AAPC Updated CPC Exam Questions and Answers by yasin

The procedure involves a tympanoplasty with a radical mastoidectomy and removal of a cholesteatoma from the middle ear, including grafting of the eardrum without ossicular chain reconstruction.

Procedure Description:

Tympanoplasty.

Radical mastoidectomy.

Removal of cholesteatoma from the middle ear.

Grafting technique used to repair the eardrum without ossicular chain reconstruction.

CPT® Coding:

69645: Tympanoplasty with mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), radical or complete, with removal of cholesteatoma; with mastoid obliteration.

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

CPT® Assistant for detailed coding guidelines on otolaryngology procedures.

This is aninitial hospital service(admitted this morning; “reason for admission”), so the correct E/M family isinitial hospital inpatient/observation carerather than subsequent hospital care (99232/99233). The encounter includes a detailed history, comprehensive exam elements focused on abdominal pathology, and meaningful initial management: NPO, IV fluids,IV morphine, ordering and reviewing lab panels, and ordering imaging (ultrasound and HIDA) with possible surgical consultation—supporting at leastmoderate MDM, consistent with99222in typical CPC exam mapping. Diagnosis coding: “rule out cholecystitis” is not a confirmed inpatient discharge diagnosis in the provided note; at this stage the physician’s final assessment isRUQ abdominal pain, rule out cholecystitis. Therefore, you report thesign/symptomcodeR10.11 (right upper quadrant pain)rather thanK81.9(cholecystitis, unspecified), because cholecystitis is not established as definitive in the note. Option A correctly pairs an initial hospital E/M code with the symptom diagnosis supported by documentation.

Modifier58is used when a subsequent procedure during the postoperative period isstaged or relatedto the original procedure and meets one of these classic criteria:(1) planned/prospective (staged), (2) more extensive than the original, or (3) therapeutic following a diagnostic procedure. It signals that the later procedure is not an unplanned complication but part of a planned course of care or an escalation of treatment. This is different from modifier78, which is for anunplanned returnto the operating room/procedure room during the postoperative period for arelated procedure(often due to complications) and typically doesnotrestart the global period. Modifier26is theprofessional componentmodifier for certain diagnostic services, not a global surgical modifier. Modifier56is not the appropriate postoperative modifier for staged/related surgical services. For CPC exam accuracy, associate58with staged/planned/more extensive/therapeutic-after-diagnostic, and78with unplanned return to OR.

U07.1 = COVID-19

J12.82 = Pneumonia due to COVID-19This follows COVID-19 coding guidelines for confirmed cases.