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1 Exam Questions for CPT Name Directions: Use the appropriate coding manual to determine the correct choice for each situation. 1. Patient underwent nerve grafting of the right foot, 3 cm Patient underwent thyroidectomy for removal of remaining thyroid tissue after previous right lobectomy for suspected malignancy Established nursing facility resident was seen for annual assessment An 81-year-old patient receives anesthesia prior to undergoing cardioversion for persistent arrhythmia. Include physical status modifier with code P P P P4 5. Surgeon performs a sphenoid sinusotomy for removal of polyps, including biopsy Physician performs a surgical biopsy of the right temporal artery A 67-year-old patient underwent contact laser vaporization of the prostate Patient underwent total abdominal hysterectomy, sparing the tubes and ovaries Radiologist directs and interprets the placement of a long gastrostomy tube in a patient who is status post cerebrovascular accident Nursing home patient was admitted for management of pneumonia which is now resolved. The physician came by the facility to discharge the patient to home, spending 20 minutes with the patient and family Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 117

2 11. The physician conducted an initial office consultation for a 44-year-old patient, 6 years status post lumbar laminectomy, with intractable sciatic pain, depression, and history of narcotic dependency/abuse, high complexity A 16-year-old patient undergoes excision of an aneurysmal bone cyst of the proximal right humerus, with allograft A 15-year-old, otherwise healthy patient receives anesthesia for electroconvulsive therapy. Include physical status modifier with code P P P P1 14. Patient who is status post cochlear implant has visit for group rehabilitation, treatment of speech, and a processing disorder Healthcare employee receives first of three Hepatitis B vaccination, intramuscular injection Patient underwent cervical conization with loop electrical excision of the transitional zone Patient underwent stereotactic biopsy of intracranial lesion under MR guidance Dr. Harris counsels a group of teenagers regarding sexually transmitted diseases and prevention. Session lasts 30 minutes Dr. Nuri examines an 18-year-old in the emergency department for recurrent, severe menstrual migraine headache Patient underwent in-office simple incision and drainage of a pilonidal cyst Current Procedural Terminology 2007 American Medical Association. All Rights Reserved.

3 21. Surgeon removes a Harrington rod in a patient with chronic irritation in the region of insertion Patient with congenital cleft palate underwent rhinoplasty with columellar lengthening, including the septum and tip Patient with suspected apnea underwent sleep study with recording of ventilation, respiratory effort, heart rate, and oxygen saturation. Technologist was in attendance Surgeon performed excision of pterygium with grafting, left eye LT LT The neonatologist was asked to be on standby for 35 minutes for cesarean delivery of baby in distress Physician performed complex repair of a 3.2 cm. scalp laceration A 65-year-old patient receives anesthesia for repair of inguinal hernia. The patient has controlled hypertension. Include physical status modifier with code P P P P2 28. The patient underwent creation of burr holes of the skull with evacuation of subdural hematoma Five-year-old patient, status post eardrum rupture, undergoes tympanic membrane repair with patch Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 119

4 30. David was scheduled to see Dr. Bronson for his six-month checkup and to have lab work done two weeks before his appointment on the 15th. As directed, the lab work was done on the first of the month. David called Dr. Bronson s office on the 3rd and talked to Dr. Bronson for 15 minutes about the tests. The doctor ordered two more tests done by the 5th so that the findings would be in the office for David's appointment on the 15th. What code would be reported for the service on the 3rd of the month? Anesthesia was administered to patient for gastric bypass procedure performed due to patient s morbid obesity. Include physical status modifier with code P P P P3 32. Physician performed excision of inguinal hidradenitis with complex repair Patient was scheduled to undergo extensive internal and external hemorrhoidectomy with fistulectomy. Ten minutes prior to the start of the procedure, after anesthesia had been administered, the patient experienced a rapid decrease in heart rate and the physician canceled the procedure Patient underwent cystourethroscopy and laser ablation of two bladder tumors, each approximately 2.7 cm. in size Patient underwent excision of Peyronie plaque, 4.0 cm., with graft Hand specialist performs neuroplasty of the ulnar nerve of the left wrist LT LT LT LT 37. Patient, age 15, is seen by his new doctor for a comprehensive physical examination and immunizations. Patient also has moderate acne on face and chest Patient underwent replantation of thumb after complete amputation from the distal tip to the MP joint Current Procedural Terminology 2007 American Medical Association. All Rights Reserved.

5 39. Patient underwent operative laryngoscopy for removal of chicken bone fragment Patient with history of hypertriglyceridemia but with normal cholesterol levels has triglyceride level determined Asthma patient receives initial evaluation and first IPPB treatment Dr. Ladwig performs an independent medical examination for patient Mr. Smith to determine Worker s Compensation impairment rating Patient receives anesthesia for extracorporeal shock wave lithotripsy with water bath. Patient has mild asthma. Include physical status modifier with code P P P P2 44. Patient underwent single-lung transplant with cardiopulmonary bypass employed during the procedure Patient with intestinal intussusception undergoes reduction through laparotomy approach Surgeon performs gastric bypass procedure for the patient s morbid obesity with small intestine reconstruction to limit absorption Ms. Jones was seen in an initial office orthopedic consultation for bilateral trochanteric bursitis; visit was considered problem-focused only Surgeon performs repair of abdominal aortic aneurysm, caused by high-grade atherosclerosis Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 121

6 49. Dr. Kelly successfully performs resuscitation for an infant suffering cardiac distress during delivery Patient underwent excision of 1.5 cm. malignant skin lesion of the left calf, as well as removal of Norplant contraceptive capsules Patient was seen in the office for trigger point injection involving the trapezius and latissimus muscle groups Patient underwent hepatic artery ligation with complex suture repair of a liver laceration following motor vehicle accident Hospital follow-up visit by Dr. Stephens to see a 59-year-old female patient, status post uncomplicated left hip fixation Family practitioner performed excision of a lipoma of the right forearm, 1.5 cm. in diameter Donor undergoes bone marrow harvesting for transplantation Patient underwent total gastrectomy with Roux-en-Y reconstruction for stomach carcinoma Surgeon performed a simple Burch urethropexy on 45-year-old, mentally underdeveloped female Newly diagnosed testicular cancer patient underwent radical orchiectomy with abdominal exploration via inguinal approach Current Procedural Terminology 2007 American Medical Association. All Rights Reserved.

7 59. Patient had reconstruction of the mandibular rami due to blunt trauma, undergoing C osteotomy with bone graft Patient underwent bilateral cerebral carotid angiography under direct radiologic supervision The patient was seen on initial endocrinology office visit, having been referred for signs and symptoms of new-onset diabetes Patient underwent emergency laparoscopic appendectomy Patient underwent nephrolithotomy for removal of large staghorn calculus occupying the renal pelvis and calyces Patient underwent flexible sigmoidoscopy to 60 cm. with removal of two small polyps using snare technique Dr. Roberts conducts a home visit for a nonambulatory patient with progressive multiple sclerosis, now experiencing respiratory difficulty. The physician spent a total of 45 minutes with the new patient and family discussing treatment options and possible admission to nursing facility Surgeon performed limited thoracotomy for lung biopsy Patient underwent marsupialization of Bartholin gland cyst Patient receives 15 minutes of ultrasound therapy to the left hip for bursitis Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 123

8 69. Patient with symptoms of poisoning underwent testing for the presence of arsenic Patient underwent pericardial window creation for drainage of excess pericardial fluid Patient with simple papilloma of the penis undergoes cryosurgical removal Pain specialist physician performs single lumbar epidural steroid injection Patient underwent emergency noncontrast head CT scan following blunt trauma to the skull Nuclear medicine ventilation and perfusion lung scan was performed on a patient with sudden shortness of breath; aerosol technique was used, two projections were obtained Patient was treated with aortofemoral-popliteal venous bypass grafting for severe occlusive disease A 12-year-old female patient underwent dilation of the urethra under general anesthesia Patient underwent radial keratotomy procedure in the right eye RT RT RT RT 78. Combative patient underwent removal of burrowed insect from external auditory canal; general anesthesia required Current Procedural Terminology 2007 American Medical Association. All Rights Reserved.

9 79. Expectant mother of twins underwent complete obstetrical ultrasound in second trimester Patient Young, on parole, was to undergo his first monthly drug testing for marijuana. The lab ran a test to detect the patient s THC level. Two-phase procedure was performed quantity Steelworker seen in the emergency room for acute eye pain associated with probable steel shaving in the affected eye, now gone Surgeon performs closure of rectovaginal fistula by vaginal approach Patient underwent before and after contrast MRI studies of the pelvis Surgeon performed open repair of a femoral neck fracture with internal fixation Patient underwent tubal ligation with use of Falope rings, vaginal approach Patient receives chiropractic manipulative treatment for pain in the temporomandibular joint region Patient undergoes sex-change operation, from male to female Surgeon performed cesarean delivery after failed VBAC attempt Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 125

10 89. Patient underwent cataract extraction with insertion of intraocular lens via phacoemulsification technique The CPT Category III codes are updated quarterly. True False 91. The doctor orders a urinalysis to screen for bacteria The patient has an automated CBC, WBC, and platelet count Dr. Roberts orders a test for total Hepatitis A antibodies The patient underwent debridement and dressing of a small burn of the forearm in Dr. Gray s office The patient underwent pelvic magnetic resonance imaging before and after contrast to rule out a pelvic mass Mary Johnson had a closed manipulation of her distal fibular fracture The radiologist supervises and interprets lymphangiography of both upper arms Patient is hospitalized for a mobilization rearrangement repair of a conjunctival laceration Current Procedural Terminology 2007 American Medical Association. All Rights Reserved.

11 99. The operative note states the patient underwent excision of a lesion of the mucosa and underlying muscle of the vestibule of the mouth Dr. Jones performed a C1-C2 anterior arthrodesis Current Procedural Terminology 2007 American Medical Association. All Rights Reserved. 127

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13 Answers to Exam Questions: CPT Name

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