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The Complete Diagnosis Coding Solution 3rd Solution By Shelley Safian – Test Bank

Chapter 08

Surgery Coding, Part 2

Multiple Choice Questions

Johnny had a fracture of his elbow, and a cast was placed by the physician. What is the appropriate code for the application of a short arm cast?
A. 29125
B. 29085
C. 29075
D. 29065

Report code 29075 if the cast is constructed from the elbow to finger. Application of cast and strapping is found in the code range of 29000–29799.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.01
Topic: Musculoskeletal System

Jason was taken to the surgical suite after arriving in the ER with a stab wound to his abdomen. The planned procedure was an exploration of the penetrating wound to the abdomen. What is the appropriate CPT code for this procedure?
A. 20100
B. 20101
C. 20102
D. 20103

Report code 20102 for exploration of an abdomen, flank, or back wound.

A surgical procedure that is performed to remove, or cut out, a portion of a bone is called a(n) _________.
A. arthrodesis
B. arthroplasty
C. discectomy
D. osteotomy

An osteotomy is a surgical procedure performed to remove, or cut out, a portion of a bone.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Estimated Time: 0-1 minute
Learning Outcome: 08.01
Topic: Musculoskeletal System

A surgical procedure that is performed for the surgical immobilization of a joint is called a(n) _______.
A. arthrodesis
B. arthroplasty
C. discectomy
D. osteotomy

Arthrodesis is the surgical fixation of a joint by a procedure designed to accomplish fusion of the joint surfaces by promoting the proliferation of bone cells.

In the treatment of fractures, what device(s) is/are used in an internal fixation?
A. Brace
B. Cast
C. Plates
D. Halo

Internal fixation is the process of placing plates and screws, pins, or other devices directly onto or around the bone, inside of the patient.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.01
Topic: Musculoskeletal System

In the treatment of fractures, what device(s) is/are used in an external fixation?
A. Plates
B. Screws
C. Pins
D. Halo

When external fixation is used, a device such as a brace, cast, or halo prevents motion in a certain area of the body.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.01
Topic: Musculoskeletal System

Dr. James performed a closed treatment of a tibia fracture with manipulation and skeletal traction on Mr. Smith, whose motorcycle ran into a tree. What is the appropriate CPT code for this procedure?
A. 27535
B. 27530
C. 27532
D. 27536

The appropriate CPT code is 27532, closed treatment of tibia fracture, proximal (plateau); with or without manipulation, with skeletal traction.

Three-year-old Susie put a marble in her nose. It was too deep in the nasal cavity and had to be removed under general anesthesia. What is the appropriate CPT code for this procedure?
A. 30400
B. 30310
C. 30300
D. 30320

The appropriate CPT code is 30310, Removal of foreign body, intranasal requiring general anesthesia.

Christopher was brought back to the surgical suite for a secondary rhinoplasty, bony work with osteotomies. What is the appropriate CPT code for this procedure?
A. 30435
B. 30430
C. 30460
D. 30462

The appropriate code is 30435, Rhinoplasty, secondary, intermediate revision (bony work with osteotomies).

A lung harvest from a cadaver donor is coded with which CPT code?
A. 32855
B. 32856
C. 32851
D. 32850

Cadaver donor pneumonectomy includes harvesting the allograft and cold preservation of the allograft (perfusing with cold preservation solution and cold maintenance). Use code 32850.

Mrs. Short was scheduled for a lung transplant, single with cardiopulmonary bypass. What is the appropriate CPT code for this surgery?
A. 32851
B. 32852
C. 32853
D. 32854

Recipient lung allotransplantation includes transplantation of a single or double lung allograft and the care of the recipient (codes 32851–32854). During the transplantation of the lung, the patient is placed on a cardiopulmonary bypass machine to maintain circulation to the organs.

Mr. Jackson was brought to the OR for repositioning of a previously implanted transvenous pacemaker. What is the appropriate CPT code for this procedure?
A. 33217
B. 33215
C. 33216
D. 33211

Use code 33215, Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode.

Jerry Rickard had a coronary artery bypass using the saphenous vein graft and three coronary venous grafts. What is the appropriate CPT code for this procedure?
A. 33513
B. 33512
C. 33514
D. 33516

When a venous graft is performed, codes 33510–33516 are used and include the saphenous vein graft.

Combined arterial-venous grafts are in which range of codes?
A. 33517–33523, 33533–33536
B. 33533–33545
C. 35682–35683
D. 33533–33536

To report combined arterial-venous grafts, it is necessary to report two codes: (1) the appropriate combined arterial-venous graft code (33517–33523) and (2) the appropriate arterial graft code (33533–33536).

A coronary artery bypass using arterial grafts and a single artery graft was performed. A femoropopliteal vein was harvested. What is/are the appropriate CPT code(s)?
A. 33533, 35600
B. 33533, 35500
C. 33533, 35572
D. 33533

Use code 33533 for coronary artery bypass, using arterial graft(s), single arterial graft; in addition to 35572 for harvesting of a femoropopliteal vein segment.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 3 Hard
Estimated Time: 1-2 minutes
Learning Outcome: 08.03
Topic: Cardiovascular System

A heart and lung transplant was performed on a patient. Organs were received from a cadaver donor. What is the appropriate CPT code for the harvesting of both organs from the cadaver?
A. 33930
B. 33940
C. 32850
D. 32855

Use code 33930, Donor cardiectomy-pneumonectomy (including cold preservation).

How many codes are used when performing a transplant procedure?
A. 1 code
B. 2 codes
C. 3 codes
D. 4 codes

Transplants with or without allotransplantation involve three distinct components of a physician’s work and all three have a separate code (cadaver donor harvesting, backbench work, and recipient transplant).

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Remember
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 1 Easy
Estimated Time: 0-1 minute
Learning Outcome: 08.03
Topic: Cardiovascular System

In an endovascular repair of an infrarenal abdominal aortic aneurysm, an aorto-aortic tube prosthesis was used along with endovascular placement of an iliac artery occlusion device. What are the appropriate CPT codes for this procedure?
A. 34800, 34808
B. 34800, 34806
C. 34802, 34808
D. 34804, 34813

Use code 34800, Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis, and add-on code 34808, Endovascular placement of iliac artery occlusion device (list separately in addition to code for primary procedure).

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 3 Hard
Estimated Time: 0-1 minute
Learning Outcome: 08.03
Topic: Cardiovascular System

A Roux-en-Y gastric bypass (RYGB) with short limb (150 cm) was performed on Mr. Clark. What is the appropriate CPT code for this procedure?
A. 43770
B. 43846
C. 43847
D. 43644

Use code 43846, Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 1-2 minutes
Learning Outcome: 08.04
Topic: Digestive System

Cynthia, a morbidly obese patient, is scheduled for a vertical sleeve gastrectomy today. What is the appropriate CPT code for this procedure?
A. 43770
B. 43775
C. 43644
D. 43846

Use code 43775, Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy).

Dr. Greg’s patient complained of urinary stress and urge incontinence. Dr. Greg performed a complex cystometrogram (CMG) with voiding pressure studies. What is the appropriate CPT code(s) for this procedure?
A. 51725
B. 57126
C. 51727
D. 51728

Urodynamic procedures are coded from range 51725–51798. A complex CMG with voiding pressure studies; any technique is reported using code 51728.

Patrick was seen by his urologist for condyloma of the penis. A simple destruction of the lesion was performed by cryosurgery. What is the appropriate CPT code for this procedure?
A. 54050
B. 54055
C. 54056
D. 54057

Use code 54056, Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery.

Mr. Sanders complained of an abscess on his epididymis, and the physician performed an incision and drainage of his abscess. What is the appropriate CPT code for this procedure?
A. 11004
B. 54700
C. 54800
D. 54830

Use code 54700, Incision and drainage of epididymis, testis, and/or scrotal space (e.g., abscess or hematoma).

Dr. Chou performed a complete radical vulvectomy with bilateral inguinofemoral lymphadenectomy. What is the appropriate CPT code for this procedure?
A. 56630
B. 56632
C. 56633
D. 56637

Vulvectomy codes range from 56620–56640 and are defined as simple, radical, partial, or complete. Code 56637 is used to report radical complete vulvectomy with bilateral inguinofemoral lymphadenectomy.

Dr. Grey performed a combined anterioposterior colporrhaphy with enterocele repair on Mrs. Smith. What is the appropriate CPT code for this procedure?
A. 57260
B. 57250
C. 57265
D. 57240

Use code 57265, Combined anterioposterior colporrhaphy; with enterocele repair.

Codes from the surgery section of CPT are used in the offices of:
A. general surgeons.
B. neurologists.
C. dermatologists.
D. All of these

Codes from the surgery section of the CPT are used by physicians and general surgeons in ambulatory surgical centers and outpatient departments.

Codes in the surgery section of CPT report:
A. excisions.
B. debridements.
C. repair of wounds.
D. All of these

Codes in the surgery section of CPT report codes for incision and drainage of a cyst, debridement, and simple repair of a superficial wound.

Procedures on the heart as well as the entire network of veins, arteries, and capillaries are coded from which section of the CPT book?
A. Respiratory System
B. Musculoskeletal System
C. Cardiovascular System
D. Digestive System

Treatments and procedures on the heart as well as the entire network of veins, arteries, and capillaries are coded from the cardiovascular subsection.

A 45-year-old male had an emergency exploration of a penetrating stab wound to the chest. What is the appropriate code to use for this procedure?
A. 20103
B. 20100
C. 20101
D. 20102

Codes 20100–20103 relate to wound(s) resulting from penetrating trauma. Code 20101 is for exploration of penetrating wound; chest.

The sections of the spine include all except:
A. cervical.
B. thoracic.
C. lumbar.
D. abdominal.

The sections of the spine include cervical, thoracic, lumbar, sacrum, and coccyx.

When a laminectomy and arthrodesis are both performed during the same session, the coder must code:
A. only the laminectomy.
B. only the arthrodesis.
C. both the laminectomy and the arthrodesis.
D. both the laminectomy and the arthrodesis with modifier 51 appended to the arthrodesis.

When an arthrodesis is done at the same time as another procedure, modifier 51 (multiple procedures) should be appended to the code for the arthrodesis.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.01
Topic: Musculoskeletal System

The notation L1 refers to:
A. lumbar vertebra number 1.
B. laminectomy performed first.
C. longitude one.
D. length of injury 1 cm.

L1 notates lumbar vertebra number 1.

Most transplantation surgeries require three steps, including:
A. diagnostic tests of the donor.
B. backbench work.
C. postoperative therapy.
D. preoperative blood tests.

Backbench work is the actual preparation of the cadaver organ prior to the transplant procedure.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.02
Topic: Respiratory System

A single-chamber pacemaker system includes a pulse generator and one electrode inserted into the:
A. atrium.
B. capillary.
C. muscle.
D. bone.

An electrode can be inserted into an atrium (single), ventricle (single), or both (dual). There is also a pacemaker that has three leads called a biventricular pacemaker, which has a lead in the atrium, right ventricle, and left ventricle. This is used in treatment of congestive heart failure.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.03
Topic: Cardiovascular System

The replacement of a pacemaker battery is actually:
A. removal of the old pulse generator and insertion of a new generator.
B. removal of the old lead and insertion of a new lead.
C. removal of a graft and the insertion of a new graft.
D. removal of the defibrillator and insertion of a new defibrillator.

Commonly referred to as replacing the battery in the pacemaker or cardioverter-defibrillator, this procedure involves the removal of the old pulse generator and the insertion of a new pulse generator. There are two codes to report, one for the removal and another code for the insertion of the new generator.

A venous graft using a harvested upper extremity vein will require ___ code(s).
A. 1
B. 2
C. 3
D. 4

To report harvesting of an upper extremity vein, use 35500 in addition to the bypass procedure.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Remember
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.03
Topic: Cardiovascular System

Reporting an arterial graft from a radial artery will require ____ code(s).
A. 1
B. 2
C. 3
D. 4

Arterial graft codes range from 33533–33545. All of these codes include the use of grafts from the internal mammary artery, gastroepiploic artery, radial artery, and arterial conduits harvested from other sites.

Aortic vascular procedure codes include the:
A. graft harvesting.
B. preoperative EKG.
C. sympathectomy.
D. postoperative therapy.

Vascular procedures codes 34001–37799 include ensuring the inflow and outflow of the arteries, operative arteriogram, and sympathectomy.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 3 Hard
Estimated Time: 0-1 minute
Learning Outcome: 08.03
Topic: Cardiovascular System

An abdominal aortic aneurysm repair code includes:
A. intravascular ultrasound.
B. placement of an endovascular graft.
C. balloon angioplasty.
D. introduction of a catheter.

Endovascular repair codes range from 34800–34900. Aneurysm repair is coded according to the type of aneurysm and the location of the aneurysm. Aneurysms are also coded according to approach, which may be endovascular (from inside vessel) or direct (from outside vessel).

An endovascular repair of an iliac aneurysm includes:
A. balloon angioplasty.
B. arterial embolization.
C. intravascular ultrasound.
D. fluoroscopic guidance.

Coronary angioplasty is accomplished using a balloon-tipped catheter inserted through an artery in the groin or arm to enlarge a narrowing in a coronary artery.

Endoscopies are coded from the CPT section for:
A. radiology.
B. surgery.
C. anesthesiology.
D. pathology.

Endoscopy is used for looking inside and typically refers to looking inside the body for medical reasons using an endoscope, an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ.

A heart transplant will be reported with a minimum of ______ code(s).
A. 1
B. 2
C. 3
D. 4

A heart transplant requires three steps to be performed by a single physician or a team of physicians. Each step has its own code (harvesting, backbench work, transplantation).

The code for a simple uroflowmetry includes:
A. performance of the procedure.
B. medications.
C. catheters.
D. All of these

Urodynamic procedures are coded from range 51725–51798. All procedures in this section imply that these services are performed by, or are under the direct supervision of, a physician or other qualified health care professional and that all instruments, equipment, fluids, gases, probes, catheters, technician’s fees, medications, gloves, trays, tubing, and other sterile supplies be provided by that individual.

The removal of a self-retaining, indwelling ureteral stent should be reported with:
A. a separate code.
B. a separate code with modifier 58.
C. no code. It is included in the placement code.
D. two codes.

Modifier 58 is used for a staged or related procedure of service by the same physician or other qualified health care professional during the postoperative period.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.05
Topic: Urinary System

The surgical treatment of skull-based lesions will typically require _______ code(s).
A. 1
B. 2
C. 3
D. 4

Three codes would include the approach, the definitive, and the repair/reconstruction.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Understand
CAAHEP: III.C.2. Describe the infection cycle
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 2 Medium
Estimated Time: 0-1 minute
Learning Outcome: 08.08
Topic: Nervous System

A meatotomy is performed on Terry, who is 1 month old and weighs 3.75 kg. This is reported with code:
A. 53020.
B. 53025.
C. 53025-63.
D. 53000.

Use code 53025, Meatotomy, cutting of meatus (separate procedure); infant.

A complete thyroidectomy is reported with code:
A. 60240.
B. 60271.
C. 60254.
D. 60260.

Use code 60240, Thyroidectomy, total or complete.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 3 Hard
Estimated Time: 0-1 minute
Learning Outcome: 08.08
Topic: Nervous System

The injection of an anesthetic agent into the vagus nerve is reported with code(s):
A. 64400.
B. 64402.
C. 64408.
D. 64400, 64408.

Use code 64408, Injection, anesthetic agent; vagus nerve.

The dilation of a bilateral punctum with irrigation is reported with code(s):
A. 68801-50.
B. 68801.
C. 68801, 31000.
D. 68801, 31000-51.

Use code 68801, Dilation of lacrimal punctum, with or without irrigation, and modifier 50 appended for the bilateral procedure.

ABHES: 8.c.3. Perform diagnostic and procedural coding
Blooms: Apply
CAAHEP: III.P.1. Participate in bloodborne pathogen training
CAHIIM: I.A.1. Apply diagnosis/procedure codes according to current guidelines
Difficulty: 3 Hard
Estimated Time: 0-1 minute
Learning Outcome: 08.09
Topic: Eye and Ocular Adnexa

A diagnostic laparoscopy (peritoneoscopy) is reported with code:
A. 49320.
B. 47560.
C. 49321.
D. 49000.

Use code 49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).

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