AAPC CPC - Certified Professional Coder (CPC) Exam

1. Procedure and CPT® Code Selection:

The patient underwent a thyroidectomy for malignancy in the right lobe, as well as the removal of the parathyroid gland due to a suspected malignant lesion.

CPT® Code 60505 is for the parathyroidectomy with exploration of parathyroid glands and is appropriate for the removal of the parathyroid gland due to a suspected malignancy.

CPT® Code 60220 represents a thyroid lobectomy (total removal of one lobe of the thyroid), which applies to the removal of the right thyroid lobe in this case.

2. Modifier 59:

Modifier 59 is added to 60220 to indicate that the thyroid lobectomy is a distinct procedure from the parathyroidectomy, performed in a separate anatomical site during the same surgical session.

3. Rationale for Excluding Other Options:

Code 60500 (in options A and C) is for a parathyroid exploration only, not including the actual removal of the parathyroid gland, so it does not apply here.

Code 60240 (in option D) is for a total thyroidectomy, which involves removal of the entire thyroid gland. Since only the right lobe was removed, 60220 (thyroid lobectomy) is correct.

4. AAPC and CPT® Coding Guidelines:

Per AAPC guidelines, 60505 is the appropriate code for parathyroidectomy procedures involving exploration or suspected malignancy, and 60220 with Modifier 59 accurately reflects the separate and distinct thyroid lobectomy procedure.

Thus, the correct answer is B. 60505, 60220-59.

The National Correct Coding Initiative (NCCI) was developed by CMS to:

Prevent unbundling

Define procedure-to-procedure (PTP) edits

Identify when modifiers (such as -59) may be appropriate

NCCI edits are critical for accurate CPT® coding and proper reimbursement.

For initial fracture care of a closed scaphoid fracture, code 25622 is used, which includes treatment and initial casting. The application of the cast is part of the fracture care and is not reported separately. CPT® guidelines specify that casting or strapping performed as part of the fracture care is included in the fracture care code.

AMA ' s CPT® Professional Edition (current year), Surgery section, Musculoskeletal System.

A41.52 = Sepsis due to Enterococcus.

When the organism is specified, a combination code is used.

No additional code for severe sepsis is documented.

1. Procedure and CPT® Code Selection:

The urinalysis performed was non-automated and without microscopy.

CPT® Code 81002 is appropriate for a non-automated urinalysis without microscopy. This code accurately reflects the test performed in the office.

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

ICD-10-CM Code R30.0 is used for dysuria, which was one of the patient ' s presenting symptoms.

ICD-10-CM Code R10.30 is used for lower abdominal pain, another presenting symptom.

Since the urinalysis ruled out a urinary tract infection, N39.0 (UTI) is not appropriate as a final diagnosis.

3. Rationale for Excluding Other Options:

Code 81000 (in options A and B) is for a urinalysis with microscopy, which was not performed here.

N39.0 is used when a UTI is confirmed, which is incorrect for this case since the urinalysis was negative, ruling out UTI.

4. AAPC and CPT® Coding Guidelines:

AAPC guidelines recommend coding based on the symptoms when a specific diagnosis (such as UTI) is ruled out. Therefore, R30.0 and R10.30 are appropriate symptom codes for this encounter.

Thus, the correct answer is C. 81002, R30.0, R10.30.