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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q59-Q64):
NEW QUESTION # 59
The physician suspects malignancy and decides to remove two lesions from the patient's back to confirm. The size of the first lesion has a diameter of 0.5 cm, and the excised diameter is 1.0 cm. The size of the second lesion has a diameter of 0.3 cm, and the excised diameter is 1.5 cm. Which CPT code(s) should be reported?
Answer: A
Explanation:
Without a patholoy report to confirm malignancy, the excision code assumes that the lesion is benign. Code selection is based on the excision size, not the size of the lesion, and the more complex code takes priority in sequence, eliminating answer C. Answers A and B can be incorrect choices due to CPT guidelines outlining that when coding more than one excision, the appropriate modifier would be 59 on each additional procedure.
NEW QUESTION # 60
A 55-year-old patient is admitted into the hospital for dialysis to treat ESRD. On day 13, the admitting physician spends 25 minutes discussing new management options for the patient's hypertension before sending a nurse to initiate the hemodialysis procedure. What CPT and ICD-IO-CM codes should be reported?
Answer: A
Explanation:
CPT codes 90935-90937 require the presence of a physician. If a physician visits the patient prior to or after the dialysis treatment but does not document their presence during the hemodialysis services, bill only the appropriate evaluation and management code (CPT 99232).
Additionally, unless otherwise stated, diagnosis selection should reflect the causal relationship that exists bet'.veen hypertension and ESRD (112.-, N18.-)-they should not be reported as unrelated.
ICD-IO-CM Z99.2 is appended to indicate hemodialysis status.
NEW QUESTION # 61
Which is NOT a violation of Health Insurance Portability and Accountability Act (HIPAA)?
Answer: A
Explanation:
HIPAA is in place to reduce the level of risk associated with a potential violation and/or breach. In answer C, even though a breach has occurred, the hospital has appropriate preventative measures in place and is not in violation of HIPAA. Leaving a laptop in an unattended vehicle or medical records outside is high-risk behavior that gives opportunity for an unauthorized person to access protected health information (PHI) and/or electronic protected health. In answer D, a medical practice is required to perform a risk analysis to PHI and/or ePHI and recti$ any failures within a timely manner.
NEW QUESTION # 62
Based on the following documentation for an established patient, which CPT code should be reported?
Number and complexity of problems addressed: Moderate
Amount or complexity of data to be reviewed and analyzed: Straightforward Risk of complications, morbidity, or mortality of patient management: Low Total time: 35 minutes
Answer: D
Explanation:
When leveling a visit based on the documentation, the lower of the two highest components should be used to determine the level of complexity. In this case, because the number and complexity of problems addressed is moderate and level of risk of complications and/or morbidity or mortality of patient management is low, the MDM is low. On the other hand, because total time is documented and would constitute a higher level of service, total time should be used to select CPT
99214.
NEW QUESTION # 63
Which form is used to make a patient aware of the potential monetary liability they will have if their procedure is not likely to be covered by Medicare?
Answer: D
Explanation:
National Coverage Determination is a reference guide for physicians to determine which services are covered by Medicare. The HIPAA Release is a form that must be signed by the patient prior to release of medical records and can be revoked at any time. The HIPAA Privacy Rule is in place to protect the patien& health information.
NEW QUESTION # 64
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