AAPC CPC Exam With Confidence Using Practice Dumps

This is aninitial hospital/observation evaluation(first visit during the stay), so the correct code family is theinitial observation/inpatient E/Mlevel. The stem providestotal time = 85 minutesand also statesmoderate MDM. Under current E/M rules, you can select the code based oneither MDM or total time(when time is used, it includes the physician’s qualifying time on that date). The time of85 minutesfits the time range for99223(the highest initial hospital/observation level by time) even if MDM is described as moderate. The prolonged service add-on99418requires meeting the threshold beyond the primary code’s time before it can be added; with 85 minutes, you do not reach the additional increment needed to report 99418. Therefore, you report99223 only. CPC exam tip: when time is explicitly provided and is high, it often drives the level; do not add prolonged time unless the documented time clearly exceeds the primary code’s requirement by the necessary increment.

1. Procedure and CPT® Code Selection:

The procedure performed was an evisceration of ocular contents without the placement of an implant. The surgical microscope was used for enhanced visualization, but this does not require a separate code if the primary procedure code includes it inherently.

CPT® Code 65091 is used for an evisceration of the ocular contents without implant placement. This code correctly describes the procedure performed on the left eye.

2. Modifier:

Modifier LT is added to indicate that the procedure was performed on the left eye.

3. Exclusion of Code 69990:

Code 69990 is for the use of an operating microscope, but it should not be billed separately when it is used as part of a procedure where enhanced visualization is typical or expected, such as an evisceration procedure. According to CPT® guidelines, 69990 is not separately reported when the microscope is used for visualization in procedures where its use is considered part of the standard of care.

4. Rationale for Excluding Other Options:

Code 65093 is for an evisceration with implant placement, which does not apply since no implant was used.

Options B and C incorrectly include 69990, which is not separately reportable in this scenario.

5. AAPC and CPT® Coding Guidelines:

According to AAPC and CPT® coding guidelines, 65091 is sufficient to capture the procedure without the need to add code 69990 for the microscope.

Therefore, the correct answer is D. 65091-LT.

CPT® code 49083 describes an abdominal paracentesis with imaging guidance, such as ultrasound. This code includes the imaging guidance as part of the procedure, so it is not necessary to separately report the ultrasonic guidance.