Miranda is in her provider's office for follow up of her diabetes. Her blood sugars remain at goal with continuing her prescribed medications. When referring to the MDM Table in the CPT code book for number and complexity of problems addressed at the encounter, what type of problem is this considered?
Correct Answer: C
1. Problem Type Selection: Miranda is following up on her diabetes, which is a chronic condition. Her blood sugars are controlled, indicating that the condition is stable with her current medication regimen. Stable, chronic illness is defined in the CPT MDM (Medical Decision Making) Table as a chronic condition that is under control and not currently worsening, even if ongoing management is required. This aligns with the patient's diabetes being well-managed with her prescribed medications. 2. Rationale for Excluding Other Options: A . Acute, uncomplicated illness or injury is not applicable as diabetes is a chronic condition, not an acute issue. B . Minimal problem refers to conditions that are minor or self-limited and typically require little to no treatment, which does not apply to chronic conditions like diabetes. D . Stable, acute illness would refer to an acute condition that has stabilized, whereas diabetes is a chronic condition, not acute. 3. AAPC and CPT Coding Guidelines: According to the CPT MDM Table, a "Stable, chronic illness" is the correct classification for a follow-up encounter on a controlled chronic condition like diabetes. Therefore, the correct answer is C. Stable, chronic illness.
Question 77
A 56-year-old female patient with a history of degenerative disc disease at levels T2-T3 and T4-T5 underwent a surgical repair procedure. Two surgeons will be working together as primary surgeons Surgeon X: Carried out the anterior exposure of the spine and mobilized the great vessels, assisted Dr. Z. and performed the closure. Surgeon Z: Performed a minimal anterior discectomy and fusion at T2-T3 and T4-T5 levels using an anterior interbody technique and solely performed utilizing a structural allograft. What is the CPT coding for the two surgeons?
Correct Answer: D
The case describes two primary surgeons working together, which supports modifier 62 (co-surgeons) on the spine fusion/discectomy codes. 22556 = primary level anterior thoracic discectomy and fusion (T2-T3) 22585 = each additional thoracic level (T4-T5) 20931 = structural allograft (reported by the surgeon who solely performed/placed the structural allograft, per the statement-Surgeon Z) Why D fits best: Surgeon X performed the approach/exposure and closure and assisted the primary surgeon → reports the co-surgeon spine procedure codes (22556-62, 22585-62). Surgeon Z performed the discectomy/fusion and solely performed utilizing a structural allograft → reports 22556-62, 22585-62, plus 20931. Options with -51 are not correct here (and add-on/related reporting logic in CPT does not support the way -51 is applied in those options).
Question 78
A patient is going to have placement of a myringotomy tube. This tube is placed in the ______ to drain excess fluid.
Correct Answer: A
A myringotomy is a surgical incision into the tympanic membrane (eardrum). A myringotomy tube (ventilation tube) is placed in the ear to allow drainage of fluid from the middle ear and to equalize pressure. Therefore, the correct answer is A. Ear.
Question 79
A therapeutic colonoscopy is performed, where the scope goes beyond the splenic flexure, but not to the cecum. Using the Colonoscopy Decision Tree illustrated in the CPTcode book, what coding is reported?
Correct Answer: A
When a therapeutic colonoscopy is attempted but does not reach the cecum, it is considered an incomplete procedure. According to the CPTColonoscopy Decision Tree, if the colonoscopy extends beyond the splenic flexure but does not reach the cecum, the appropriate way to code this incomplete colonoscopy is by appending modifier 53 to indicate a discontinued procedure due to extenuating circumstances or risk to the patient. A: 45378-53 is the correct answer as it designates a diagnostic colonoscopy with modifier 53, signifying that the procedure was started but not completed. B: 45330 is incorrect as it represents a sigmoidoscopy, which only goes up to the splenic flexure. C: 45331-45347 refers to therapeutic colonoscopies that were completed to the cecum. D: 45379-45398 with modifier 52 is incorrect because modifier 52 is used for reduced services, which does not accurately describe an incomplete colonoscopy. Thus, the correct answer is A. 45378-53.
Question 80
(A 32-year-old is in the outpatient clinic for anesophagoscopydue to increased difficulty swallowing with hiseosinophilic esophagitis. The flexible scope is inserted into the esophagus. Examination notes narrowing in the distal esophagus. Following an injection of Kenalog, atransendoscopic balloon dilationis performed in the area of stenosis, eventually reaching 18 mm. What CPT coding is reported for this procedure?)
Correct Answer: C
This encounter includes two reportable endoscopic services:esophagoscopy with dilationand asubmucosal injectionperformed via the endoscope. Balloon dilation of an esophageal stricture/stenosis performed transendoscopically is captured by43220(esophagoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus). The scenario also documents aninjection of Kenalogdelivered endoscopically to the stenotic area; endoscopic injection is reported with43201(esophagoscopy with directed submucosal injection [s]). These services are not mutually exclusive when both are performed and documented, and no separate diagnostic-only esophagoscopy code is reported because the therapeutic codes include the scope. Option D is incorrect because43200is the base diagnostic esophagoscopy and should not be reported in addition to the therapeutic dilation; modifier -59 does not fix that bundling. Options A and B include codes that do not match the described esophagoscopy balloon dilation plus injection combination. Therefore,43220 and 43201is correct.
