Medicine

1. Colin had a comprehensive audiometry threshold evaluation and speech recognition testing to the
left ear. What code(s) capture this procedure? a. 92557-52 b. 92553, 92556 c. 92557
d. 92700-59

2. An adult patient had the following immunizations with administration:

 Yellow fever vaccine, subcutaneous injection
 Hepatitis B (adult dose) vaccine, intramuscular injection
 Plague vaccine, intramuscular injection How would you report these services?
a. 90460, 90461 x 2, 90717-51, 90746-51, 90727-51
b. 90471, 90472 x 2, 90717, 90746, 90727
c. 90473, 90474 x 2, 90746, 90727, 90717
d. 90471, 90472 x 2, 90727-51, 90746-51, 90717-51

3. Sally suffered from dehydration after running a marathon. She was taken into her primary care doctor’s
office. Dr. Small checked Sally and ordered hydration therapy with normal saline. The hydration lasted 45
minutes. How would you report this service? a. 96365, 96361 b. 96369 c. 96360
d. 96360, 96361

4. A patient had a bronchoscopy with destruction for relief of stenosis by laser therapy. During this
procedure photodynamic therapy by endoscopic application of light was used to ablate abnormal
tissue via activation of photosensitive drugs. The photodynamic therapy lasted 60 minutes. How
would you report this procedure? a. 31645, 96567 b. 96567 x 2 c. 31643, 96570-51, 96571-51
d. 31641, 96570, 96571 x 2
5. Dr. George asked the local pharmacist to review Ann’s new medications with her when she picked
them up. Ann is a new patient who just moved into the area and required several new medications. Ann
is hard of hearing and had a difficult time understanding Dr. George when he called her. The pharmacist
spent 35 minutes with Ann and documented a review of her history, recommendations for improving
health outcomes, and treatment compliance. The pharmacist faxed this note back to Dr. George’s office.
How would the pharmacist report his services?
a. 99605, 99607x2 b. 99605, 99607 c. 99607 x 3 d. 99213

6. What code would report an internet assessment and management service provided by a
qualified non-physician healthcare professional to an established patient not originating from a
related assessment and management service provided within the previous seven days? a. 99422
b. 98971
c. 98970
d. 99421

7. An ulnar motor Nerve Conduction Studies (NCS) from the abductor digit minimi and the first
dorsal interosseous? a. 95909 b. 95908
c. 95907
d. 95905

8. Jane has a family history of skin melanoma. Her primary care doctor asked for a consult with Dr. John.
During Jane’s first visit with her new dermatologist, Dr. John, he documented a comprehensive history,
comprehensive examination, and medical decision-making of moderate complexity. Dr. John also
performed a whole-body integumentary photography for monitoring of Jane’s skin. Dr. John sent a
report back to her PCP and told Jane she should return in one year or before then if anything should
change on her skin. What code(s) would you use to report Dr. John’s services? a. 99244-25, 96904 b.
99213
c. 96904
d. 99204, 96904

9. What services can you report in addition to the general ophthalmological services or evaluation and
management services?
a. Intermediate ophthalmological services
b. Special ophthalmological services
c. Only new patient general ophthalmological services
d. Only established patient general ophthalmoligical services

10. The physician performs angioplasty in the left anterior descending coronary and right
coronary arteries. What code(s) should you use to report these services? a. 92920 x 3 b.
92920, 92928-51
c. 92920-LD, 92920- RC
d. 92924, 92928, 92989 x 2

11. 4-year-old is getting over his cold and will be getting three immunizations in the pediatrician’s office
by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next one is the
influenza (live) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous
route. What CPT® codes are reported for the administration and vaccines?

A. 90713, 90658, 90716, 90460, 90461 x 2 B. 90714, 90656, 90716, 90460, 90461 x 1
C. 90713, 90660, 90716, 90471, 90472, 90474 D. 90713, 90658, 90716, 90471, 90472, 90473

12. A patient with chronic renal failure is in the hospital being evaluated by his endocrinologist after just
placing a catheter into the peritoneal cavity for dialysis. The physician is evaluating the dwell time and
running fluid out of the cavity to make sure the volume of dialysate and the concentration of
electrolytes and glucose are correctly prescribed for this patient. What code should be reported for this
service?

A. 90935 B. 90937 C. 90947 D. 90945

13. An established patient had a comprehensive exam in which she has been diagnosed with dry eye
syndrome in both eyes. The ophthalmologist measures the cornea for placement of the soft contact lens
for treatment of this syndrome. What codes are reported by the ophthalmologist?

A. 92014-25, 92071 B. 99214-25, 92325-50

C. 92014-25, 92325-50 D. 92014-25, 92310

14. A patient who is a singer has been hoarse for a few months following an upper respiratory infection.
She is in a voice laboratory to have a laryngeal function study performed by an otolaryngologist. She
starts off with the acoustic testing first. Before she moves on to the aerodynamic testing she complains
of throat pain and is rescheduled to come back to have the other test performed. What CPT® code(s)
should be reported?

A. 99211, 92520 B. 92700 C. 92520-52 D. 99211, 92700-52

15. A new patient is having a cardiovascular stress test done in his cardiologist’s office. Before the test is
started the physician documents a comprehensive history and exam and moderate complexity medical
decision making. The physician will be supervising and interpreting the stress on the patient’s heart
during the test. What procedure code should be documented for this encounter?
A. 93015-26, 99204-25
B. 93016, 93018, 99204-25
C. 93015, 99204-25
D. 93018-26, 99204-25

16. A cancer patient is coming in to have a chemotherapy infusion. The physician notes the patient is
dehydrated and will first administer a hydration infusion. The infusion time was 1 hour and 30 minutes.
Select the code(s) that should be reported for this encounter?
A. 96360
B. 96360, 96361
C. 96365, 96366
D. 96422

17. A patient that has multiple sclerosis has been seeing a therapist for four visits. Today’s visit the
therapist will be performing a comprehensive re-evaluation to determine the extent of progress in
parameters and if the patient is reaching his goals for common impairments associated with this
neurologic condition, which includes performing activities of daily living, movement, muscle strength
and reasoning abilities for independent living. What CPT® and ICD-9-CM codes should be reported? A.
97168 B. 97165 C. 97166
D. 97164

18. Patient with hemiparesis on the dominant side due to having a CVA lives at home alone and has a
therapist at his home site to evaluate meal preparation. The therapist observes the patient’s
functional level of performing kitchen management activities within safe limits. The therapist then
teaches meal preparation using one handed technique along with adaptive equipment to handle
different kitchen appliances. The total time spent on this visit was 45 minutes. Report the CPT® codes
for this encounter.
A. 97530 x 3
B. 97537 x 3
C. 97129 x 3
D. 97535 x 3

19.10-year-old patient had a recent placement of a chochlear implant. She and her family see an
audiologist to check the pressure and determine the strength of the magnet. The transmitter,
microphone and cable are connected to the external speech processor and maximum loudness levels
are determined under programming computer control. Which CPT® code should be used? A. 92601
B. 92603
C. 92562
D. 92626

20. A cardiologist pediatrician sends a four-week-old baby to an outpatient facility to have an

echocardiogram. The baby has been having rapid breathing. He is sedated and a probe is placed on the
chest wall and images are taken through the chest wall. A report is generated and sent to the
pediatrician. The interpretation of the report by the pediatrician reveals the baby has an atrial septal
defect. Choose the CPT® code the cardiologist pediatrician should report.
A. 93303
B. 93315-26
C. 93303-26 D. 93315

21. A patient presents to her oncologist’s office for schedule chemotherapy. The patient is severely
dehydrated. The physician decides to schedule the chemotherapy for another day and orders hydration
therapy to be performed today instead of the chemotherapy. The therapy is ordered and administered
for one hour and 10 minutes. Select the code(s).
A. 96413-53, 96360 B. 96360
C. 96360, 96361 D. 96413, 96361
22. Left heart catheterization retrograde from the femoral artery with injection procedures for selective
coronary angiography and selective left ventriculography, including imaging supervision and
interpretation with report, are performed. The cardiologist performed all of the services at the hospital.
The CPT® codes are:
A. 93458 C. 93452, 93454
C. 93452, 93563 D. 93458, 93565

23. The correct code for OMT performed on the cervical, thoracic and sacral regions would be:
A. 97110 B. 98941
C. 98926 D. 97124

24. A 40-year-old female with intractable epilepsy is admitted to the epilepsy monitoring unit for
presurgical evaluation to localize the seizure focus. Long-term Video EEG (VEEG) recording is started.
Antiepileptic medications are tapered to provoke seizures. Five typical seizures are captured over the
course of 4 days of VEEG recording and patient is discharged on preadmission anti-epileptic medication
in the afternoon of day 5.
A. 95720 x 5 B. 95719 x 4 C.95719 x 5 D. 95720 x 4

25. A pediatrician is managing the care of a patient who is at home on a ventilator under the care of a
home health agency. The patient has cystic fibrosis and is suffering from recurrent pneumonia. The MD
did the initial plan of care for the home health agency and now is following this monitor vent
management oversight on day 20. The provider has a total 45 minutes for this month how should he
code?
A. 94002 B. 94003
C. 94005 D. 94004
26. A two-month-old comes in for a well check-up and several shots (Rota RV5, DTaP-IPC/Hib, PCV) with
her paediatrician. He offers suggestions to the mom, completes the exam, and counsels her on the
vaccinations. How should this be coded?
A. 99391-25, 90471, 90472 x 2, 90680, 90698, 90696
B. 99381-25, 90460, 90461 x 2, 90698, 90680, 90696
C. 99381-25, 90471, 90472 x3, 90698
D. 99391-25, 90460, 90461 x 2, 90680, 90698, 90670

27. Mary, who has food allergies, came to her physician for her weekly allergen immune therapy that
consists of two injections prepared and provided by the physician. The correct code is:
A. 95125 B. 95117
C. 95131 D. 95146
28. Photodynamic therapy involving application of light externally to destroy premalignant lesions on
the lower lip was provided to a 63-year-old patient. Code the encounter.
A. 96570 B. 96999
C. 96567 D. 96913
29. The patient presents to see the nurse for his scheduled vitamin B12 injection. The physician ordered
the injection at the patient’s last visit. The physician is in the office seeing other patients. The nurse
administers the 1000 mcg of vitamin B12 intramuscularly. She schedules the patient for his next
appointment.
A. 99211-25, 96372, J3420 B. 99211-25, J3420
C. 96372, J3420 D. 96401, J3420

30. 32-year-old ETOH dependent female is in a partial hospitalization program and has been seeing
an addictive disease specialist (psychotherapist) in a chemical dependency program. Her employer is
aware of her problem. She was referred to the group through their Employee Assistance Program. As
long as she is in compliance, they will support her efforts. Recently, she has arrived late at the meetings.
The physician met with the patient and discussed the importance of her treatment, compliance with the
program and avoidance of situations in which she may use alcohol. She denies contacts with her
previous associates and assures the physician she has had no alcohol intake since beginning the
substance abuse treatment program. They will continue to reinforce her progress and successful
sobriety. Time of the session was 45 minutes. What CPT® and ICD-10-CM codes are reported? a. 90832,
F10.220 b. 90834, F10.20 c. 90832, F10.20 d. 90834, F10.220

31. Mae’s physician asked her to wear a glucose monitoring device to obtain more accurate
information about her blood sugars. She had sensors placed and was then hooked up to a calibrated
wearable device. Once this was complete, the technician provided Mae with training for the noninvasive
ambulatory continuous glucose monitoring device. After wearing the device for 72 hours, Mae’s
physician’s office removed the device, printed recordings, and downloaded analyses reports to its
computer system. Which code captures this service?

a. 95249
b. 99091
c. 95250
d. 95251

32. Edna, a 72-year-old patient, returned to her regular pulmonologist for a follow-up visit. Dr. Harry
documented Edna’s chief complaint as fatigue after recovering from a minor flu. His documentation
supports a past history of smoking, COPD, and well-controlled diabetes. Edna lives with her husband,
maintains her weight with a balanced diet, and exercises in the warm weather but feels “shut in” during
the winter. Dr. Harry noted a detailed examination, reviewed multiple treatment options, and reviewed
moderate risks for complications. Dr. Harry completed a six-minute walking pulmonary stress test to
evaluate distance, dyspnea, desaturation, and heart rate. The stress test was repeated with adequate rest
walks, heart rate and oximetry, and oxygen titration and evaluation protocol for Edna’s entry into a
pulmonary rehabilitative program. Which code(s) should Dr. Harry report for today’s services? a. 99214-
25, 94618
b. 99204-25, 94619
c. 94617
d. 99213-25, 94618 x 2

33. A young child received a mumps, measles, rubella and varicella (MMRV) injection at a neighborhood
clinic with physician counseling. What CPT® code(s) are reported? a. 90707, 90716, 90471, 90472 x 3
b. 90707, 90716, 90460, 90461 x 3
c. 90710, 90460
d. 90710, 90460, 90461 x 3

34. What codes are not reported in conjunction with the following code descriptor?
Comprehensive electrophysiologic evaluations including insertion and repositioning of multiple
electrode catheters with indication or attempted induction of arrhythmia; with right atrial pacing
and recording, right ventricular pacing and recording, and His bundle recording a. 93600, 93602,
93610, 93612, 93618, 93619
b. No codes are restricted from conjunction reporting with 93620
c. 93600-51, 93602-51, 93610-51, 93612-51, 93618-51, 93619
d. Both a & c

35. An 11-year-old female had one face-to-face visit with her physician and received three daily dialysis
services during a one-month period prior to her kidney transplant. How should these services be
reported? a. 90945 b. 90968 x 3 c. 90964 x 3
d. 90956

36. A patient suffering from nystagmus completed a basic vestibular function evaluation with
testing and recording in five different positions with gaze fixation; optokinetic, bidirectional, foveal,
and peripheral stimulation; and oscillation. An additional vertical electrode and vertical axis
rotational testing was employed during testing. How should this procedure be reported? a. 92545,
92541-59, 92542-59, 92540-59
b. 92540, 92545, 92542, 92546, 92547
c. 92540, 92546, 92547
d. 92545, 92547-51

37. A patient underwent a left heart catheterization by transseptal puncture through an intact septum
with image supervision and interpretation and intraprocedural injection for left ventriculography.
During the procedure, pharmacologic agents were administered and measured. An arm ergometry was
employed for exercise study to assess hemodynamics before and after the procedure. How should this
procedure be reported?
a. 93458, 93462, 93463, 93464 x 2
b. 93452, 93566, 93462, 93463, 93464 x 2
c. 93452, 93566, 93462, 93463, 93464 x 2
d. 93452, 93462, 93463, 93464

38. A patient completed a diagnostic computerized ophthalmic scan of the retina on both eyes. The
physician’s interpretation and report included changes to the retina in the right eye from a previous
study. The left retina looked stable with no changes noted. The patient is scheduled for a follow-up
study in three weeks to assess any new changes and treatment as needed. How should the physician
report her services?
a. 92132-50, 92134-26
b. 92132
c. 92134
d. 92134-50

39. A 28-year-old female with no prior medical history is admitted to an inpatient neurology service for
characterization of events of loss of consciousness. Long-term EEG monitoring without video was
started. During her stay, the neurologist generated formal EEG reports each morning after reviewing the
EEG recording from the prior day and overnight. On the first day, the patient had a typical event which
was determined to be epileptic on EEG review. Levetiracetam was started the following morning and
she was discharged that afternoon after 30 hours of monitoring.
A. 95717 x 1 95719 x 1 B. 95717 x 1, 95718 x 1 C. 95720 x 2 D. 95719 x 1, 95720 x 1
ANSWERS
1. “a” The description under code 92557 lists the codes that are combined and should not be reported
separately. In addition, the subcategory guidelines for the Audiologic Function Tests with Medical
Diagnostic Evaluation state to add modifier -52 if studies are completed on one ear.

2. “b” Administration of vaccines are reported according to the route and the age of the patient. These
vaccines, all injections, were given to an adult patient; therefore, you would report the codes 90471
and 90472 x 2. The vaccines are reported for each type given or injected. According to the
guidelines under the Vaccines, Toxoids subsection, do not report modifier -51 for the vaccines when
performed with the administration procedures.

3. “c” Use code 96360 to report hydration of 31 minutes to one hour.

4. d” You can find this answer by looking in the index of the CPT Professional under Endoscopy,
Bronchi, Stenosis.

5. “b” Medication Therapy Management Services. The guidelines for these codes indicate the
documentation elements and times necessary to select a code.

6. “c” Code 98970 is reportable for non-physician healthcare professionals.

7. “c” study of 2 nerves

8. “a” The notes above the code 96904 indicate this service is typically consultative and the
consultation evaluation and management code may be appropriate in addition to the special
dermatological procedures. The other answers are incorrect due to the reporting of the evaluation
and management code.

9. “b” See the subsection Ophthalmology in the CPT Professional Edition under for the definition of
special ophthalmological services, “…these services may be reported in addition….”

10. “c” Report 92920 - LD Percutaneous transluminal coronary angioplasty; single major coronary artery
or branch for the left anterior descending artery angioplasty. For the right coronary artery
angioplasty, report 92920- RC
11. C The young child was administered the Poliovirus vaccine by intramuscular route guiding you to
code 90713 eliminating multiple choice B. The influenza vaccine was for intranasal route is code
90660 eliminating multiple choices A and D. For the administration codes the vaccines were
administered without face-to-face counseling eliminating multiple choice answers A and B. The first
 vaccination was administered by the intramuscular route guiding you to code 90471. The second
vaccine (additional vaccine) was administered by the intranasal route guiding you to code 90474.
The third vaccine (additional vaccine) is given by the subcutaneous route guiding you to code 90472.

12. D Patient is having an evaluation for peritoneal dialysis eliminating multiple choices A and B. There
is no documentation in the scenario where the physician repeated the dialysis evaluation of the
patient due to a complication, eliminating multiple choice C.

13. A Patient is having an ophthalmological evaluation service provided, eliminating multiple choice B.
The contact lens is being fitted for a therapeutic use, eliminating multiple choice answers C and D.
The description of 92071 states “fitting of contact lens”; therefore, modifier -50 is inappropriate.

14. C The evaluation and management service (99211) would not be reported since the patient is being
further evaluated and analyzed for a specific problem that relates to a special otorhinolaryngologic
service in determining the patient’s therapeutic treatment, eliminating answers A and D. The
patient is having a laryngeal function study in which an acoustic test was performed, eliminating
multiple choice answer B. The aerodynamic testing was not performed on this visit so modifier 52 is
appended since a parenthetical note states “For performance of a single test, use modifier 52“.
15. C All three components are documented to report code 93015, in which the cardiologist is
supervising, he owns the equipment (tracing), since the test is being performed in the office, and
the physician interpreted the test. Modifier 26 would be inappropriate to append to code 93015
since it denotes the global service.

16. A Patient is having a hydration infusion eliminating multiple choices C and D. The add-on-code is
incorrect to report for this scenario. A parenthetical statement states: (Report 96361 for hydration
infusion intervals of greater than 30 beyond 1 hour increments) meaning if the hydration infusion is
30 minutes or less you would not report 96361.

17. A This patient is coming in for occupational therapy which helps a patient to improve basic motor
functions and reasoning abilities for independent daily living. This eliminates multiple choice B. This
is a re-evaluation visit eliminating multiple choice C. patient is receiving occupational therapy,
eliminating multiple choice D.

18. D The therapist is at the patient’s home site to teach home management for self care, guiding you
to code 97535.

19. B The patient is 10-years-old with a cochlear implant. The CPT index for Cochlear Device,
Programming guides you to code 92603.

20. C Infant is having the echocardiogram performed through the chest (transthoracic) not through the
a device in the esophagus (transesophageal), eliminating multiple choices B and D. Modifier 26
 needs to be appended since only the interpretation of the echocardiogram was performed by the
pediatrician.
21. B. Although the patient is scheduled for chemotherapy, only hydration therapy is performed.
Hydration therapy codes are selected based on time. The total time for this procedure is one hour and
10 minutes. There is a parenthetical note following code 96361 which states “Report 96361 for infusion
intervals greater than 30 minutes beyond one hour increments. Because there are only 10 additional
minutes beyond the first hour, only 96360 is reported.

22. A. Injection, catheterization, angiography and supervision and interpretation are included in 93458
itself. It is not necessary to code separately.

23. C. OMT stands for “osteopathic manipulative treatment”. This was performed on three body regions
(cervical, thoracic and sacral) which leads you to code 98926.

24. D.

25. C. The site of service indicates the code to select. The physician is overseeing the home ventilator
management care plan. There is one code for home ventilator care which is 94005. This code
requires a minimum of 30 minutes. This physician has performed 45 minutes of care.
26. D. We know this patient is established because she is seeing “her pediatrician.” The well check up is
coded as a preventive service. The patient is two-months-old. The proper code is 99391. According
to NCCI, modifier 25 is appended when a significant and separately identifiable E/M service is
performed with other services at the same encounter. In this case vaccinations are performed. A
vaccine administration for each is coded as well as the vaccine itself. In this case three vaccines are
performed; rotavirus (90680), combination vaccine DTapIPV/Hib (90698) and Pneumococcal
(90670). The physician counsels the patient’s mother regarding the vaccinations. 90465 is reported
for the initial vaccine and 90466 is reported for the second and third vaccine.
27. A. In this case the patient presents for allergen immune therapy for food allergies. The injections are
prepared and provided by the physician, which is reported with 95125 for two injections. The
therapy is not for an insect which makes 95131 and 95146 incorrect answers. 95117 does not
include the provision of the extract so it is also incorrect.
28. C. The photodynamic therapy is performed externally in this case which eliminates option A.
Photochemotherapy is not used, which eliminates option D. The code description for 96567 reports
the services provided for this patient.
29. C. A nurse visit (99211) is not supported in this case. The patient presents for a scheduled injection,
which is the only service performed. Injections are coded by route. In this case, the injection is given
intramuscularly which is reported with 96372. The 1000 mcg of vitamin B12 is reported with J3420.
The substance injected is not a chemotherapy medication; 96401 is an incorrect answer.

30. B : In the CPT® Index, look for Psychotherapy/Individual Patient/Family Member, you are directed to
a code range. Code selection is based on time. The duration of the counseling session was 45
 minutes making 90834 the correct code. Evaluation and Management services were not performed.
The diagnosis is ETOH dependence. ETOH is alcohol. The patient is alcohol dependent, although
there is no indication of the frequency of her intoxication. Look in the ICD-10-CM Index to Diseases
and Injuries for Dependence/alcohol, directing you to F10.20. Report code F10.20 for the condition
as there is not mention of intoxication or complications. Verification in the Tabular List confirms
code selection.

31. c. The second parenthetical note below code 99090 directs the coder to report with more
specific codes when possible. In this question, the patient wore a 72-hour ambulatory glucose
monitoring device, which is reported with a specific code.

32. a. Reporting an evaluation and management code with pulmonary stress testing is
appropriate.

33. D Rationale: In the CPT® Index, look for Vaccine/Measles, Mumps, Rubella and Varicella (MMRV),
you are directed to 90710. According to the guidelines for Vaccines and Toxoids, an administration
code from 90460-90474 is also reported. Because counselling was included, a code from
9046090461 should be used for the administration. According to the guidelines, 90460 and 90461
are reported per component of the vaccine. Although it is one vaccination, there are four
components, so 90460 and 90461 x 3 are reported. In the CPT® Index, look for Immunization
Administration.

34. a. Analytical testing strategies should be employed when encountering this type of question.
First, review the possible answers. Notice in answer b the code number is listed for the code
descriptor. Second, look up the code 93620 and review the descriptor, then review the
parenthetical notes listed below the code, which provide conjunction code reporting rules.
Third, notice modifier -51 exempt statuses with codes listed, and finally, check off the codes
listed in the test question to ensure proper exemption and/or reporting restrictions.
35. b. The subcategory guidelines provided in the CPT® Professional Edition with end-stage
renal disease services provide code selection criteria. Additionally, examples are provided to
assist with proper code selection.
36. c. One way to find this answer in the index of the CPT® Professional Edition is under
“Vestibular function tests.” Once this code range is located, review of the codes and
parenthetical notes will help with code selection.
37. d. The subcategory guidelines, codes, and reporting rules for cardiac catheterization have
undergone extensive updates for 2011. Review of this section in the CPT® Professional
Edition and CPT® Changes: An Insider’s View 2011 will help with correct reporting. For
this question, review the primary procedure and then the add-on codes, with special attention
to the parenthetical notes for correct code selection.
38. c. The code descriptor includes services delivered bilaterally; therefore, modifier -50 is not
required when reporting. Additionally, the anatomic location of the scan is important when
selecting a code from this section.
39. A.