AAPC Updated CPC Exam Questions and Answers by timothy

The procedure described involves the removal of electrodes from the cranial area after making an incision in the scalp and performing a craniectomy.

Procedure Description:

Incision in the scalp.

Craniectomy to access the area with electrodes.

Removal of electrodes.

Closure of the surgical wound.

CPT® Coding:

61860: Removal of intracranial neurostimulator electrodes, including burr hole(s) or craniectomy.

AMA ' s CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on neurostimulator procedures.

The procedure involves a laparoscopic partial colectomy where the surgeon removes the proximal colon and terminal ileum, then reconnects the cut ends of the distal ileum and remaining colon.

Procedure Description:

Laparoscopic partial colectomy.

Removal of the proximal colon and terminal ileum.

Anastomosis of the distal ileum and remaining colon.

CPT® Coding:

44204: Laparoscopy, surgical; colectomy, partial, with anastomosis.

ICD-10-CM Coding:

C18.2: Malignant neoplasm of ascending colon.

AMA ' s CPT® Professional Edition (current year).

ICD-10-CM for corresponding diagnosis codes.

The correct ICD-10-CM coding for this patient is B20, M54.50. The first code, B20, is used for HIV disease, which is a confirmed diagnosis of HIV infection. It’s important to note that this code can be used regardless of whether the patient is symptomatic or asymptomatic, as long as the patient has been diagnosed with HIV.

The second code, M54.50, refers to low back pain, which would be used to report the loin pain described by the patient. " Loin pain " typically refers to pain in the lower back area, and this code specifically covers the general category of low back pain not otherwise specified.

The other options are not as accurate:

A (B20, M54.9) includes a nonspecific code for back pain (M54.9), which does not fully specify the pain’s location.

B (M54.51, B20) incorrectly includes a code for thoracic or lumbar radiculopathy (M54.51), which is not indicated here.

D (M54.50, B20) is similar to the correct answer, but it incorrectly lists the codes in reverse order. It is important to list the HIV diagnosis first in ICD-10-CM.

Reference topics: ICD-10-CM Coding for HIV Disease; Pain Coding

ICD-10-CM has a clear hierarchy when the same substance is documented with multiple levels of severity.Dependencerepresents a higher severity classification thanabuse, andabuseis higher thanuse. When two or more of these are documented for the same substance, you generally assignonly one code, selecting thehighest level of severitysupported: dependence over abuse, and abuse over use. Therefore, if bothuse and dependenceare documented, you assigndependence only(Option D). Option A is incorrect because you do not code both use and abuse for the same substance; you choose the higher severity (abuse). Option B is incorrect because if abuse and dependence are both documented, you would codedependence, not abuse. Option C is incorrect because ICD-10-CM does not support reporting all three separately for the same substance; doing so would be duplicative and noncompliant. CPC exam tip: remember the mnemonicD-A-U→Dependence > Abuse > Use(pick the highest).