CBCS

A patient presents to their physician for an annual wellness visit. During the visit, the physician also evaluates a new complaint of persistent knee pain and orders an X-ray. How should the coder report this encounter?

• AReport only the preventive visit code since it was the primary reason for the encounter
• BReport both the preventive visit code and a separate E/M code with modifier -25 for the k…
• CReport only the E/M code for the knee evaluation since it required more medical decision-…
• DReport the preventive visit with the X-ray code only; no additional E/M is allowed

Under the current E/M guidelines for office and outpatient visits, what are the two methods a provider can use to select the appropriate level of service?

• AHistory complexity and number of diagnoses addressed
• BPhysical examination detail and review of systems
• CMedical decision-making (MDM) or total time spent on the date of the encounter
• DChief complaint severity and number of tests ordered

A surgeon performs a laparoscopic cholecystectomy. The global surgical package for this procedure has a 90-day global period. Which of the following services would require a separate CPT code during the global period?

• AA follow-up office visit on post-operative day 14 to check the incision site
• BRemoval of surgical staples at the 10-day follow-up
• CA phone call to discuss the pathology results of the removed gallbladder
• DTreatment of a urinary tract infection unrelated to the surgery on post-operative day 30

Which CPT code range is used to report Evaluation and Management (E/M) services for office and other outpatient visits?

• A99281-99285
• B99221-99223
• C99241-99245
• D99202-99215

A provider performs a diagnostic colonoscopy and discovers a polyp, which is then removed by snare technique during the same session. How should this be coded?

• AReport both the diagnostic colonoscopy and the polypectomy codes separately
• BReport only the diagnostic colonoscopy code since the polypectomy was incidental
• CReport only the polypectomy code since it includes the diagnostic colonoscopy
• DReport the diagnostic colonoscopy with modifier -22 for the additional work

A coder notices that a provider documented a level-4 new patient office visit (99204) but only documented low-complexity medical decision-making in the note. What action should the coder take?

• ACode 99204 as the provider documented
• BAutomatically downcode to 99202 since the documentation is insufficient
• CAdd modifier -22 to justify the higher code level
• DQuery the provider to clarify the level of service and reconcile the discrepancy

A patient receives a flu vaccine (administration and the vaccine itself) at their physician's office during a routine visit. How many CPT codes are typically needed to report the vaccination?

• ATwo codes: one for the vaccine product and one for the administration
• BOne code for the vaccine product only
• CThree codes: one for the E/M, one for the vaccine, and one for the administration
• DOne code that covers both the vaccine and administration together

A physician performs a procedure on both the right and left knee during the same operative session. The procedure has the same CPT code for each side. What is the correct way to report this bilateral procedure?

• AReport the CPT code once with modifier -50 (Bilateral Procedure)
• BReport the CPT code twice with no modifier
• CReport the CPT code once with modifier -59 (Distinct Procedural Service)
• DReport the CPT code once with modifier -22 (Increased Procedural Services)

A patient is seen in the office for management of type 2 diabetes mellitus with diabetic chronic kidney disease, stage 3. Under ICD-10-CM combination code conventions, which coding approach is correct?

• AAssign a single combination code for diabetes with kidney complications, then a separate…
• BAssign separate codes for diabetes, kidney disease, and the stage individually with no co…
• CAssign only the diabetes code since the kidney disease is assumed to be included
• DAssign only the CKD code since it is the more specific diagnosis

A patient presents to the emergency department after falling from a ladder at home while cleaning gutters, sustaining a fracture of the left distal radius. Which of the following is the correct sequencing of ICD-10-CM codes?

• AFracture code first, then the external cause code, then the place of occurrence and activ…
• BPlace of occurrence first, then the fracture code, then the activity code
• CExternal cause code first, then the fracture code, then the place of occurrence
• DThe fracture code only; external cause codes are optional and typically not required

In ICD-10-CM, what does the 7th character extension "A" indicate when used with injury codes?

• AThe injury is an adverse effect of a medication
• BThe injury is associated with an assault
• CThe patient has an allergy related to the injury
• DThe encounter is for active treatment of the injury (initial encounter)

A patient is diagnosed with acute bronchitis. The provider documents the causative organism as Streptococcus. The coder finds that ICD-10-CM code J20.2 (Acute bronchitis due to streptococcus) captures both the condition and the organism. What type of code is this?

• AA manifestation code
• BAn unspecified code
• CA placeholder code
• DA combination code

A patient is seen in the office for a cough. After evaluation, the provider documents "rule out pneumonia" in the assessment. The chest X-ray is negative. How should the coder assign the ICD-10-CM diagnosis code for this outpatient encounter?

• ACode pneumonia as the primary diagnosis since it was considered
• BCode the cough as the primary diagnosis since the pneumonia was not confirmed
• CCode both pneumonia and cough as confirmed diagnoses
• DDo not assign any diagnosis code until the pneumonia is definitively ruled out

A patient is being seen for follow-up management of hypertension and type 2 diabetes. The provider also documents a history of breast cancer with no current evidence of disease. How should these diagnoses be sequenced?

• AHistory of breast cancer first, then hypertension and diabetes
• BThe condition chiefly responsible for the encounter should be listed first; the order of…
• CHypertension first, then diabetes, then personal history of breast cancer
• DType 2 diabetes first since it has more potential complications