1. A 67-year-old patient presents with chest pain and shortness of breath. The physician performs a diagnostic cardiac catheterization with coronary angiography. What is the correct CPT code for this procedure?

2. During an annual wellness visit, a patient receives pneumococcal vaccination (PCV13) and influenza vaccination. Which diagnosis code should be reported as the primary diagnosis?

3. A dermatologist performs shave excision of a 0.6 cm benign lesion on a patient’s neck. What is the appropriate CPT code?

4. Patient undergoes robotic-assisted total laparoscopic hysterectomy. The surgeon documents total procedure time of 2 hours. What modifier should be appended to the primary procedure code?

5. A Medicare patient presents with Type 2 diabetes with diabetic chronic kidney disease stage 3. What is the correct ICD-10-CM code sequence?

6. A physician performs arthroscopic rotator cuff repair on the right shoulder with biceps tenodesis. What is the correct CPT code combination?

7. During an established patient visit for diabetes management, the physician spends 40 minutes total, with 25 minutes in direct face-to-face care and 15 minutes reviewing labs and updating the care plan. What is the correct E/M code?

8. A patient presents with malignant neoplasm of the lower outer quadrant of the right breast with metastasis to the axillary lymph nodes. What is the correct ICD-10-CM code sequence?

9. A dermatologist performs destruction of 12 actinic keratoses on a patient’s face. What is the correct CPT code?

10. A patient undergoes CT-guided needle biopsy of a lung nodule. The radiologist performs the imaging guidance and the pulmonologist performs the biopsy. How should this be coded?

11. A Medicare patient presents with a Stage 2 pressure ulcer of the right heel and Type 2 diabetes with peripheral neuropathy. What is the correct primary diagnosis code?

12. A family physician provides an annual wellness visit for an established Medicare patient. During the visit, the physician identifies and separately addresses moderate hypertension, prescribing a new medication. What is the correct coding for this encounter?

13. A general surgeon performs a diagnostic laparoscopy which is then converted to an open cholecystectomy due to extensive adhesions. What is the correct CPT code(s)?

14. During a single encounter, a dermatologist removes a 1.2 cm diameter malignant melanoma from the patient’s right cheek with narrow margins (less than 1 cm) and performs an excision of a 0.8 cm benign lesion from the back. What are the correct CPT codes?

15. A patient presents with acute bronchitis due to vaping-induced acute lung injury. What is the correct ICD-10-CM code sequence?

16. A cardiologist performs a diagnostic left heart catheterization with coronary angiography and left ventricular angiography. During the same session, a drug-eluting stent is placed in the left anterior descending artery. What is the correct CPT code combination?

17. Medicare patient presents with Type 2 diabetes with diabetic chronic kidney disease stage 4 and diabetic proliferative retinopathy with macular edema. What is the correct ICD-10-CM code sequence?

18. An orthopedic surgeon performs arthroscopic ACL reconstruction using autograft on a patient’s right knee. During the same session, a partial medial meniscectomy is also performed arthroscopically. What are the correct CPT codes?

19. A physician spends 50 minutes on the date of service for a level 4 established patient visit, with 30 minutes face-to-face and 20 minutes reviewing records and coordinating care. The medical decision making is moderate. Which code should be reported?

20. A patient undergoes screening colonoscopy (Medicare patient). During the procedure, the physician removes a 1.5 cm sessile polyp from the ascending colon by snare technique. What are the correct CPT and modifier combinations?

21. A pulmonologist performs bronchoscopy with transbronchial lung biopsies. Fluoroscopic guidance is used for the biopsies, performed by the same physician. What is the correct CPT coding?

22. A 45-year-old patient with well-controlled type 2 diabetes presents to the emergency department with a displaced fracture of the right distal radius after falling at home. The physician performs a detailed history and exam, with moderate complexity medical decision making. After x-rays confirm the diagnosis, closed reduction with casting is performed under conscious sedation.

23. During an established patient visit for hypertension management, a 67-year-old male mentions a suspicious mole on his back. After completing the planned E/M service (detailed history and exam with moderate MDM), the physician evaluates the lesion and performs a shave removal of the 0.7 cm lesion which appears benign.

24. A cardiologist performs a diagnostic left heart catheterization with coronary angiography and left ventricular angiography. A 70% stenosis of the left anterior descending artery is identified and a drug-eluting stent is placed during the same session.

25. A dermatologist performs Mohs micrographic surgery for a basal cell carcinoma on the right cheek. The first stage requires 5 tissue blocks, and cancer cells are found in one margin. A second stage requiring 3 tissue blocks is performed with all margins clear. The final defect measures 2.2 x 2.5 cm and is closed with a complex layered closure.

26. A 35-year-old female undergoes diagnostic laparoscopy for pelvic pain. During the procedure, endometriosis is identified and ablated. The surgeon also removes multiple peritoneal adhesions using sharp dissection.

27. An orthopedic surgeon performs arthroscopic ACL reconstruction using autograft on a patient’s right knee. During the same session, a partial medial meniscectomy is also performed arthroscopically.

28. A general surgeon performs an open cholecystectomy with intraoperative cholangiography. During the procedure, exploration of the common bile duct is required and stones are removed via choledochotomy.

29. A pulmonologist performs bronchoscopy with transbronchial lung biopsies. Fluoroscopic guidance is used for the biopsies, performed by the same physician.

30. A 72-year-old Medicare patient presents to the ER with chest pain. The ED physician performs a detailed history and exam with moderate complexity decision making. A cardiac CT with contrast is ordered and EKG performed. The patient is discharged home after ruling out acute coronary syndrome.

31. A patient presents with a severe nosebleed. The physician performs anterior nasal packing and cauterizes a bleeding vessel using silver nitrate.

32. A Medicare patient receives their initial pneumococcal vaccine (PCV13) along with a seasonal flu shot during a nurse visit. No physician was present.

33. An 81-year-old female presents to the ED after falling at home. X-rays show a pertrochanteric femur fracture. The physician documents a detailed history and exam with moderate complexity MDM and admits the patient for surgical repair. Total ED time was 45 minutes.

34. A gastroenterologist performs screening colonoscopy on a 65-year-old Medicare patient. During the procedure, a 1.2 cm sessile polyp is found and removed by snare technique.

35. During a routine obstetric visit at 28 weeks gestation, the physician performs a biophysical profile with non-stress test on a patient with gestational diabetes.

36. A dermatologist destroys a 0.7 cm actinic keratosis on the patient’s right forearm and a 0.3 cm seborrheic keratosis on the left cheek using cryotherapy.

37. A patient with acute blood loss anemia requires transfusion of 3 units of packed red blood cells over 4 hours. The physician supervises and monitors the transfusion.

38. A surgeon performs repair of a 3.5 cm full-thickness laceration of the left cheek. The wound is heavily contaminated and requires extensive cleaning before layered closure.

39. A cardiologist performs a non-imaging exercise tolerance test with continuous ECG monitoring and interpretation. The test is terminated early due to chest pain.

40. An audiologist performs comprehensive audiometry including air/bone conduction, speech reception threshold, word recognition testing and tympanometry.

41. A 67-year-old patient with COPD undergoes anesthesia for a total knee arthroplasty. The anesthesiologist spends 15 minutes in pre-operative evaluation, 2 hours providing anesthesia, and 20 minutes in post-operative care.

42. The pathologist performs microscopic examination of prostate needle biopsy specimens from 12 separate sites. The report shows adenocarcinoma in 3 cores.

43. A patient presents with sudden onset atrial fibrillation. The physician reviews a 12-lead ECG, performs cardioversion, and provides critical care services for 65 minutes.

44. During an annual Medicare wellness visit, the physician identifies dementia and spends 20 additional minutes counseling the patient and caregiver about safety and resources.

45. A urologist performs cystoscopy with bilateral retrograde pyelogram. A ureteral stone is identified and removed using basket extraction.

46. An ophthalmologist performs a comprehensive eye exam on an established patient with diabetic retinopathy. Extended ophthalmoscopy with drawing is done for both eyes.

47. A patient with chronic systolic heart failure receives an initial 30-minute outpatient therapeutic exercise session from a physical therapist.

48. A general surgeon performs open repair of a recurrent incisional hernia with mesh placement. The defect measures 12 cm.

49. A neurosurgeon performs laminectomy and excision of herniated disc at L4-L5 and L5-S1 using a posterior approach.

50. A patient with end-stage renal disease receives hemodialysis three times per week in an outpatient facility. The physician rounds on the patient 4 times during the month.

51. A Medicare patient presents to radiology for screening mammogram. The radiologist identifies a suspicious mass and immediately performs a diagnostic mammogram with spot compression views of the right breast.

52. A pediatrician provides a well-child check for a 4-year-old established patient. All required components including developmental screening and immunizations are performed.

53. A hospitalist admits a patient with diabetic ketoacidosis, provides initial hospital care (comprehensive history/exam, high complexity MDM) and spends 75 minutes at bedside managing critical insulin drip.

54. A dermatopathologist reviews multiple skin biopsy specimens: one shave biopsy shows basal cell carcinoma, two punch biopsies reveal melanoma in situ.

55. A pulmonologist performs bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of four lymph node stations.

56. A physical therapist evaluates a patient with shoulder pain, performing tests/measures and developing plan of care. Total time spent is 45 minutes.

57. A surgeon performs open reduction internal fixation (ORIF) of both the radius and ulna fractures through a single incision approach.

58. An established patient presents for routine diabetic retinopathy screening. Extended ophthalmoscopy is performed on both eyes with interpretation and report.

59. A speech therapist provides 45 minutes of dysphagia therapy to a stroke patient in an outpatient setting.

60. A patient presents to wound care for debridement of a stage 3 pressure ulcer of the sacrum measuring 16 sq cm with muscle involvement.

61. A patient with recurring nosebleeds undergoes endoscopic ligation of the sphenopalatine artery. The surgeon makes an incision in the lateral nasal wall, identifies the vessel using endoscopic guidance, and ligates it using clips.

62. A patient with uncontrolled type 2 diabetes is discharged from the hospital. A home health nurse performs initial assessment and initiates care plan including blood sugar monitoring and insulin administration teaching.

63. A 4-month-old presents for well-child check. The pediatrician performs all age-appropriate screenings and administers scheduled vaccines (DTaP, IPV, Hib, PCV13, and Rotavirus).

64. An interventional radiologist performs ultrasound-guided biopsy of a thyroid nodule using fine needle aspiration technique. Three passes are made with cytology done on site.

65. A neurosurgeon performs posterior lumbar interbody fusion at L4-5 using locally harvested bone graft. Pedicle screws and rods are placed for stabilization.

66. A patient has a CT-guided core needle biopsy of a 2.5 cm lung nodule performed. The radiologist provides imaging guidance and the pulmonologist performs the biopsy.

67. An occupational therapist provides therapeutic activities and ADL training to a stroke patient. Total treatment time is 53 minutes.

68. A podiatrist performs nail avulsion of the right great toe followed by matrixectomy using phenol technique.

69. A general surgeon performs open right hemicolectomy with primary anastomosis for colon cancer. Extensive lysis of adhesions is required taking over an hour.

70. A patient with a grade 2 MCL sprain receives physical therapy. Treatment includes therapeutic exercise, manual therapy, and ultrasound. Total time is 60 minutes.

71. A Medicare patient presents with a suspicious skin lesion. The physician performs shave biopsy which confirms melanoma. The patient returns for excision with 2 cm margins. The lesion measures 1.2 cm and is located on the back.

72. A patient presents for nuclear medicine thyroid scan with uptake studies at 4 and 24 hours for evaluation of hyperthyroidism.

73. During a routine prenatal visit at 32 weeks, the physician performs a detailed fetal anatomic ultrasound due to suspected growth restriction.

74. A patient undergoes outpatient drug screening. The lab performs presumptive testing followed by definitive testing for opiates and benzodiazepines after positive screen.

75. A cardiologist performs cardiac catheterization with coronary angiography, left ventriculography, and right heart pressures.

76. A patient with malignant pleural effusion undergoes thoracentesis with ultrasound guidance for removal of 1500 cc fluid.

77. An allergist performs skin endpoint titration testing using 80 percutaneous tests and 15 intradermal tests.

78. A patient undergoes exchange of a tunneled central venous catheter over a guidewire due to infection.

79. A patient with newly diagnosed Type 2 diabetes receives one-on-one education from a registered nurse diabetes educator. Session lasts 45 minutes.

80. A pathologist reviews a bone marrow biopsy and aspirate with flow cytometry and cell markers for suspected leukemia.

81. A surgeon performs laparoscopic bilateral inguinal hernia repair with mesh. Each defect requires a separate mesh placement.

82. A 65-year-old presents with 10-minute TIA symptoms. The ED physician documents expanded problem focused history/exam with moderate complexity MDM. CT head and carotid ultrasound are ordered.

83. An audiologist performs comprehensive audiometry with air/bone conduction, speech reception thresholds, word recognition testing, and tympanometry with acoustic reflexes.

84. A dermatologist performs excision of a 0.8 cm basal cell carcinoma from the right cheek with complex repair.

85. A patient with cirrhosis undergoes diagnostic paracentesis with removal of 4 liters of ascitic fluid under ultrasound guidance.

86. A physical therapist performs initial evaluation of moderate complexity and provides therapeutic exercise for chronic low back pain. Total time 60 minutes.

87. A patient with recurrent DVT has an IVC filter placed via right femoral vein approach under fluoroscopic guidance.

88. An OB/GYN performs colposcopy with cervical biopsy and endocervical curettage.

89. A pain management physician performs lumbar facet joint injections at L4-5 and L5-S1 bilaterally under fluoroscopic guidance.

90. A patient with advanced dementia receives hospice care at home. The physician performs a routine home visit lasting 45 minutes.

91. A procedure describes incision of the hepatic duct. The prefix ‘hepat-‘ refers to which organ?

92. Medicare requires an ABN to be obtained:

93. A patient needs a power wheelchair due to ALS. Which of the following is NOT required in the documentation?

94. The suffix ‘-itis’ means inflammation. An AMA CPT Assistant article describes tendinitis of the supraspinatus. This condition affects the:

95. Which anatomical plane divides the body into right and left portions?

96. Under OIG compliance guidelines, which activity requires immediate reporting?

97. A prosthetist provides a right below knee prosthesis. Which L-code describes the base device?

98. The prefix ‘thorac-‘ combined with suffix ‘-centesis’ describes a procedure involving:

99. For proper ICD-10-CM coding of burns, what anatomical information is required?

100. Under HIPAA Security Rule, which is required for ePHI?