Explore Free AAPC Certified Professional Coder Certification CPC Practice Questions for Exam Mastery

View MR 099401

MR 099401

Established Patient Office Visit

Chief Complaint: Patient presents with bilateral thyroid nodules.

History of present illness: A 54-year-old patient is here for evaluation of bilateral thyroid nodules. Thyroid ultrasound was done last week which showed multiple thyroid masses likely due to multinodular goiter. Patient stated that she can ''feel" the nodules on the left side of her thyroid. Patient denies difficulty swallowing and she denies unexplained weight loss or gain. Patient does have a family history of thyroid cancer in her maternal grandmother. She gives no other problems at this time other than a palpable right-sided thyroid mass.

Review of Systems:

Constitutional: Negative for chills, fever, and unexpected weight change.

HENT: Negative for hearing loss, trouble swallowing and voice change.

Gastrointestinal: Negative for abdominal distention, abdominal pain, anal bleeding, blood in stool, constipation, diarrhea, nausea, rectal pain, and vomiting

Endocrine: Negative for cold Intolerance and heat intolerance.

Physical Exam:

Vitals: BP: 140/72, Pulse: 96, Resp: 16, Temp: 97.6 F (36.4 C), Temporal SpO2: 97%

Weight: 89.8 kg (198 lbs ), Height: 165.1 cm (65'')

General Appearance: Alert, cooperative, in no acute distress

Head: Normocephalic, without obvious abnormality, atraumatic

Throat: No oral lesions, no thrush, oral mucosa moist

Neck: No adenopathy, supple, trachea midline, thyromegaly is present, no carotid bruit, no JVD

Lungs: Clear to auscultation, respirations regular, even, and unlabored

Heart: Regular rhythm and normal rate, normal S1 and S2, no murmur, no gallop, no rub, no click

Lymph nodes: No palpable adenopathy

ASSESSMENT/PLAN:

1) Multinodular goiter - the patient will have a percutaneous biopsy performed (minor procedure).

What E/M code is reported for this encounter?

View MR 004397

MR 004397

Operative Report

Preoperative Diagnosis: Calculi of the gallbladder

Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis

Procedure: Cholecystectomy

Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.

Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.

What CPT coding is reported for this case?

A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.

What anesthesia coding is reported?

A 65-year-old man had a right axillary block by the anesthesiologist. When the arm was totally numb, the arm was prepped and draped, and the surgeon performed tendon repairs of the right first, second, and third fingers. The anesthesiologist monitored the patient throughout the case.

What anesthesia code is reported?

A patient with malignant lymphoma is administered the antineoplastic drug Rituximab 800 mg and then 100 mg of Benadryl.

Which HCPCS Level II codes are reported for both drugs administered intravenously?