Example 1: Medical Terminology
The term “Salping-Oophorectomy” refers to
a. The removal of the fallopian tubes and ovaries
b. The surgical sampling or removal of a fertilized egg
c. Cutting into the fallopian tubes and ovaries for surgical purposes
d. Cutting into a fertilized egg for surgical purposes
The term “salp” means tube, the term “ooph” refers to the ovary, and the suffix “ectomy” means to surgically remove. Some CPT books (like the professional edition put out by the AMA) contains pages with common medical terms like these in the beginning of the book (prior to the coding guidelines)
Example 2: ICD-10-CM
Jim was at a bonfire when he tripped and fell into the flames. Jim sustained multiple burns. He came to the emergency room via an ambulance and was treated for second and third degree burns of his face, second degree burn on his shoulders and forearms, and third degree burns on the fronts of his thighs.
a. T20.20XA, T20.30XA, T22.259A, T22.219A, T24.319A, T31.42, X03.0XXA
b. T20.30XA, T24.319A, T22.299A, T31.42, X03.0XXA
c. T20.09XA, T22.099A, T24.099A, T31.64, X03.0XXA
d. T20.30XA, T22.299A, T24.319A, T31.64, X03.0XXA
Burn codes always have at least three codes: A burn code, a total body surface area code, or T31 category code, and an external cause code. Burn codes have the following rules, which can be found at the beginning of the ICD-10-CM manual under Guideline I.C.19.d Coding of burns and corrosions. Always code one location to the highest degree. For example, for first and second degree burns on the arm, you would only code second degree. When sequencing burn codes, always list the highest degree burn code first and end with the lowest degree burn code. For example, regarding first degree burns to the face and third degree burns to the arm, you would list the arm burn first and then the face burn. For question 33, answer B is correct because its codes describe the highest degree burn to each location and the burn codes are also arranged the in the correct order of highest to lowest degree of burn. To find the codes for the actual burns, we start with the areas with the third degree burns, in this case the face and thigh burns. Look up Burn/ face, and you will find Burn/ head. Burn, head, third degree is T20.30-. Search for Burn, thigh, third degree and you will find T24.319-9-. The second degree burns are for the upper and forearms. In the index, Burn, arm points to Burn, upper, limb. Looking up Burn, upper limb, multiple sites to code for both the upper arm and forearm, you will find that second degree is T22.299-. All of these need seven characters, with the seventh character being A, for initial encounter. The T31.42 (TBSA code) has the correct calculation when using the rule of nine (fourth digit burned to any degree; 9 x 5 = 45; five areas burned are head, arm1, arm2, leg1, leg 2; 5th digit describes only 3rd degree burns which are head (9), leg1 (9), and leg2 (9). 9×3=27). To find the code using the index, look up Burn, extent 40-49 percent with 20-29 percent third degree burns which points to T31.42. The external cause code correctly describes the bonfire incident. In the External Causes Index, look up Exposure, fire, not in building or structure which designates code X03.0. This also requires a seventh character of A, making the code X03.0XXA. Verify all codes in the Tabular.
Example 3: Anesthesia
When does anesthesia time begin?
a. After the induction of anesthesia is complete
b. During the pre-operative exam prior to entering the OR
c. When the anesthesiologist begins preparing the patient for the induction of anesthesia
d. Once the supervising physician signs over the patient’s care to the anesthesiologist
The answer to this question can be located in the anesthesia coding guidelines under the title “Time Reporting”