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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions (Q17-Q22):

NEW QUESTION # 17
A female patient with type II diabetes, asthma, and hypertension is admitted with complaints of chest pain. Testing rules out heart attack and other underlying conditions as the cause. Which diagnosis codes should be listed on the discharge note?

A. Z03.89
B. R07.9, Ell.9, J45.909, 110
C. Z03.89
D. R07.9

Answer: B

Explanation:
The primary diagnosis on an inpatient record would be the primary reason the patient was admitted. In this case, because a definitive diagnosis could not be confirmed, the symptom of chest pain would be selected instead. The previously confirmed chronic conditions would also be coded because they affect the management of inpatient care. Diabetes would be coded to an unspecified code because the term "with" implies a causal relationship between the conditions that is not implicitly documented. Per ICD-IO-CM guidelines, a rule-out code is not assigned when "any signs or symptoms related to the suspected condition are present."

NEW QUESTION # 18
If all the following statements were documented by the anesthesiologist in one record, which would be chosen as the start time for anesthesia services?

A. Request for services is received for an operation that begins in 1 hour.
B. A pulse oximeter is attached to the patient,s finger while in the operating room.
C. Medical history and vital signs for the patient are obtained prior to the surgery.
D. Propofol is administered to the patient intravenously.

Answer: B

Explanation:
Anesthesia time begins when the provider begins to prepare the patient for anesthesia services. This usually will take place in the operating room or an equivalent area. Although answer B would not be incorrect as a chosen starting point, answer C is more accurate according to the anesthesia time definition. Preoperative evaluations of the patient, such as a history intake, cannot be counted as anesthesia time.

NEW QUESTION # 19
A patient with right knee pain is seen in a physician's office for an x-ray. Anteroposterior and lateral views of the right knee were obtained by the technician, and images confirm right knee pain secondary to degenerative osteoarthritis. Which CPT and ICD-IO-CM code(s) should be reported?

A. 73560-26-RT, MI 7.11, M25.561
B. 73560-TC-RT, MI 7.11
C. 73560-TC-RT, MI 7.11, M25.561
D. 73560-RT, MI 7.11

Answer: D

Explanation:
The CPT crosswalk for x-ray of knee directs the coder to 73560-73580. Because two views were obtained, the correct code would be 73560 (radiologic examination, knee; I or 2 views).
Modifier TC and modifier 26 indicate only technical and professional components: however, because the x-ray was performed in a physician's office, 73560 would be reported without either because the practice provided both components. In terms of diagnosis, the knee pain would not be reported because it is a symptom of a definitive diagnosis.

NEW QUESTION # 20
What is the difference between presumptive and definitive testing?

A. Presumptive testing is based on exhibited signs and/or symptoms; definitive testing isbased on lab results.
B. Presumptive testing assumes a diagnosis; definitive testing confirms a diagnosis.
C. Presumptive testing confirms the presence of a drug class; definitive testing identifies thequantity or presence of a drug.
D. Presumptive testing requires additional observation time; definitive testing requires ablood draw.

Answer: C

Explanation:
A presumptive test reports whether the patient is positive or negative for a specific drug. A definitive test would analyze which specific agent and/or how much of that agent is in the patients' system.

NEW QUESTION # 21
A patient with preexisting hypertension presents to the office at 23-weeks' gestation for prenatal care. Her blood pressure is slightly elevated, and a transabdominal ultrasound shows the fetus is small for dates. The provider advises rest and to follow up as normal. How would the provider code the visit if the patient has an insurance that accepts the global obstetrical package?

A. 99213-25, 76815, 010.012, 036.5920, Z3A. 23
B. 0502F, 76815, 010.012, 036.5920, Z3A 23
C. 99213-25, 76816, 010.012, Z3A. 23
D. 0502F, 76816, 010.012, Z3A. 23

Answer: D

Explanation:
The global obstetrical package includes routine prenatal care visits and blood pressure checks, so a placeholder code (0500F-0503F) is used to report that a visit occurred instead of an E/M code. CPT 76816 is reported when biometric measurements are taken ofthe fetus, whereas CPT 76815 is limited to one element of the fetus, such as the position or heartbeat. Per ICD-IO-CM, codes beginning with 035- and 036- are reported only "when the fetal condition is actually responsible for modifying the management of the mother."

NEW QUESTION # 22
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