CPC Exam Dumps : Certified Professional Coder (CPC) Exam

A 55-year-old patient with suspected liver cancer was seen by the physician to obtain a biopsy. The special biopsy needle was placed using ultrasonic guidance. The physician obtained a small tissue sample from the liver, which was then sent to pathology.

What CPT® codes are reported?

View MR 099407

MR 099407

Emergency Department Visit

Chief Complaint: VOMITING.

This started just prior to arrival and is still present. He has had nausea and vomiting. No diarrhea, black stools, bloody stools or abdominal pain. Pt is diabetic and has been having elevated blood sugars (320 mg/dL).

REVIEW OF SYSTEMS: Unobtainable due to patient's altered mental status.

PAST HISTORY: Poorly controlled diabetes mellitus, with history of poor compliance.

Medications: See Nurses Notes.

Allergies: PCN.

SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.

ADDITIONAL NOTES: The nursing notes have been reviewed.

PHYSICAL EXAM

Appearance: Lethargic. Patient in mild distress.

Vital Signs: Have been reviewed-tachycardic.

Eyes: Pupils equal, round and reactive to light.

ENT: Dry mucous membranes present.

Neck: Normal inspection. Neck supple.

CVS: Tachycardia. Heart sounds normal. Pulses normal.

E D. Course: Insulin IV drip per protocol, at 10 units/hr.

Zofran 8 mg 01:33 Jul 13 2008 IVP.

Phenergan 25 mg IVP. 07:52. Discussed case with physician. Dr. X. Reviewed test results. Agreed upon treatment plan. Physician will see patient in hospital.

Total critical care time: 45 min.

Disposition: Admitted to Intensive Care Unit. Condition: stable.

Admit decision based on need for monitoring and IV hydration and medications.

CLINICAL IMPRESSION: Vomiting, diabetic ketoacidosis, probable diabetes insipidus.

What E/M code is reported for this encounter?

View MR 002395

MR 002395

Operative Report

Pre-operative Diagnosis: Acute rotator cuff tear

Post-operative Diagnosis: Acute rotator cuff tear, synovitis

Procedures:

1) Rotator cuff repair

2) Biceps Tenodesis

3) Claviculectomy

4) Coracoacromial ligament release

Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.

Findings: Complete tear of the right rotator cuff, synovitis, impingement.

Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the

supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.

What CPT® coding is reported for this case?