Cumulative Test – Chapters 11, 12, 13, 14 and 15

A needle biopsy is a way of obtaining a piece of tissue out of the body, using a tiny incision, so the tissue can be examined under a microscope by a pathologist. Because this biopsy is performed through the skin, it is called a percutaneous biopsy.

An orthopedic surgeon cannot report the service of ultrasonic guidance because this is a radiologic procedure, and only a radiologist can report services represented in the Radiology section.

The codes for wound exploration can be reported for exploration of any type of wound.

Codes for arthrodesis include the bone graft and instrumentation, and these cannot be coded separately.

According to information in 99468, what is the age of a neonate?
28 days or younger

Critical care codes are reported based on:

Bruising would be an element of review of this organ system.

Arthrocentesis is:
all of the above

An excision of the left great toe nail and matrix, complete for permanent removal:

Excision defined as full thickness would be through the:

Fracture codes are based on:
treatment type

Incision and drainage codes are divided into subcategories according to the:
condition for which the procedure is performed

Mohs micrographic surgery requires a single physician to act in two integrated but separate and distinct capabilities of a surgeon and a(n):

A physician performs an operative procedure that has a 90-day surgical package. On day 40, the same physician performs an unrelated procedure on the same patient. What modifier would you attach to the CPT code when reporting the second procedure?

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?

Single-layered closure of heavily contaminated wounds that require extensive cleaning or removal of particulate matter constitutes what type of repair?

These elements would be part of the ____ history: employment, education, use of drugs.

The level of E/M service is based on:
all of the above

key components
contributing factors

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?

The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?

The HPI must be documented in the medical record by:
the physician

The Hospital Inpatient Services subsection is used for patients admitted to:
an acute care facility

Location: Hospital

The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.

IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow. From my standpoint, she can mobilize and weight bear as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status II.

CPT Code: ____________________


LOCATION: Inpatient, Hospital

PATIENT: Gloria Baxter


This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.

The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient’s intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.

The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep it over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better.

This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.)

CPT Code: ____________________


Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the intensive care unit with acute respiratory distress syndrome.

CPT Codes: _____________, _______________


Location: Emergency Room

SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the “eye doctor earlier today” and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.

OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.
ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.

PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.

CPT Code: ____________________


Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.

CPT Code: ____________________


A new patient presents to the physician’s office at which time the physician provides a comprehensive history and exam with a high complexity MDM.

CPT Code: ____________________


An established patient has a simple removal of sutures performed by the nurse. The physician did NOT perform the initial repair.

CPT Code: ____________________


A 40-year-old established patient presents to the physician office for a preventive care exam.

CPT Code: ____________________


History and exam of the normal newborn infant born in a hospital setting.

CPT Code: ___________________


An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past ____________________ years.
3 three

A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is 99° F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, lungs, and heart. Vital signs were taken in the office. The physician diagnosed the patient with otitis media and an upper respiratory infection and prescribed an antibiotic. The MDM is stated to be moderate.

CPT Code: ____________________


Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow.

Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problem-focused examination, he is alert and oriented.
Eyes: PERL, EOMI conjugate without nystagmus. Funduscopic exam reveals the discs to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: nontender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is nontender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture.
Assessment: Contusion, left elbow and left knee (the MDM was of low complexity).
Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis.

CPT Code: ____________________


History and exam of the normal newborn infant born in a hospital setting.
CPT Code: ___________________

Location: Emergency Room

SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling. This patient had right neck lymph node biopsy done 3 days ago. Patient has a dressing in place ever since then. For the past 24 hours, she feels like she has increased swelling and she presents now because of it. She denies any accompanying fever, chills, or sweats.

PAST MEDICAL HISTORY: No known drug allergies. Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy. Medically, she has a history of depression.

REVIEW OF SYSTEMS: Respiratory: She denies dyspnea.
OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress. Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%. HEENT: Conjunctivae and lids normal. Mouth well hydrated. Pharynx normal. Neck is supple. I have removed the dressing. There is a Pen Rose drain in place. The wound seems to be healing well. There is some soft tissue swelling which extends about 3 cm from the wound itself. There is no erythema and no warmth to the area.

ASSESSMENT: Postoperative swelling.

PLAN: I have discussed the case with the ENT surgeon. We have redressed the area. Patient is reassured and will be following up with her doctor tomorrow for drain removal.

CPT Code: ____________________


Open treatment of a hip fracture of proximal neck with prosthetic femoral hip replacement.

Location: Hospital



PROCEDURE PERFORMED: Excision of pilonidal cyst, simple.

ANESTHESIA: General endotracheal anesthesia with 30 cc of local infiltrated directly into the wound.

PROCEDURE IN DETAIL: After good general endotracheal anesthesia, the patient was carefully placed in the prone position. Care was taken to pad dependent areas. The area around the pilonidal cyst was shaved, prepped, and draped sterilely. After this, a total of 30 cc of Marcaine was injected into the area around the pilonidal sinus and a small elliptical incision was made to include the two sinuses. Wide dissection was carried down to the coccyx to include all inflamed tissue. After this, the wound was irrigated. Hemostasis was obtained with electrocautery. The wound was packed with Vaseline gauze and dressed. The patient tolerated the procedure well and was returned to the recovery room in good condition.

CPT Code: ____________________


Location: Inpatient Hospital


PREOPERATIVE DIAGNOSIS: Left knee medial meniscus tear.
POSTOPERATIVE DIAGNOSIS: Left knee medial meniscus tear.

PROCEDURE PERFORMED: Left knee arthroscopic partial medial meniscectomy.


ESTIMATED BLOOD LOSS: Minimal, no drains.

This 41-year-old female suffering with left knee pain was taken to surgery. After appropriate level of anesthesia achieved, the left knee was prepped and draped in orthopedic manner. We made two portals in the knee, one medial and the other lateral to the patellar tendon. Sharp dissection was carried through skin; blunt dissection was carried into the joint space. On examination of the knee, there was a sort of a bucket-handle type tear of the posterior horn of the medial meniscus, in the avascular area, but it was very complex. We went ahead and debrided this back to stable tissue, again in the avascular area. Remainder of the meniscus was probed and felt to be intact. The anterior cruciate ligament was probed, felt to be intact, lateral meniscus probed and felt to be intact. No loose bodies were appreciated in the suprapatellar pouch, medial or lateral gutters. The articular surface was generally in good condition except for the patellofemoral joint. The patella had some areas of Grade 3 chondromalacia especially centrally. We went ahead and irrigated the wound copiously. We injected 20 cc of 0.25% Marcaine through the joint space and portal sites. We dressed the wound with interrupted nylon sutures. The patient tolerated the procedure well and left the operating room in good condition.

CPT Code: ____________________


Steven was able to make an appointment with the orthopedist within a few hours of being seen in the ED for a splint to his left wrist after a fall. The orthopedist reviewed the x-rays from the emergency room and agreed with emergency room physician that the distal radius was fractured. A short-arm fiberglass cast was applied, and the fracture was expected to heal in 6-8 weeks. Report the closed treatment of this fracture.

CPT Code: ____________________


Sally presents to the physician’s office with pain in the toes of her left foot. The physician took x-rays of her foot and toes and it was determined that she had fractures in her second, third, and fourth digit on her left foot. Strapping was applied (closed treatment). (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.).

CPT Codes: ____________________________________

28510 X 3 28510, 28510-51 x2 28510-T1, 28510-T2, 28510-T3

Modifier ____________________ is used to indicate that a separately identifiable E/M service was performed by the same individual on the same day as the preventive medicine service.


PREOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7. POSTOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.
PROCEDURE PERFORMED: Placement of halo.


PROCEDURE: Under general anesthesia, the patient’s head was prepped. The halo was applied. The pins were secured. The vest was secured. The patient was monitored with sensory-evoked potentials. There were no changes throughout the case. Films were done postop which showed the alignment was acceptable at C6-7.

CPT Code: ____________________


The term used to describe a patient who has NOT been formally admitted to a health care facility is ____________________.

This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.

P/E: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Andrews for further treatment.

CPT Code: ____________________


This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity.
This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM. She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes. There was no speech impairment, no involvement of the face or leg, and no associated headache. These symptoms completely returned to normal. She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities. About 2 days later, she again had a similar spell. She has not had any further episodes since that time.

Patient’s history is significant for hypertension since age 35. She had no previous history of heart disease or diabetes. Two years ago she was seen by Dr. Smith for left putamen hemorrhage. Patient was also found to have right meningioma arising near the petrous region. She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly. She could not recall whether either eye was affected or if this was the right peripheral vision. The last such episode was about 4 months ago.
This past winter she also had about a 2-week period when the right foot seemed to drag. There has been no recent head injury, and there is no prior history of seizures.
Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion. No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion. Calcified plaque was also noted in the left carotid bulb. Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia. There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma. This is basically unchanged from the previous scan.

Past Medical History:

No serious illnesses.


1. Hysterectomy and bladder repair
2. Bilateral blepharoplasty
3. D&C times 4




1. Hytrin, 5 mg, one daily
2. Lozol, 2.5 mg, one daily


Does not smoke




Bachelor’s degree

Review of Systems:

No recent head trauma, blackout spells, or seizures; no recent problems with headaches


As noted






Negative except for hypertension




No diabetes or thyroid problems


Some arthritis, both hands



Family history:

Mother deceased from heart disease; father had multiple strokes; two brothers, one with polio; three children whose health is good

Physical Examination:

Very pleasant elderly female, in no distress at this time


Blood pressure is 140/84; pulse, 90; 150/90
Left arm sitting position




No skin lesions present


No lymphadenopathy


Clear to auscultation


Reveals a regular rhythm; I did not hear any murmurs or gallops


Soft, no masses





Higher cortical function:

Intact; speech is fluent

Cranial nerves II-XII:

Intact; pupils are equal, reactive to light both direct and consequently; confrontation fields are intact; funduscopic exam was normal; ocular sensation is intact; there is no facial paresis or droop


1/1 throughout; plantar responses are downgoing bilaterally


Felt to be normal throughout with particular attention paid to the left upper extremity


Reveals no sensory deficits, again with attention paid to the left upper extremity




Reveals no abnormalities; she is able to walk on heels and toes without difficulty; tandem walk is normal; Romberg is negative


(1) recurrent episodes of left upper-extremity paralysis and numbness; subclavian steal syndrome (Moderate MDM)


This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol.

PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).
Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones.

CPT Code: ____________________


Total hip replacement for the treatment of severe osteoarthritis.

Suture of superficial wounds of cheek: one 1-cm laceration, one 3-cm laceration, and one 2-cm laceration.

CPT Code: ____________________



CC: Dizziness

SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is “sticky.” She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.

OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.

ASSESSMENT: Hypothyroidism (MDM was low).

PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.

CPT Code: ____________________


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