                4. D) dual-energy x-ray absorptiometry scans

                 

                41) What does a DXA scan measure?

                1. A) bone mass density
                2. B) length of bones
                3. C) age of bones
                4. D) weight of bones

                 

                42) What is the development of a plan for the course of radiation therapy?

                1. A) simulation-aided field setting
                2. B) radiation treatment delivery
                3. C) clinical treatment planning
                4. D) radiation treatment management

                 

                43) What is the name of the procedure that visualizes and defines the exact treatment area and helps decide the size and location of ports?

                1. A) simulation-aided field setting
                2. B) radiation treatment delivery
                3. C) clinical treatment planning
                4. D) radiation treatment management

                 

                44) How are codes for Clinical Treatment Planning and Simulation-Aided Field Settings further subdivided?

                1. A) age of the patient
                2. B) anatomic site
                3. C) simple, intermediate, or complex
                4. D) simple or complicated

                 

                45) The application of radioactive isotopes for internal radiation is:

                1. A) simulation-aided field setting
                2. B) brachytherapy
                3. C) proton beam treatment delivery
                4. D) internal radiation

                 

                46) What is nuclear medicine?

                1. A) uptakes and imaging scans
                2. B) visualization of the exact treatment area to determine the size and location of ports
                3. C) computer-aided detection procedures
                4. D) field of study involving diagnostic and therapeutic use of radioactive materials

                 

                47) In what code range will a coder find procedures involving nuclear medicine?

                1. A) 78012-79999
                2. B) 77401-77425
                3. C) 77427-77499
                4. D) 77520-77525

                 

                48) All of the following are examples of radioactive materials used to perform nuclear medicine procedures except:

                1. A) iodine
                2. B) Xenon
                3. C) DTPA2
                4. D) cambriolite

                 

                49) Radioactive materials used in nuclear medicine procedures can be administered via all of the following routes except:

                1. A) ingestion
                2. B) inhalation
                3. C) injection
                4. D) infusion

                 

                50) Providers will use all of the following terms except ________ to describe nuclear medicine studies in documentation.

                1. A) millicures
                2. B) radiopharmaceutical
                3. C) plane
                4. D) microcuries

                 

                51) In which code range will a coder find diagnostic nuclear medicine procedures performed on the thyroid?

                1. A) 78012-78099
                2. B) 78201-78299
                3. C) 78300-78399
                4. D) 78414-78499

                 

                52) Which organ is being scanned in a hepatobiliary scan?

                1. A) liver
                2. B) spleen
                3. C) kidney
                4. D) gallbladder

                 

                53) A bone scan is performed on the shoulder. Which CPT code is correct to assign to this procedure?

                1. A) 78315
                2. B) 78305
                3. C) 78300
                4. D) 78306

                 

                54) How is the “whole body” defined in CPT code 78306?

                1. A) neck to knees
                2. B) head to waist
                3. C) either head to pelvis or torso to feet
                4. D) head to knees

                 

                55) A three-phase study bone scan contains all of the following components except:

                1. A) blood pool images
                2. B) uptake images
                3. C) initial vascular flow
                4. D) delayed static images

                 

                56) What is the correct abbreviation for a single-photon emission computed tomography scan?

                1. A) SET
                2. B) SPET
                3. C) SPECT
                4. D) SECT

                 

                57) Select the correct acronym for multigated acquisition scan:

                1. A) MAS
                2. B) MUAS
                3. C) MUGAS
                4. D) MUGA

                 

                58) An orthopedic specialist provides only the professional component of a whole body scan, CPT code 78306. Which modifier is appropriate to append to report this service?

                1. A) 26
                2. B) TC
                3. C) 52
                4. D) 59

                 

                59) CPT code 77067 identifies screening mammography, bilateral (2 view study of each breast). A patient receives unilateral screening mammography. Which modifier is appropriate to append to this procedure?

                1. A) 59
                2. B) 76
                3. C) TC
                4. D) 52

                 

                60) A diagnostic angiography is performed at the same session as an interventional procedure. The angiography is reported as a distinct procedure. Which modifier is appropriate to append to report this service?

                1. A) 51
                2. B) 59
                3. C) 58
                4. D) 79

                 

                61) Select the correct description of modifier 76:

                1. A) Repeat procedure or service by another physician or another qualified healthcare professional
                2. B) Surgical team
                3. C) Staged or related procedure
                4. D) Repeat procedure or service by the same physician or other qualified healthcare provider

                 

                62) Select the correct modifier for the description Repeat procedure or service by another physician or another qualified healthcare professional:

                1. A) 82
                2. B) 77
                3. C) 79
                4. D) 62

                 

                63) The vertical plane running from side to side that divides the body into anterior and posterior portions is the ________ plane:

                1. A) sagittal
                2. B) axial
                3. C) coronal
                4. D) median

                 

                64) What is the vertical plane running from front to back that divides the body into right and left sides?

                1. A) sagittal
                2. B) axial
                3. C) coronal
                4. D) median

                 

                65) Select the name of the horizontal plane that divides the body into upper and lower portions:

                1. A) sagittal
                2. B) axial
                3. C) coronal
                4. D) median

                 

                 

                66) What is the name of the plane through the middle of the body that divides the body into right and left halves?

                1. A) sagittal
                2. B) axial
                3. C) coronal
                4. D) median
                5. E) sagittal and median

                 

                67) Select the correct definition of the term distal:

                1. A) to the front of the body
                2. B) above another body part
                3. C) below another body part
                4. D) body part farthest from the point of reference, midpoint, or beginning

                 

                68) What is the term used to describe something to the front of the body or front of an organ?

                1. A) anterior
                2. B) superior/cephalic
                3. C) proximal
                4. D) inferior/caudal

                 

                69) Select the term used to describe something to the back of the body or back of an organ:

                1. A) posterior
                2. B) superior/cephalic
                3. C) proximal
                4. D) inferior/caudal

                 

                70) What does the term superior (or cephalic) mean?

                1. A) body part closest to the point of reference, midpoint, or beginning
                2. B) above another body part or toward the head
                3. C) to the back of the body or back of an organ
                4. D) to the front of the body of front of an organ

                 

                71) Which term refers to increasing the angle at the joint?

                1. A) supination
                2. B) pronation
                3. C) extension
                4. D) flexion

                 

                72) Materials such as MDP, Xenon, and DTPA are examples of:

                1. A) single-photon emission computed tomography
                2. B) dual-energy x-ray absorptiometry
                3. C) radiopharmaceuticals
                4. D) protease inhibitor

                 

                 

                73) When a coder sees documentation of a centesis procedure performed to drain excess fluid, this typically is referring to:

                1. A) single-photon emission computed tomography
                2. B) dual-energy x-ray absorptiometry
                3. C) arthritis
                4. D) ascites

                 

                74) Which term refers to decreasing the angle at the joint?

                1. A) supination
                2. B) pronation
                3. C) extension
                4. D) flexion

                 

                75) What is the body motion of bending upward?

                1. A) supination
                2. B) pronation
                3. C) extension
                4. D) flexion

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