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Medical Tests American Academy of Professional Coders: Certified Professional Coder Sample Questions:

1. What must the documentation for a consultation include?

A) Which family member prompted the consultation, a written report ofthe physical findings/recommendations, and the time spent discussing the recommended treatment plan
B) Who requested the consultation, the consulting providers, professional opinion, and awritten report that is provided to the referring physician
C) Documentation of assumption of care, who requested the consultation, and the consultingproviders, professional opinion
D) The reason for the consultation, the time spent discussing the recommended treatmentplan, and a medical decision-making of moderate complexity

2. Which term describes a migraine that is unmanageable with treatment?

A) Intractable migraine
B) Classical migraine
C) Status migrainosus
D) A migraine with aura

3. Code the following procedure note:
A 45-year-old female was referred for a urodynamics study due to complaints of bladder pain and weak urination. The provider places a rectal catheter simultaneously with a urethral catheter and begins to fill the bladder with water.
Using calibrated equipment, cytometry was done with a medium fill rate of 40 cc/ minute. A strong desire to void occurred at 84 cc. and the patient is instructed to void. The provider determines that the maximum urinary flow rate is 12 cc per second with a voiding time of 45 seconds and a voided volume of 102 cc. She voided with a sustained detrusor pressure. An abdominal pressure measurement was also taken, indicating no urinary leaking with abdominal straining. EMG patches were placed on the anal sphincter and found to be elevated with increased intra- abdominal pressure. All catheters and EMG patches were removed, and the procedure was completed without complications. A report will be forwarded to the referring provider, who will provide the interpretation of the results to the patient.

A) 51728-TC, 51784-TC, 51797-TC, 51741-TC
B) 51728-TC, 51784-TC, 51797-TC
C) 51726-TC, 51784-51-TC, 51797-51-TC
D) 51726-TC, 51784-59-TC, 51797-59-TC, 51741-59-TC

4. A 39-year-old female patient has developed a diaphragmatic hernia after an episode of domestic violence. The surgeon repairs the hernia through an incision into the abdomen. The patient is later discharged with no complications. How should this encounter be reported?

A) 39540,K44.9, T 76.1 IXA
B) 39541, K44.O, T76.1 IXA
C) 39540, K44.9, T74.11XA Y07.9
D) 39541, K44.O, T74.11YA Y07.9

5. In which scenario would the modifier 53 be appended?

A) An IUD removal is not completed because the patient reports severe pain when thespeculum is inserted.
B) A surgeon decides to stop a gallbladder removal procedure in the hospital operating roomafter the patient has extensive bleeding at the incision site.
C) A patient receives an x-ray of one femur when the doctor ordered bilateral views.
D) The surgeon decides to terminate a routine colonoscopy when the patient becomeshypertensive before receiving anesthesia in the outpatient procedure room.

Solutions: