AAPC Updated CPC Exam Questions and Answers by inaaya

In ICD-10-CM coding, an Excludes2 note under a code indicates that the condition listed in the note is not included in the definition of the code, but it does not necessarily mean they cannot coexist. This type of note means that while the conditions are distinct, it may be appropriate to report both codes if a patient has both conditions at the same time.

A. is incorrect because Excludes1, not Excludes2, indicates that certain codes should not be reported together.

C. is a description of an Excludes1 note, which implies that the two conditions should not be coded together because they cannot occur simultaneously.

D. is also a description of an Excludes1 note, which serves as a "NOT CODED HERE!" directive.

Therefore, the correct answer is B. It is acceptable to report both the code and the excluded code together, when applicable.

88027 = Autopsy, gross and microscopic, with CNS examination

88016/88020 exclude spinal cord or microscopy

The patient presented for a follow-up visit for chronic conditions, including hypokalemia, hypertension, and esophageal reflux. During this visit, the physician reviewed and discussed lab results, managed prescriptions, and noted that there were no new symptoms or complaints.

The level of service provided included an appropriate history and exam, as well as the management of multiple chronic conditions, which aligns with the criteria for CPT® code 99214. This code is used for an established patient office or other outpatient visit that requires at least 2 of the following 3 key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity.

CPT® Professional Edition, AMA

Evaluation and Management Coding Guidelines

Frozen section pathology coding rules:

88331 – Frozen section, first tissue block, each specimen

88332 – Frozen section, each additional tissue block, same specimen

Breakdown:

Specimen 1

Block 1 → 88331 × 1

Block 2 → 88332 × 1

Specimen 2

Block 1 → 88331 × 1

Block 2 → 88332 × 1

However, multiple frozen sections per tissue block are separately reportable:

Total first blocks = 4 frozen sections → 88331 × 4

Total additional blocks = 3 frozen sections → 88332 × 3

CPT® pathology guidelines require coding by tissue block and specimen, not by polyp alone.