AAPC CPC Exam Final with Answer 2016

56 Pages·2016·0.507 MB·English

by  AAPC

2016 Final with Answers
10000 Series

1. While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index
finger and underwent formation of a direct pedicle graft with transfer from his left middle finger.
Immobilization was accomplished with a plaster splint. What CPT® code is reported?
a. 15574 c. 15750
b. 15740 d. 15758

ANS: A
Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code
selection is based on location. Subsection guidelines for Flaps state the codes refer to the recipient site
not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from
one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source
location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes
a direct pedicle graft of the hands with or without transfer.

2. A patient presents to the ED physician with multiple burns. After examination the physician
determines the patient has 3rd degree burns of the anterior and posterior portion of his left leg, starting
at the knee extending above the ankle (4.5%). He also has 3rd degree burns of the anterior portion of
the left side of his chest (4.5%). The patient also has 2nd degree burns of the posterior portion of his
upper back and left upper arm (13.5%). What ICD-10-CM codes are reported?
a. T24.292A, T24.192A, T31.20
b. T21.399A, T21.39XA, T21.29XA, T22.299A, T31.31
c. T24.109A, T25.112A, T21.21XA, T22.392A, T21.23XA, T31.31XA
d. T24.392A, T21.31XA, T21.23XA, T22.232A, T31.20

ANS: D
Rationale: ICD-10-CM Guidelines 1.C.19.d.1 indicate, when more than one burn is present to sequence
first the code reflecting the highest degree of burn. In the Index to Diseases and Injuries, look for
Burn/lower/limb/multiple sites, except ankle and foot/left/third degree T24.392-. Third degree burns to
the left leg at the knee extending above the ankle (multiple sites) are coded as T24.392-; third degree
burns to the left side of the chest is indexed Burn/chest wall/third degree referring you to code T21.31-;
second degree burns to the posterior upper back is indexed Burn/back/upper/second degree referring
you to code T21.23-; and second degree burns to the left upper arm is indexed Burn/upper limb/above
elbow - see Burn, above elbow. Look for Burn/above elbow/left/second degree referring you to code
T22.232. The Tabular List indicates these codes need seven characters. The seventh character A is
reported for all the burn codes and use X place holders to keep the A in the seventh position. Last code
to report is the extent or percentage of the body burned. Look for Burn/extent (percentage of body
surface). Category T31 is used to identify the extent of the body surface involved. The fourth character
identifies the total body surface area (TBSA) involved (all degree burns totaled), the TBSA is 22.5%
(T31.2-). The fifth character identifies the percentage of body surface involved in only the third-degree
burns. Third degree burns total 9% reporting the fifth character 0. This is coded with T31.20. The TBSA
codes are only five characters long and does not need a seventh character extender to complete the
code.

3. Patient is an 81-year-old male with a biopsy proven basal cell carcinoma of this posterior neck just
near his hairline; additionally the patient had two additional areas of concern on his cheek. Informed
consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention
was first directed to the basal cell carcinoma of the neck, I excised the lesion measuring 2.6 cm as drawn
down to the subcutaneous fat. With extensive undermining of the wound I closed in layers using 4.0
Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5cm. Attention was then directed to the
other two suspicious lesions on his cheek; after administering local anesthesia I proceeded to take a
3mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the
procedures well. Pathology later showed the basal cell carcinoma was completely removed and the
biopsies indicated actinic keratosis. What CPT® codes should be reported?
a. 13132, 11623-51, 11100-59, 11101 c. 12042, 11623-51, 11100-59, 11101
b. 13131, 11622-51, 11100-59, 11100-59 d. 13132, 11623-51, 11440-51, 11440-51

ANS: A
Rationale: Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell
carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range
11600-11646. The range is narrowed by the location (neck, 11620-11626). The excision was 2.6 cm
making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of
multiple suture materials support use of a complex closure. Complex repairs are indexed under
Repair/Skin/Wound/Complex referring you from range 13100-13160. The range is narrowed again by
location (neck, 13131-13133). The repair length is 4.5 cm making 13132 the correct code. After the
lesion of the neck is removed the provider took two biopsies on the cheek. Look in the CPT® Index for
Skin/Biopsy which refers you to codes 11100 and 11101. 11100 is used for the first biopsy and add-on
code 11101 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use
modifier 59 for the first biopsy indicating it was performed at a different location than the excision. A
modifier 59 is not used on the second biopsy code because it is an add-on code.

4. Patient is a 53-year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a
basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to
reconstruct the site. Dr. Jones discussed with the patient his planned closure which was a Ying-Yang
type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion
being careful to keep betadine solution out of the open wound. Wound preparation was done by
excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on
the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat,
staying superior to the galea; then Dr. Jones incised his planned flap on the left elevating the flap with
full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily
closed using the skin stapler. Once it was determined there was minimal tension on the wound; the
galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl
and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie
cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are
reported?
a. 14021-22 c. 14301
b. 14021, 15004-51 d. 14301, 15004-51

ANS: D
Rationale: A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT®
Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When
the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq.
cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq. cm. 14301 is reported for
the first 30 sq. cm – 60.0 sq. cm. Wound preparation was also performed, in the CPT® index look for
Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring
you to codes 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate
multiple procedures were performed.

5. Patient presents to the emergency department with multiple lacerations due to a knife fight at the
local bar. After examination it was determined these lacerations could be closed using local anesthesia.
The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following
closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm;
4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT®
codes are reported?
a. 13132, 12035-59, 12004-59
b. 13132, 12034-59, 12032-59, 12004-59
c. 13132, 12036-59
d. 13152, 12035-59, 12004-59

ANS: A
Rationale: Four lacerations are repaired. The lacerations are separated first by classification (simple,
intermediate, complex); then by location. There is one simple closure which is 7.6 for the right forearm
(12004). Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper
chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are
both intermediate, so the lengths are added together to total 16 cm (12035). The last repair is a complex
repair of the neck, 4.7 cm (13132). Subsection guidelines state to append Modifier 59 to indicate that
multiple repair procedures are performed. These codes are indexed in CPT® under Skin/Wound Repair.
6. Patient presents to the operative suite with a biopsy proven squamous cell carcinoma of the left
ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The
lesion was excised as drawn and documented as measuring 2.4 cm with margins. Using the Padgett
dermatome the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1.5
x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the
skin graft using Xeroform and 4-0 nylon and the lower extremity was wrapped with bulky cast padding
and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin
graft measured 9cm² in total. What CPT ® and ICD-10-CM codes are reported?
a. 15100, 11603-51, C44.729 c. 15120, 13100-51, D22.72
b. 15100, C44.729 d. 15240, 11603-51, C44.729

ANS: A
Rationale: The excision of the lesion is found by looking in the CPT® Index for
Skin/Excision/Lesion/Malignant, you are referred to code range 11600-11646. The lesion is on the ankle
(leg) narrowing the code range to 11600-11606. The lesion is 2.4 cm making the correct code 11603.
The guidelines for Excision – Malignant Lesions tell us to report reconstructive closure (15002-15261,
15570-15770) separately. In this case a split thickness skin graft was used. Look in the CPT® Index for
Skin Graft and Flap/Split Graft which refers us to code range 15100-15101, 15120-15121. 15100 is the
correct code choice. The diagnosis is squamous cell carcinoma. In the Alphabetic Index look for
Carcinoma – see also Neoplasm, by site, malignant. Look in the Table of Neoplasms for Neoplasm,
neoplastic/skin NOS/ankle and you are referred to see also Neoplasm, skin, limb, lower. Skin/limb
NEC/lower/squamous cell carcinoma refers you to C44.72-. In the Tabular List a sixth character is
reported for laterality. The code is specific to the left extremity (C44.729).

7. Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician
marked the area for excision. The lesion measured 0.9 cm. The wound measuring 1.2 cm was closed in
layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst.
What codes are reported?
a. 11401, D22.62 c. 13121, 11401-51, D22.62
b. 12031, 11401-51, L72.3 d. 11402, L72.3

ANS: B
Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for
Skin/Excision/Lesion/Benign referring you to code range 11400-11446. The lesion is coded based on size
and location for 11401. The note also indicates the wound was closed in layers allowing for
intermediate closure, also coded based on location and size, 12031. In the ICD-10-CM Alphabetic Index,
look for Cyst/sebaceous directs you to L72.3. Verify in the Tabular List.
8.
Operative Report:
Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead
Basal Cell Carcinoma, right cheek
Suspicious lesion, left nose
Suspicious lesion, left forehead

Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins
Basal Cell Carcinoma, right cheek with clear margins
Compound nevus, left nose with clear margins
Epidermal nevus, left forehead with clear margins

INDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy-proven basal cell
carcinoma of his forehead and a biopsy-proven basal cell carcinoma of his right cheek. We were not
quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline
lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical
excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked
the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for
biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for
elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also
drew a possible rhomboid flap that we would use if the wound became larger. He observed all these
margins in the mirror, so he could understand the surgery and agree on the locations, and we
proceeded.

DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped
and draped in sterile fashion. I excised the lesion of the forehead measuring 6-mm and right cheek
measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left
forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene.
Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound
first. Defects were created at each end of the wound to facilitate primary closure and because of this I
considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and
6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0
Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the
patient tolerated the procedure well. What ICD-10-CM codes are reported?
a. C44.310, D04.39, D48.5, D23.39
b. C44.310, D23.39
c. C44.202, C44.40, D22.23, D23.39
d. C44.202, C44.309, D48.5, D49.2

ANS: B
Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Alphabetic Index look for
Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for
Neoplasm, neoplastic, skin NOS/forehead - see also Neoplasm, skin, face. Neoplasm, neoplastic/skin
NOS/face NOS/basal cell carcinoma refers you to code C44.310. Next, is basal cell carcinoma, right
cheek, which also directs you to see also Neoplasm, skin, face (C44.310). Because, both basal cell
carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the
Alphabetic Index for Nevus/skin/nose directs you to D23.39. Nevus/skin/forehead directs you to
D22.39. Because the codes are the same. The code is reported only once.

9. 56-year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The
surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6
tissue blocks. What is the best way to code for both stages?
a. 17311, 17315 c. 17311, 17312, 17315
b. 17313, 17314, 17315 d. 17311, 17312

ANS: C
Rationale: Mohs codes are selected based on location and number of stages, each including up to five
blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the
CPT® Index, see Mohs Micrographic Surgery. Code 17311 is for the first stage and 17312 for the second
stage, based on the documentation of the site: “forehead.” The second stage consisted of six tissue
blocks; the sixth tissue block is reported with the add-on code 17315.

10. Which statement is true regarding the Neoplasm Table in ICD-10-CM?
a. The Neoplasm Table is found by looking for “Neoplasm” in the Index to Diseases and Injuries.
b. There is not a Neoplasm Table in ICD-10-CM.
c. The Neoplasm Table is found in the Tabular List.
d. There are six columns in the Neoplasm Table; Primary malignancy, secondary malignancy, CA in situ,
benign, and uncertain behavior.

ANS: D
Rationale: The Neoplasm Table in ICD-10-CM is broken down into six columns; Primary malignancy,
secondary malignancy, CA in situ, benign, and uncertain behavior.

20000 Series
11. 44-year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion
has undergone deformity correction. He now requires exchange of an external fixation strut 45 days
postoperatively. The intraoperative mounting parameters, deformity parameters, and initial strut
settings are inserted into the computer prior to Jim’s discharge and a daily schedule is generated for him
to perform the gradual deformity correction necessary. What CPT® code(s) should be reported?
a. 20696 c. 20694
b. 20697 d. 20692, 20697

ANS: B
Rationale: The exchange of a computer assisted external strut is coded with 20697. There is a
parenthetical note under code 20697 that it is not to be used in combination with 20672 or 20696.
20697 can be found in the CPT ® Index under External Fixation /Application/Stereotactic Computer
Assisted

12. A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be
biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle
biopsy is taken. What CPT® code is reported for this service?
a. 20205 c. 20225
b. 20206 d. 27324

ANS: B
Rationale: In the CPT® Index, look for Biopsy/Muscle. You are referred to 20200-20206. The biopsy is
taken through the skin, or percutaneous with a needle. Although the biopsy is deep, it is performed
percutaneous, which is reported with 20206.

13. The patient presents today for closed reduction of the nasal fracture. The depressed right nasal
bone was elevated using heavy reduction forceps while the left nasal bone was pushed to the midline.
This resulted in good alignment of the external nasal dorsum. What CPT® code is reported for this
procedure?
a. 21325 c. 21315
b. 21310 d. 21337

ANS: C
Rationale: In the CPT® Index, look for Fracture/Nasal Bone/Closed Treatment. You are referred to
21310-21320. Review codes to choose the appropriate service. 21315 is the correct code to report a
displaced nasal fracture that is manipulated with the forceps to realign the nasal bones. Code 21310 is
reported when a non-displaced fracture of the nose requires no manipulation just treatment by
prescribing medication and application of ice.

14. A 22-year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the
left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was
opened by a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner
wire was located within the distal phalanx. It was removed and closed with sutures. What CPT® code is
reported?
a. 10120-F4 c. 20670-F4
b. 20680-F4 d. 10121-F4
ANS: B
Rationale: In the CPT® Index, look for Removal/Fixation Device. You are referred to 20670-20680.
Review the codes to choose the appropriate service. 20680 is the correct code because a deep incision
was made all the way to the bone to locate the wire for removal. Modifier F4 is reported to indicate the
finger the procedure is performed on.

15. The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal
for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar
side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also
entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its
borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported?
a. 29880 c. 29881, 29877-59
b. 29870, 29877-59 d. 29881

ANS: D
Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Knee. You are referred to 29871-29889.
Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the
“medial meniscus”. A meniscectomy as well as debridement with a shaver (or chondroplasty) were
performed. 29877 would not be reported as this is covered with code 29881. 29880 is not appropriate
as the procedure would have had to be performed on both the medial and lateral compartments. The
surgery started out as a “diagnostic procedure,” but changed when the physician decided to perform
surgical procedures on the knee, rather than only examining the knee for diagnostic purposes.

16. A 3-year-old is brought into the ER crying. He cannot bend his left arm after his older brother
twisted it. The physician performs an X-ray to diagnose the patient has a dislocated nursemaid’s elbow.
The ER physician reduces the elbow successfully. The patient is able to move his arm again. The patient
is referred to an orthopedist for follow-up care. What CPT® and ICD-10-CM codes are reported?
a. 24640-54-LT, S53.032A, W50.2XXA
b. 24565-54-LT, S53.194S, Y33.XXXA
c. 24640-54-LT, S53.091A, W50.2XXA
d. 24600-54-LT, S53.002A, W49.9XXA

ANS: A
Rationale: In the CPT® Index, look for Elbow/Dislocation/Closed Treatment. You are referred to 24600-
24605, and 24640. Review the codes to choose appropriate service. 24640 is the correct code to report
treatment of a dislocated nursemaid’s elbow with manipulation. Modifier 54 is used to report that the
ED physician performed the surgical portion of the service only. The patient is referred to an orthopedist
for follow-up care. Modifier LT is appended to indicate the procedure was performed on the left side.

In the ICD-10-CM Index to Diseases and Injuries, look for Nursemaid’s/elbow. You are referred to
S53.03-. Reviewing the subcategory code in the Tabular List the sixth character indicates the selection is
based on left or right. Documentation supports this as the left arm. A 7th character is also required to
indicate the episode of care. Because the patient is in the ER, this supports initial encounter and A is
used. The complete code is S53.032A. In the ICD-10-CM External Cause of Injuries Index, look for
Twisted by person(s) (accidentally) referring you to W50.2. In the Tabular List this code requires a 7th
character, in which the character A is used and X will be used as a placeholder for the fifth and sixth
character positions.

17. A 50-year-old male had surgery on his upper leg one day ago to remove an intramuscular tumor
and presents with serous drainage from the wound. He was taken back to the operating room for
evaluation of a hematoma. His wound was explored down to the rectus femoris muscle, and there was a
hematoma, which was very carefully evacuated. The wound was irrigated with antibacterial solution,
and the wound was closed in multiple layers. What CPT® and ICD-10-CM codes are reported?
a. 10140-79, M96.810 c. 10140-76, T81.9XXA
b. 27603-78, T81.4XXA d. 27301-78, M96.831

ANS: D
Rationale: In the CPT® Index, look for Hematoma/Leg, Upper. You are referred to 27301. Verify the code
for accuracy. Modifier 78 is appended to 27301 to indicate that an unplanned procedure related to the
initial procedure was performed during the postoperative period. In the ICD-10-CM Index to Diseases
and Injuries, look for Complications/surgical procedure (on)/hematoma/post procedural – see
Complication, post procedural, hemorrhage. Look for Complication/post procedural/hemorrhage
(hematoma)/musculoskeletal structure/following non-orthopedic surgery referring you to M96.831. His
wound was explored down to the level of the rectus femoris muscle, so the excision of the mass did not
just involve the skin. The codes selection is specific to the location of the hematoma as well as the body
system for which the procedure was performed. Review the code in the Tabular List for accuracy.

18. A 22-year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture
while on vacation. The patient was put under general anesthesia and the elbow was reduced and was
stable. The medial elbow was held in the appropriate position and was reduced in acceptable position
and elevated to treat non-surgically. A long arm splint was applied. The patient is referred to an
orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported?
a. 24575-54-RT, 24615-54-51-RT c. 24577-54-RT, 24600-54-51-RT
b. 24576-54-RT, 24620-54-51-RT d. 24565-54-RT, 24605-54-51-RT

ANS: D
Rationale: In the CPT® Index, look for Fracture/Humerus/Epicondyle/Closed Treatment. You are
referred to code 24560-24565. Review the codes to choose the appropriate service. 24565 is the correct
code to report an epicondyle fracture manipulated (reduced) without a surgical incision to perform the
procedure. In the CPT® Index, look for Dislocation/Elbow/Closed Treatment. You are referred to 24600,
24605. Review the codes to choose appropriate service. 24605 is the correct code because the patient
was put under general anesthesia to perform the procedure. Modifier 54 is used to report the physician
performed the surgical portion only. The patient is referred to an orthopedist for follow up or
postoperative care. Modifier 51 is used to report multiple procedures were performed. Append
modifier RT to indicate the procedure is performed on the right side.

19. A 45-year-old presents to the operating room with a right index trigger finger and left shoulder
bursitis. The left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. An
incision was made over the A1 pulley in the distal transverse palmar crease, about an inch in length. This
incision was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its
entirety. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected
with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. Clean dressing was
applied. What CPT® codes are reported?
a. 26055-F6, 20610-76-LT c. 26055-F6, 20610-51-LT
b. 20552-F6, 20605-52-LT d. 20553-F6, 20610-51-LT

ANS: C
Rationale: In the CPT® Index, look for Trigger Finger Repair. You are referred to 26055. Review the code
to verify accuracy. In the CPT® Index, look for Injection/Joint. You are referred to 20600-20610. Review
the codes to choose appropriate service. 20610 is the correct code since the shoulder was injected.
Modifier F6 is used to report the right index finger that was repaired. Modifier LT is used to indicate the
left shoulder joint. Modifier 51 is used to indicate multiple procedures were performed.

20. What ICD-10-CM code is used to report effusion of the right ankle joint?
a. M25.471 c. M25.48
b. M25.474 d. M25.571

ANS: A
Rationale: Look in the Index to Diseases and Injuries for Effusion/joint/ankle. In the Tabular List, code
M25.47- Effusion, ankle and foot requires the application of a sixth character to specify the location
(foot or ankle) and laterality. M25.471 Effusion, right ankle

30000 Series

21. A patient presents with wheezing and shortness of breath. After evaluating the patient, the
physician determines the patient is suffering from an exacerbation of his asthma. The physician orders
nebulizer treatments to be administered in his office. According to the ICD-10-CM guidelines for coding
signs and symptoms, what is/are the correct ICD-10-CM code(s)?
a. J45.901 c. R06.2, R06.02
b. J45.902, R06.2, R06.02 d. J45.902

ANS: A