Questions for the CPC were updated on : Nov 21 ,2025
View MR 099407
MR 099407
Emergency Department Visit
Chief Complaint: VOMITING.
This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea,
black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood
sugars (320 mg/dL).
REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.
PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.
Medications: See Nurses Notes.
Allergies: PCN.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
PHYSICAL EXAM
Appearance: Lethargic. Patient in mild distress.
Vital Signs: Have been reviewed-tachycardic.
Eyes: Pupils equal, round and reactive to light.
ENT: Dry mucous membranes present.
Neck: Normal inspection. Neck supple.
CVS: Tachycardi
a. Heart sounds normal. Pulses normal.
E D. Course: Insulin IV drip per protocol, at 10 units/hr.
Zofran 8 mg 01:33 Jul 13 2008 IVP.
Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon
treatment plan. Physician will see patient in hospital.
Total critical care time: 45 min.
Disposition: Admitted to Intensive Care Unit. Condition: stable.
Admit decision based on need for monitoring and IV hydration and medications.
CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.
What E/M code is reported for this encounter?
B
Explanation:
99291: This code is used for the first 30-74 minutes of critical care, evaluation, and management of
the critically ill or critically injured patient.
99292: This code is used for each additional 30 minutes of critical care service beyond the first 74
minutes.
The documentation indicates that the patient received a total of 45 minutes of critical care, which
involves continuous IV insulin for diabetic ketoacidosis, administration of antiemetics, and admission
to the ICU. The critical care time documented justifies the use of 99291 for the first 30-74 minutes
and 99292 for each additional 30 minutes.
Reference:
CPT® Professional Edition, AMA
View MR 099405
MR 099405
CC: Shortness of breath
HPI: 16-year-old female comes into the ED for shortness of breath for the last two days. She is an
asthmatic.
Current medications being used to treat symptoms is Advair, which is not working and breathing is
getting worse. Does not feel that Advair has been helping. Patient tried Albuterol for persistent
coughing, is not helping. Coughing 10-15 minutes at a time. Patient has used the Albuterol 3x in the
last 16 hrs. ED physician admits her to observation status.
ROS: No fever, no headache. No purulent discharge from the eyes. No earache. No nasal discharge or
sore throat. No swollen glands in the neck. No palpitations. Dyspnea and cough. Some chest pain. No
nausea or vomiting. No abdominal pain, diarrhea, or constipation.
PMH: Asthma
SH: Lives with both parents.
FH: Family hx of asthma, paternal side
ALLERGIES: PCN-200 CAPS. Allergies have been reviewed with child’s family and no changes
reported.
PE: General appearance: normal, alert. Talks in sentences. Pink lips and cheeks. Oriented. Well
developed. Well nourished. Well hydrated.
Eyes: normal. External eye: no hyperemia of the conjunctiv
a. No discharge from the conjunctiva
Ears: general/bilateral. TM: normal. Nose: rhinorrhea. Pharynx/Oropharynx: normal. Neck: normal.
Lymph nodes: normal.
Lungs: before Albuterol neb, mode air entry b/l. No rales, rhonchi or wheezes. After Albuterol neb.
improvement of air entry b/l. Respiratory movements were normal. No intercostals inspiratory
retraction was observed.
Cardiovascular system: normal. Heart rate and rhythm normal. Heart sounds normal. No murmurs
were heard.
GI: abdomen normal with no tenderness or masses. Normal bowel sounds. No hepatosplenomegaly
Skin: normal warm and dry. Pink well perfused
Musculoskeletal system patient indicates lower to mid back pain when she lies down on her back
and when she rolls over. No CVA tenderness.
Assessment: Asthma, acute exacerbation
Plan: Will keep her in observation overnight. Will administer oral steroids and breathing treatment.
CXR ordered and to be taken in the morning.
What E/M code is reported?
D
Explanation:
99222: This code is used for initial hospital care, per day, for the evaluation and management of a
patient, which requires a detailed or comprehensive history, a detailed or comprehensive
examination, and medical decision making of moderate complexity.
The documentation shows a detailed history (including HPI, ROS, PMH, SH, and FH) and a detailed
examination (covering multiple organ systems). The medical decision making involves the
management of an acute asthma exacerbation, which includes admitting the patient to observation
status, administering oral steroids, and planning for further diagnostic testing.
Reference:
CPT® Professional Edition, AMA
View MR 099401
MR 099401
Established Patient Office Visit
Chief Complaint: Patient presents with bilateral thyroid nodules.
History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules.
Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to
multinodular goiter. Patient stated that she can “feel" the nodules on the left side of her thyroid.
Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does
have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at
this time other than a palpable right-sided thyroid mass.
Review of Systems:
Constitutional: Negative for chills, fever, and unexpected weight change.
HENT: Negative for hearing loss, trouble swallowing and voice change.
Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool,
constipation, diarrhea, nausea, rectal pain, and vomiting
Endocrine: Negative for cold Intolerance and heat intolerance.
Physical Exam:
Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 °F (36.4 °C), Temporal SpO2: 97%
Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65”)
General Appearance: Alert, cooperative, in no acute distress
Head: Normocephalic, without obvious abnormality, atraumatic
Throat: No oral lesions, no thrush, oral mucosa moist
Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD
Lungs: Clear to auscultation, respirations regular, even, and unlabored
Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click
Lymph nodes: No palpable adenopathy
ASSESSMENT/PLAN:
1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).
What E/M code is reported for this encounter?
B
Explanation:
The patient is an established patient presenting with bilateral thyroid nodules and has a detailed
history and examination performed.
Procedure Description:
Detailed history and examination of bilateral thyroid nodules.
Review of systems and physical examination.
Assessment and plan for a percutaneous biopsy.
CPT® Coding:
99214: Office or other outpatient visit for the evaluation and management of an established patient,
which requires a medically appropriate history and/or examination and moderate medical decision
making.
Reference:
AMA's CPT® Professional Edition (current year).
CPT® Assistant for detailed coding guidelines on evaluation and management services.
View MR 007400
MR 007400
Radiology Report
Patient: J. Lowe Date of Service: 06/10/XX
Age: 45
MR#: 4589799
Account #: 3216770
Location: ABC Imaging Center
Study: Mammogram bilateral screening, all views, producing direct digital image
Reason: Screen
Bilateral digital mammography with computer-aided detection (CAD)
No previous mammograms are available for comparison.
Clinical history: The patient has a positive family history (mother and sister) of breast cancer.
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: No dominant speculated mass or suspicious area of clustered pleomorphic
microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.
What CPT® coding is reported for this case?
C
Explanation:
The procedure performed is a bilateral screening mammogram with computer-aided detection
(CAD). CPT code 77067 is for bilateral screening mammography with CAD. ICD-10-CM code Z12.31 is
for an encounter for screening mammogram for malignant neoplasm of the breast. Z80.3 is for a
family history of malignant neoplasm of the breast. Therefore, the correct coding is 77067, Z12.31,
Z80.3. Reference: CPT® Professional Edition (current year), ICD-10-CM (current year).
View MR 006399
MR 006399
Operative Report
Preoperative Diagnosis: Chronic otitis media in the right ear
Postoperative Diagnosis: Chronic otitis media in the right ear
Procedure: Eustachian tube inflation
Anesthesia: General
Blood Loss: Minimal
Findings: Serous mucoid fluid
Complications: None
Indications: The patient is a 2-year-old who presented to the office with chronic otitis media
refractory to medical management. The treatment will be eustachian tube inflation to remove the
fluid. Risks, benefits, and alternatives were reviewed with the family, which include general
anesthetic, bleeding, infection, tympanic membrane perforation, routine tubes, and need for
additional surgery. The family understood these risks and signed the appropriate consent form.
Procedure in Detail: After the patient was properly identified, he was brought into the operating
room and placed supine. The patient was prepped and draped in the usual fashion. General
anesthesia was administered via inhalation mask, and after adequate sedation was achieved, a
medium-sized speculum was placed in the right ear and cerumen was removed atraumatically using
instrument with operative microscope. The tube is dilated, an incision is made to the tympanum and
thick mucoid fluid was suctioned. The patient was awakened after having tolerated the procedure
well and taken to the recovery room in stable condition.
What CPT® coding is reported for this case?
D
Explanation:
The procedure involves eustachian tube inflation to remove serous mucoid fluid in the right ear of a
2-year-old patient with chronic otitis media.
Procedure Description:
Eustachian tube inflation to remove fluid.
General anesthesia.
Incision to the tympanum and suctioning of thick mucoid fluid.
CPT® Coding:
69421-RT: Eustachian tube inflation, transnasal or transoral; with catheterization, including general
anesthesia. The modifier -RT indicates the right ear.
Reference:
AMA's CPT® Professional Edition (current year).
CPT® Assistant for detailed coding guidelines on eustachian tube procedures.
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right
flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin
incision was made between the 11th and 12th ribs laterally. The incision was carried down through
the underlying subcutaneous tissues, muscles, and fasci
a. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney
was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was
dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and
divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures.
The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter
were then submitted for pathologic evaluation. The operative field was inspected, and there was no
residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was
then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for
subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent
aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT® coding is reported for this case?
B
Explanation:
The procedure involves a right nephrectomy with partial ureterectomy for a nonfunctioning right
kidney with ureteral stricture.
Procedure Description:
Right nephrectomy (removal of the kidney).
Partial ureterectomy (removal of part of the ureter).
CPT® Coding:
50220: Nephrectomy, including partial ureterectomy, any open approach.
Reference:
AMA's CPT® Professional Edition (current year).
CPT® Assistant for detailed coding guidelines on nephrectomy procedures.
View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound
revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion.
After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was
insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope
was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was
enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional
ports were placed and graspers were used to free the gallbladder from the liver bed with a
combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is
injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction.
Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?
B
Explanation:
47563: Laparoscopic cholecystectomy with cholangiography is coded as 47563. The report details the
laparoscopic removal of the gallbladder with intraoperative cholangiography.
74300-26: The radiological supervision and interpretation for the cholangiography is coded as 74300
with modifier -26 (Professional Component) since the interpretation was done by the physician.
Reference:
CPT® Professional Edition, AMA
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral
artery
Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion.
Right common femoral artery is found, and an incision is made over the artery exposing it. The artery
is opened transversely, and the tip of the balloon catheter was placed in the right common femoral
artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after
local anesthesia of 2 cc of 1% Xylocaine is used to numb the are
a. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The
patient tolerated the procedure. There were no complications.
What CPT® coding is reported for this case?
A
Explanation:
The procedure involved the placement of an intra-aortic balloon pump (IABP) through the right
common femoral artery for a patient with acute MI and severe left main arteriosclerotic coronary
artery disease.
Procedure Description:
Placement of an intra-aortic balloon pump (IABP).
Right common femoral artery approach.
Confirmation of good waveform and securement of the catheter.
CPT® Coding:
33975: Insertion of intra-aortic balloon assist device, percutaneous.
Reference:
AMA's CPT® Professional Edition (current year).
CPT® Assistant for detailed coding guidelines on cardiac procedures.
View MR 002395
MR 002395
Operative Report
Pre-operative Diagnosis: Acute rotator cuff tear
Post-operative Diagnosis: Acute rotator cuff tear, synovitis
Procedures:
1) Rotator cuff repair
2) Biceps Tenodesis
3) Claviculectomy
4) Coracoacromial ligament release
Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.
Findings: Complete tear of the right rotator cuff, synovitis, impingement.
Procedure: The patient was prepared for surgery and placed in left lateral decubitus position.
Standard posterior arthroscopy portals were made followed by an anterior-superior portal.
Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-
thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back
to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity.
Sutures were passed through the subcapulans in a combination of horizontal mattress and simple
interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the
biceps. The biceps were released and then anchored in the intertubercular groove with a screw.
There was a large anterior acromial spur with subacromial impingement. A CA ligament was released
and acromioplasty was performed. Attention was then directed to the
supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior
to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil
anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors
was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted
after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes
at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve
the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed
and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was
transferred to recovery in stable condition.
What CPT® coding is reported for this case?
A
Explanation:
29827: Arthroscopic rotator cuff repair is correctly coded as 29827.
29828: Arthroscopic biceps tenodesis is an additional procedure and should be coded as 29828 with
modifier -51 (Multiple Procedures).
29824: Arthroscopic claviculectomy (partial resection of the distal clavicle) is coded as 29824 with
modifier -51.
29826: Arthroscopic subacromial decompression, including coracoacromial ligament release, is
coded as 29826.
All these procedures were performed arthroscopically and documented in the operative report,
justifying the use of these codes and the use of modifier -51 for multiple procedures.
Reference:
CPT® Professional Edition, AMA
View MR 001394
MR 001394
Operative Report
Procedure: Excision of 11 cm back lesion with rotation flap repair.
Preoperative Diagnosis: Basal cell carcinoma
Postoperative Diagnosis: Same
Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly
through a 30-gauge needle for the patient's comfort.
Location: Back
Size of Excision: 11 cm
Estimated Blood Loss: Minimal
Complications: None
Specimen: Sent to the lab in saline for frozen section margin control.
Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and
draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise
the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin
tension lines as much as possible The lesion was removed full thickness including epidermis, dermis,
and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for
hemorrhage control. The specimen was sent to the lab on saline for frozen section.
Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma
of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure
technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the
situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of
the anatomy in the are
a. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.
What CPT® coding is reported for this case?
D
Explanation:
For the excision of an 11 cm lesion with a rotation flap repair, the appropriate CPT codes are 14001
for the adjacent tissue transfer or rearrangement (12 sq cm flap) and 11606-51 for the excision of a
malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm.
Modifier 51 indicates multiple procedures. The detailed operative report specifies the lesion size and
the technique used, justifying these codes.
Reference: CPT® Professional Edition (current year), AMA.
Patient has undergone open surgery for a left total knee arthroplasty. While in the recovery room, he
continued to have severe postoperative pain. The surgeon ordered a femoral block for postoperative
pain. The anesthesiologist evaluated the patient and performed a left femoral block, which provided
significant post-operative pain relief.
What CPT® coding is reported?
C
Explanation:
The patient has undergone a left total knee arthroplasty and subsequently received a femoral nerve
block for postoperative pain management. CPT code 01402 is used for anesthesia for total knee
arthroplasty. Code 64447-59-LT is for a femoral nerve block (single injection) for postoperative pain
management, with modifier 59 indicating a distinct procedural service and LT indicating the left side.
Therefore, the appropriate codes are 01402 and 64447-59-LT.
Reference: CPT® Professional Edition (current year), AMA.
A patient is taken to the radiology department for a radiological cardiac catheterization. An acute MI
of the left anterior descending coronary artery is found. The cardiologist performs a suction
thrombectomy, followed by atherectomy and a stent to the artery. A CRNA provides MAC for this
patient, who is status P5.
What code/modifier combination would you report for the services of the CRNA?
C
Explanation:
The patient is undergoing a cardiac catheterization with a CRNA providing monitored anesthesia care
(MAC). Code 00520 is for anesthesia for heart catheterization procedures. Modifier QX indicates
CRNA service with medical direction by a physician, QS indicates MAC, and P5 indicates a patient
with a severe systemic disease that is a constant threat to life. Thus, the correct code and modifier
combination is 00520-QX-QS-P5.
Reference: CPT® Professional Edition (current year), AMA.
A patient presents to the labor and delivery department for a planned cesarean section for triplets.
She is at 37 weeks gestation. She is given a continuous epidural for the delivery.
What anesthesia coding is reported?
A
Explanation:
The patient presents for a planned cesarean section for triplets and receives continuous epidural
anesthesia. CPT code 01967 is used for neuraxial labor analgesia/anesthesia for planned vaginal
delivery, and code 01968 is an add-on code for cesarean delivery following neuraxial labor
analgesia/anesthesia. Since this is a planned cesarean section with triplets, both codes 01967 and
01968 are applicable.
Reference: CPT® Professional Edition (current year), AMA.
A 65-year-old man had a right axillary block by the anesthesiologist. When the arm was totally numb,
the arm was prepped and draped, and the surgeon performed tendon repairs of the right first,
second, and third fingers. The anesthesiologist monitored the patient throughout the case.
What anesthesia code is reported?
A
Explanation:
The anesthesia code for an axillary block for procedures on the upper arm and elbow, which includes
the monitoring by the anesthesiologist throughout the procedure, is 01830. This code is appropriate
for anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of the shoulder and
axilla.
Reference:
CPT® Professional Edition, AMA
Anesthesia Coding Guidelines
A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and
then 100 mg of Benadryl.
Which HCPCS Level II codes are reported for both drugs administered intravenously?
B
Explanation:
The patient with malignant lymphoma is administered Rituximab (800 mg) and Benadryl (100 mg)
intravenously.
Procedure Description:
Administration of Rituximab (800 mg) intravenously.
Administration of Benadryl (100 mg) intravenously.
HCPCS Level II Coding:
J9312: Injection, Rituximab, 10 mg.
For 800 mg, report 80 units of J9312.
J1200: Injection, Diphenhydramine HCl, up to 50 mg.
For 100 mg, report 2 units of J1200.
Reference:
HCPCS Level II Code Book (current year).
HCPCS Level II coding guidelines for intravenous drug administration.