AAPC Updated CPC Exam Questions and Answers by leona

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 fascia. 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?

(Full Case:Location:ABC Outpatient Clinic.Patient:60-year-old menopausal female.Independent radiologist (not employed by hospital):Dr. Q.Chief complaint:Uterine cramping.Procedure:Transvaginal ultrasound.Findings:Ovaries normal; measurements given (note: left ovary listed twice with different dimensions); uterus 5.2 × 5.1 × 4.0; endometrial stripe 0.8 cm; uterus without focal hypoechoic mass; ovoid anechoic foci in lower uterus/cervix due to Nabothian cysts; no adnexal fluid or mass; cervix thickness/length normal; true sagittal thickest portion measured.Question:What CPT® and ICD-10-CM codes are reported for the independent radiologist that provided the interpretation of the ultrasound?)

A patient comes to the gynecologist's office to check if she is pregnant. A urine sample is taken and tested. The visual result is positive that she is pregnant.

What CPT® code is reported'

A 47-year-old male recently injured as a passenger in a car accident sustained multiple fractures. The patient now has physical restraints due to pulling out foley catheter, IV catheters and

attempted to pull out NG tube. Emergency department physician is asked to come see patient and injects 0.5 lidocaine into lumbar region of the spine. An indwelling catheter is placed into the

lumbar region for continuous infusion with fluoroscopy for pain management.

What CPT® is reported for the Emergency department physician?