Exam 1

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Question #1

A 92-year-old new patient is seen in the patient’s home to evaluate symptoms that include a cough and fever. The patient has a history of diabetes, and the family does not wish the patient to be hospitalized. A comprehensive history and examination with high-complexity decision making is performed. What is the correct E/M code assignment for this service?

A 99356

B 99345

C 99236

D 99457

Question #2

The physician conducts a home visit for an established patient who is bed-ridden. A comprehensive interval history and comprehensive examination is performed with medical decision-making of moderate complexity. What is the correct E/M code for this encounter?

A 99345

B 99344

C 99350

D 99349

Question #3

The patient is seen for a chief complaint of shortness of breath and fatigue. The physician performs a detailed history, comprehensive examination, and medical decision-making is of moderate complexity. What is the correct E/M code for this service?

A 99213

B 99203

C 99204

D 99214

Question #4

Which of the following diagnoses would not meet medical necessity for a patient needing an ultrasound?

A Gingivitis

B Appendicitis

C Abdominal Pain

D Raptured Ovarian Cyst

Question #5

A patient is seen in a clinic for a laceration of the elbow. The wound requires suturing. On the claim form, which of the following types of codes would be assigned to represent the diagnosis of laceration?

A ICD -10 – CM

B ICD 10 – PCS

C National Codes

D Level 111 Codes

Question #6

Center for Medicare and Medicaid Services (CMS) are responsible for managing

A PCS

B CPT

C CM

D HCPCS

Question #7

What code set describes the diagnosis code to support medical necessity?

A HCPCS

B CPT

C Procedure Code Set ( PCS)

D Diagnosis Code Set ( CM)

Question #8

On December 3, 2018 Dr. Smith saw a Medicare patient with a diagnosis of rectal abscess in Central Hospital. She performed an incision and drainage in the outpatient surgery department.
Which coding system would Central Hospital use to bill for the surgical services?

A CPT

B ICD CM

C ICD PCS

D HCPCS

Question #9

On December 3, 2018 Dr. Smith saw a Medicare patient with a diagnosis of rectal abscess in Central Hospital. She performed an incision and drainage in the outpatient surgery department.
Which coding system would be used to capture the diagnosis of rectal abscess?

A ICD PCS

B HCPCS

C ICD CM

D CPT

Question #10

A MAC differs from moderate (conscious) sedation in that:

A It is limited to only the support of vital functions

B The potential for progression to general anesthesia is always present

C c. It always includes diagnosis and treatment of clinical problems that arise during the procedure

D All of these

Question #11

Which of the following is the correct physical status modifier to use when reporting a patient with a severe systemic disease that is a constant threat to life?

A P2

B P6

C P3

D P4

Question #12

Which of the following covers all aspects of anesthesia care including a preprocedure visit, intraprocedural care, and postprocedure anesthesia management?

A General anesthesia

B Monitored Anesthesia Care (MAC)

C Local anesthesia

D Oximetry

Question #13

Which of the following terms describes the passing of a thin tube or catheter into the right side of the heart and the arteries leading to the lungs?

A Capnography

B Mass Spectrometry (MS)

C Swan Ganz

D Oximetry

Question #14

Which of the following terms describes blood oxygen concentration?

A Capnography

B Swan Ganz

C Oximetry

D Mass spectrometry (MS)

Question #15

Which of the following catheterization procedures is considered an invasive form of monitoring?

A Swan Ganz

B Intra-arterial

C Central venous

D All of these

Question #16

A 55-year-old patient is diagnosed with a 5.5-cm aortoiliac aneurysm. General anesthesia was used for an endovascular repair of the aneurysm with pump oxygenator. What is the correct coding for this situation?

A 00562

B 00561

C 00560

D 00563

Question #17

An open procedure is performed to revise a total hip arthroplasty on a 78-year-old patient with uncontrolled diabetes and long-term congestive heart failure. What is the correct coding for this situation?

A 01215 P3, 99100

B 01214 P3, 99100

C 01214 P3

D 01214 P2

Question #18

After many hours of labor with no pain medication and the baby not moving properly into the birth canal for a successful vaginal delivery, a decision was made to perform a cesarean section under general anesthesia. What is the correct coding for this situation?

A 01967, 01968

B 01968

C 01961

D 01961, 01968

Question #19

A Type 2 diabetic patient having had several weeks of abdominal pain, now has surgery for a cholecystectomy. What is the correct coding for this situation?

A 00790 P2

B 00750 P2

C 00740 P2

D 00740

Question #20

When anesthesia is provided by an anesthesiologist for an orchiopexy in an 11-month-old boy, what are the correct codes to report?

A 00928, 99100

B 00934, 99100

C 00930, 99100

D 00924, 99100

Question #21

When anesthesia is provided by an anesthesiologist for a total left knee replacement surgery, what is the correct code to report?

A 01404

B 01432

C 01420

D 01402

Question #22

When anesthesia is provided by an anesthesiologist for a repair of a cleft palate under general anesthesia, what is the correct code to report?

A 00212

B 00170

C 00172

D 00210

Question #23

When anesthesia is provided by an anesthesiologist for a transurethral resection of the prostate, what is the correct code to report?

A 00906

B 00914

C 00916

D 00918

Question #24

When coding the anesthesia provided by a certified registered nurse anesthetist for a cesarean section of a patient who did not have an epidural during labor, what is the correct code to report?

A 00192

B 01961

C 01924

D 01960

Question #25

When does anesthesia time begin?

A When the anesthesiologist has the patient fully anesthetized

B When the anesthesiologist begins to prepare the patient for coming out of anesthesia

C When the anesthesiologist begins to prepare the patient for the induction of anesthesia

D When the anesthesiologist meets with the patient preoperatively

Question #26

When anesthesia is provided by an anesthesiologist for arthroscopic meniscus repair of the right knee, which CPT code(s) is reported?

A 01430

B 01404

C 01402

D 01400

Question #27

In the event code 99140 is reported, an emergency in anesthesia is considered:

A Anesthesia performed in an elective situation by the patient’s choice

B Anesthesia performed outside the normal weekday schedule

C Anesthesia performed in a location outside the hospital

D Anesthesia performed when delay in treatment would lead to a significant increase in threat to life or to a body part

Question #28

Which of the following refers to the technique of anesthetizing the roots or trunks of the brachial plexus in the neck between the anterior and middle scalene muscles?

A Digital nerve block

B Intravertebral nerve block

C Local nerve block

D Interscalene nerve block

Question #29

In addition to physical status modifiers, it may be appropriate to report other CPT modifiers when codes for procedural services are reported in addition to the basic anesthesia service. If an anesthesiologist performs additional procedures, how is this reported?

A Only the basic anesthesia service is reported with modifier 25 appended

B Each service is separately reportable

C Each anesthesia service is reported with modifier 59 appended

D None of the above

Question #30

A morbidly obese patient with diabetes and hypertension is seen in an established patient office visit. After performing an expanded problem-focused history and examination, blood work reveals that this patient needs to start insulin. Medical decision making is of moderate complexity. The documentation for this patient visit shows that the patient is counseled regarding the insulin regimen and attendant risks for 15 minutes of the total 25-minute visit. What is the correct code to report?

A 99213

B 99214

C 99244

D 99243

Question #31

When code 99285 is reported for an emergency department encounter, the emergency department physician may or may not be able to perform all three key components as required for a level 5 visit. Which term describes the reason an emergency department physician could report code 99285?

A Repeat visits in a three-day time span

B Severity

C Urgency of the problem or condition

D Chronic condition

Question #32

Codes reserved for encounters in the emergency department can be used by which of the following health care professionals if multiple providers treat the patient in the emergency department?

A Hospitalists on duty when the patient is admitted

B Consulting health care professionals along with the emergency department physicians

C Admitting physicians

D Only emergency department physicians

Question #33

Which key component considers the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed?

A History

B Time

C Medical decision making

D Counseling

Question #34

Medical decision making refers to:

A The complexity of establishing a diagnosis and/or selecting a management option

B The level of education and experience the physician of record brings to the encounter

C The intensity of the history and examination process

D A collection of lab and other diagnostic tests

Question #35

Which listing below best covers some of the seven dimensions of HPI?

A Severity, repeat symptoms, duration

B Modifying factors, severity, medication history

C Associated signs and symptoms, family history, time

D Location, quality, context

Question #36

Match the following CPT codes with the appropriate subcategory label: New Patient

A 99291-99292

B 99201-99205

C 99231-99233

D 99218-99220

E 99241-99245

Question #37

Match the following CPT codes with the appropriate subcategory label: Subsequent Hospital Care

A 99201-99205

B 99241-99245

C 99291-99292

D 99218-99220

E 99231-99233

Question #38

Match the following CPT codes with the appropriate subcategory label: Initial Observation Care

A 99218-99220

B 99291-99292

C 99241-99245

D 99201-99205

E 99231-99233

Question #39

Match the following CPT codes with the appropriate subcategory label: Critical Care Services

A 99201-99205

B 99241-99245

C 99231-99233

D 99218-99220

E 99291-99292

Question #40

Match the following CPT codes with the appropriate subcategory label: Office or Other Outpatient Consultations

A 99201-99205

B 99241-99245

C 99291-99292

D 99218-99220

E 99231-99233

Question #41

Of the following seven components listed, which are considered the “key components” used in determining levels of E/M service?
1. History
2. Examination
3. Medical decision making
4. Counseling
5. Coordination of care
6. Nature of presenting problem
7. Time

A 1-2-3

B 7-6-5

C 5-3-2

D 6-3-1

Question #42

Which of the following terms is described as a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present?

A History of present illness

B Chief complaint

C Review of illness

D Family or social history

Question #43

Within the history key component, a major description of the reason the patient is seeking medical help is known as the:

A Severe or chronic descriptor

B Social history

C Review of systems

D Chief complaint

Question #44

In both the 1995 and 1997 CMS Documentation Guidelines, medical decision making is composed of which of the following?

A HPI, problem list, and medication list

B Severity of condition, comorbidities, and co-mortality

C The presenting problem, amount and complexity of data to be reviewed, and risk

D Treatment options, HPI, and severity of condition

Question #45

In the 1995 CMS Documentation Guidelines, there were seven body areas and eleven organ systems. The 1997 CMS Documentation Guidelines called for how many general multisystem examinations?

A 12

B 10

C 8

D 11

Question #46

Non–Face-to-Face Services (99441-99449) include which of the following?

A Consultation with a social worker

B Telephone and online medical evaluations

C a. Consultation with a speech-language specialist

D d. Consultations with occupational therapists

Question #47

Preventive Medicine Services (99381-99429) include which of the following subcategories?

A Initial preventive medicine E/M visits for an established patient and periodic preventive medicine reevaluation and management services for established patient visits

B Initial preventive medicine E/M visits for an established patient

C Initial preventive medicine E/M visits for a new patient and periodic preventive medicine reevaluation and management services for established patient visits

Question #48

Case management is defined as a process by which a physician/QHP is responsible for which of the following?

A Coordinating and managing access to health care services needed by the patient

B All of these

C Directly caring for a patient

D Initiating and/or supervising other health care services needed by the patient

E None of the above

Question #49

The Healthcare Common Procedure Coding System (HCPCS) consists of two levels: Level I, which is the CPT code set, and Level II, which represents medical supplies, durable medical goods, nonphysician services, and services not represented in the Level I code set. Which of the following were developed to be used with both HCPCS levels?

A Quality performance modifiers

B Physical condition modifiers

C Durable goods modifiers