CPC Exam Dumps : Certified Professional Coder (CPC) Exam

To accurately code this emergency department visit, we need to assess the three key components: history, examination, and medical decision making (MDM).

History:

The documentation supports an expanded problem-focused history. This includes a chief complaint, a brief history of present illness (HPI), a review of systems (ROS) with pertinent positives and negatives, and a past medical history.

Examination:

The examination is also expanded problem-focused. The physician focused on the relevant systems (constitutional, HENT, respiratory) and documented specific findings related to the chief complaint (appears tired).

Medical Decision Making:

The MDM complexity is low. The physician is assessing a new problem (shortness of breath and weakness) with a low level of risk. No further testing or treatment is documented in this encounter.

Based on these components, 99283 is the most appropriate code.

Why other options are incorrect:

99282: Requires a problem-focused history and examination, which is less comprehensive than what was documented.

99284 and 99285: Require a higher level of MDM (moderate or high complexity) and/or a more detailed examination. The documentation doesn ' t support this level of service.

1. Procedure and CPT® Code Selection:

The patient underwent a pulmonary function test that included spirometry, vital capacity, breathing capacity, and flow volume measurements before and after bronchodilator administration.

CPT® Code 94060 is for spirometry, including the bronchodilator responsiveness testing, which involves capturing pre- and post-bronchodilator measurements. This code accurately reflects the testing performed.

CPT® Code 94010 is for spirometry testing without bronchodilator, which might be considered redundant in this case since 94060 encompasses spirometry testing with and without bronchodilator. However, some practices may code both, but generally, 94060 alone should suffice.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code J45.901 is used for unspecified asthma with acute exacerbation. This code is appropriate given that the diagnosis indicates intermittent asthma with exacerbation.

J45.21 represents mild intermittent asthma without the specification of exacerbation, making it less accurate than J45.901 in this context.

3. Rationale for Excluding Other Options:

Code 94070 (options B and C) is for bronchospasm provocation testing, which does not apply to standard pulmonary function testing with bronchodilator responsiveness.

Option D includes J45.21, which does not capture the exacerbation aspect and is therefore incorrect.

4. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 94060 should be used when pre- and post-bronchodilator spirometry is performed, and J45.901 is appropriate for asthma with exacerbation.

Therefore, the correct answer is A. 94060, 94010, J45.901.

CPT Code 00811: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing

This code is reported for anesthesia services provided during a colonoscopy that is diagnostic in nature.

ICD-10-CM Code D62: Acute posthemorrhagic anemia

This is the most accurate postoperative diagnosis. The operative report states " Anemia due to acute blood loss. "

ICD-10-CM Code N18.6: End stage renal disease

This code captures the patient ' s documented history of ESRD.

ICD-10-CM Code Z99.2: Dependence on renal dialysis

This code is necessary to report the patient ' s dialysis status, as it affects the overall risk of the procedure.

Why other options are incorrect:

00812: This code is for therapeutic colonoscopies, not diagnostic.

D64.9: This code is for anemia, unspecified. D62 is more specific to the patient ' s condition.

K62.5: This code is for lower gastrointestinal bleeding, but the anemia is the primary diagnosis in this case.