AAPC CPC - Certified Professional Coder (CPC) Exam

47000 = Percutaneous liver biopsy

76942 = Ultrasound guidance

K74.3 = Primary biliary cirrhosis

1. Procedure and CPT® Code Selection:

The procedure performed was a hysteroscopy to examine the uterine cavity due to abnormal vaginal bleeding. This is a diagnostic hysteroscopy.

CPT® Code 58555 is specifically for a diagnostic hysteroscopy to examine the uterine cavity, which aligns with the procedure performed in this case.

2. Rationale for Excluding Other Options:

Code 58558 is for a hysteroscopy with a surgical procedure, such as biopsy or removal of a lesion or polyp, which was not performed in this case.

Code 58579 is an unlisted procedure code for the female genital system and is unnecessary here because there is a specific code (58555) for diagnostic hysteroscopy.

Code 58578 is also an unlisted hysteroscopic procedure code and is not appropriate when a specific diagnostic code exists.

3. AAPC and CPT® Coding Guidelines:

AAPC guidelines indicate that 58555 should be used for diagnostic hysteroscopy procedures without any surgical intervention.

Therefore, the correct answer, following CPT® guidelines, is C. 58555.

1. Problem Type Selection:

Miranda is following up on her diabetes, which is a chronic condition. Her blood sugars are controlled, indicating that the condition is stable with her current medication regimen.

Stable, chronic illness is defined in the CPT® MDM (Medical Decision Making) Table as a chronic condition that is under control and not currently worsening, even if ongoing management is required. This aligns with the patient's diabetes being well-managed with her prescribed medications.

2. Rationale for Excluding Other Options:

A. Acute, uncomplicated illness or injury is not applicable as diabetes is a chronic condition, not an acute issue.

B. Minimal problem refers to conditions that are minor or self-limited and typically require little to no treatment, which does not apply to chronic conditions like diabetes.

D. Stable, acute illness would refer to an acute condition that has stabilized, whereas diabetes is a chronic condition, not acute.

3. AAPC and CPT® Coding Guidelines:

According to the CPT® MDM Table, a "Stable, chronic illness" is the correct classification for a follow-up encounter on a controlled chronic condition like diabetes.

Therefore, the correct answer is C. Stable, chronic illness.

50500 = Repair of kidney laceration

N99.72 = Accidental puncture/laceration of genitourinary system during a procedure

S37.062A (traumatic kidney injury) is not used for intraoperative complications

The nephrologist does not report the colectomy, nor modifier -80

69905 = Transmastoid labyrinthectomy

69990 = Operating microscope (separately reportable)

H81.391 = Peripheral vertigo, right ear

R42 (dizziness) is not reported when a definitive diagnosis exists

RADIOLOGY & IMAGING QUESTIONS

69209-RT – Removal of impacted cerumen using irrigation

69210-LT – Removal of impacted cerumen using instrumentation

Coding Rules Applied:

Different techniques → different CPT codes

Different ears → RT/LT modifiers, not modifier -50

Why Other Options Are Incorrect:

A – Modifiers reversed

B / D – Modifier -50 inappropriate when different CPT codes are used

ICD-10-CM has a clear hierarchy when the same substance is documented with multiple levels of severity.Dependencerepresents a higher severity classification thanabuse, andabuseis higher thanuse. When two or more of these are documented for the same substance, you generally assignonly one code, selecting thehighest level of severitysupported: dependence over abuse, and abuse over use. Therefore, if bothuse and dependenceare documented, you assigndependence only(Option D). Option A is incorrect because you do not code both use and abuse for the same substance; you choose the higher severity (abuse). Option B is incorrect because if abuse and dependence are both documented, you would codedependence, not abuse. Option C is incorrect because ICD-10-CM does not support reporting all three separately for the same substance; doing so would be duplicative and noncompliant. CPC exam tip: remember the mnemonicD-A-U→Dependence > Abuse > Use(pick the highest).

Open Roux-en-Y Gastric Bypass: The procedure involves creating a small gastric pouch and anastomosing it to the jejunum.

CPT Code 43847: This code describes a surgical gastric restrictive procedure with gastric bypass for morbid obesity, open.

ICD-10-CM Code E66.01: This code represents morbid (severe) obesity due to excess calories.

ICD-10-CM Code Z68.42: This code indicates a BMI of 45.

60220 = Total lobectomy, unilateral thyroid

60500 = Parathyroidectomy (single gland)

Modifier -59 is appropriate to indicate a distinct procedure

The urinalysis performed is described asautomated, without microscopy, which corresponds to CPT81003(urinalysis, automated, without microscopy). CPT81001includes microscopy and is not supported because the question explicitly states “without microscopy.” For diagnosis coding, the providersuspecteda UTI, but the urinalysis is negative andUTI is ruled outas the final diagnosis. Under ICD-10-CM reporting principles, conditions documented asruled outarenot codedin the outpatient/office setting; instead, you code thesigns and symptomsthat prompted the visit and testing. The symptoms documented aredysuriaandlower abdominal pain, which are coded asR30.0andR10.30(as presented in the answer choices). Therefore, the correct combination is81003withR30.0andR10.30only. CPC exam tip: outpatient “rule out” → codesymptoms, not the excluded diagnosis.