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Tuesday, October 1, 2019

MUSCULOSKELETAL SYSTEM SAMPLE QUESTIONS - 002


1.       Code an amputation of the right leg just above the knee.
a. 27598
b. 27590
c. 27290
d. 28825

2.  A patient had a unilateral percutaneous intradiscal electrothermal annuloplasty on L3-L5 with fluoroscopic guidance for needle placement. How would you report this professional service procedure?
a. 22526, 22527
b. 22526, 22527, 77002-26
c. 22899, 77002-51
d. 22526, 22527, 77003-26

3. A 42-year-old man has his “total knee” prosthesis removed after he develops an inflammatory reaction. Choose the best procedure codes for the service
a. 27372
b. 27486
c. 27438
d. 27488

4. 52 year old female has a mass growing on her right flank for several years. It has finally gotten significantly larger and is beginning to bother her. She is brought to the Operating Room for definitive excision. An incision was made directly overlying the mass. The mass was down into the subcutaneous tissue and the surgeon encountered a well encapsulated lipoma approximately 4 centimeters. This was excised primarily bluntly with a few attachments divided with electrocautery. What CPT should be reported?
A. 21932
B. 21935
C. 21931
D. 21925

5. While playing at home, Riley dislocated his patella, when he fell from a tree. The surgeon documented an open dislocation. Riley underwent a closed treatment under anesthesia. How would you report the treatment and diagnoses?
a. 27420, S83.006A
b. 27562, S83.013A
c. 27840, 27562-51, S83.006A
d. 27562, S83.006A

6. How should you report a deep biopsy of soft tissue of the thigh or knee area?
a. 27323
b. 27324
c. 20206
d. 27328

7. This is a 32 year old female who presents today with sacroilitis. On the physical exam there was pain on palpation of the left sacroiliac joint and imaging confirmation was done for the needle positioning. Then 80 mg of Depo-Medrol and 1 mL of bupivacaine at 0.5% was injected into the left sacroiliac joint with a 22 gauge needle. The patient was able to walk from the exam room without difficulty. Follow up will be as needed. The correct CPT code is:
A. 20610, 77003-26
B. 20551
C. 27096-LT
D. 20555

8. Code an arthrocentesis into the acromioclavicular joint of the left shoulder
a. 20550
b. 20610
c. 20605
d. 20600

9. Patient is having ongoing back and hip pain. The physician elects to perform a sacroiliac injection at an ambulatory surgery center. After sterile prep, the patient is placed prone and under fluoroscopic guidance; the needle is placed into the SI joint with a mixture of 20 mg of Celestone and Marcaine for pain relief. Code the procedure(s).
A. 27096, 77003-26
B. 20610
C. 27096, 73542-26
D. 27096

10. Patient is seen in the hospital’s outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the following techniques: An incision was made in the area of the lateral epicondyle. This was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 nylon for the skin. Dressings and a long arm cast were applied. Which are the correct ICD-10-CM and CPT® codes assignment?
A. 24579, 29065-51, S42.451B
B. 24577, S42.451B
C. 24579, S42.451A
D. 24575, S42.451A

11. A 35-year-old female patient presents with acute onset of severe pain since October. Her workup has revealed evidence of disk herniation with loss of lordosis at the C5-C6. Intraoperative findings were consistent with two large fragments of free disk fragments in the foramen at C5-C6 on the right side. After general anesthesia, the patient was placed on the operative table in the supine position. All pressure points were cushioned and a transverse skin incision was fashioned under fluoroscopic guidance over the C5-C6 disc space. Dissection through the platysma eventually allowed for exposure of the anterior entrance to the vertebral body of C5 and C6 and retractors were inserted to maintain adequate exposure. The operating microscope was brought into the field. Caspar posts were placed and slight distraction allowed exposure. A complete discectomy was performed at C5-C6 by using endplate curets pituitary rongeurs and Kerrison rongeurs. The posterior longitudinal ligament was resected and beneath the posterior longitudinal ligament, two significant sized disc fragments were noted in the foramen at C5-C6. These were removed using
pituitary and Decker instruments. The endplates were then decorticated so that they were parallel to each other and a midline keel was performed on AP and lateral fluoroscopy. A size #1 by 5 mm interbody Kineflex-C device was placed under fluoroscopic guidance. Satisfied with the positioning of the device, the decision was made to close. What is the correct code for this procedure?
A. 63075
B. 63081
C. 22856
D. 22554

12. A patient suffered a fracture of the femur head. He had an open treatment of the femoral head with a replacement using a Medicon alloy femoral head and methyl methacrylate cement. How would you report this procedure?
a. 27236
b. 27235
c. 27238
d. 27275, 27236-59

13. PREOPERATIVE DIAGNOSIS: Right scaphoid fracture. TYPE OF PROCEDURE: Open reduction and internal fixation of right scaphoid fracture. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, anesthesia having been administered. The right upper extremity was prepped and draped in a sterile manner. The limb was elevated, exsanguinated, and a pneumatic arm tourniquet was elevated. An incision was made over the dorsal radial aspect of the right wrist. Skin flaps were elevated. Cutaneous nerve branches were identified and very gently retracted. The interval between the second and third dorsal compartment tendons was identified and entered. The respective tendons were retracted. A dorsal capsulotomy incision was made, and the fracture was visualized. There did not appear to be any type of significant defect at the fracture site. A 0.045 Kirschner wire was then used as a guidewire, extending from the proximal pole of the scaphoid distalward. The guidewire was positioned appropriately and then measured. A 25-mm Acutrak drill bit was drilled to 25 mm. A 22.5-mm screw was selected and inserted and rigid internal fixation was accomplished in this fashion. This was visualized under the OEC imaging device in multiple projections. The wound was irrigated and closed in layers. Sterile dressings were then
applied. The patient tolerated the procedure well and left the operating room in stable condition. What code should be used for this procedure?
A. 25628-RT
B. 25624-RT
C. 25645-RT
D. 25651-RT

14. An infant with genu valgum is brought to the operating room to have a bilateral medial distal femur hemiepiphysiodesis done. On each knee, the C-arm was used to localize the growth plate. With the growth plate localized, an incision was made medially on both sides. This was taken down to the fascia, which was opened. The periosteum was not opened. The Orthofix figure-of-eight plate was placed and checked with x-ray. We then irrigated and closed the medial fascia with 0 Vicryl suture. The skin was closed with 2-0 Vicryl and 3-0 Monocryl. What procedure code should be used?
A. 27470-50
B. 27475-50
C. 27477-50
D. 27485-50

15. After adequate anesthesia was obtained the patient was turned prone in a kneeling position on the spinal table. A lower midline lumbar incision was made and the soft tissues divided down to the spinous processes. The soft tissues were stripped way from the lamina down to the facets and discectomies and laminectomies were then carried out at L3-4, L4-5 and L5-S1. Interbody fusions were set up for the lower three levels using the Danek allografts and augmented with structural autogenous bone from the iliac crest. The posterior instrumentation of a 5.5 mm diameter titanium rod was then cut to the appropriate length and bent to confirm to the normal lordotic curve. It was then slid immediately onto the bone screws and at each level compression was carried out as each of the two bolts were tightened so that the interbody fusions would be snug and as tight as possible. Select the appropriate CPT code(s) for this visit?
A. 22612, 22614 x 2, 22842, 20938, 20930
B. 22533, 22534 x 2, 22842
C. 22630, 22632 x 2, 22842, 20938, 20930
D. 22554, 22632 x 2, 22842

16. PREOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. POSTOPERATIVE DIAGNOSIS: Displaced impacted Colles fracture, left distal radius and ulna. OPERATIVE PROCEDURE: Reduction with application external fixator, left wrist fracture FINDINGS: The patient is a 46-year-old right-hand-dominant female who fell off stairs 4 to 5 days ago sustaining an impacted distal radius fracture with possible intraarticular component and an associated ulnar styloid fracture. Today in surgery, fracture was reduced anatomically and an external fixator was applied. PROCEDURE: Under satisfactory general anesthesia, the fracture was manipulated and C-arm images were checked. The left upper extremity was prepped and draped in the usual sterile orthopedic fashion. Two small incisions were made over the second metacarpal and after removing soft tissues including tendinous structures out of the way, drawing was carried out and blunt-tipped pins were placed for the EBI external fixator. The frame was next placed and the site for the proximal pins was chosen. Small incision was made. Subcutaneous tissues were carried out of the way. The pin guide was placed and 2 holes were drilled and blunt-tipped pins placed. Fixator was assembled. C-arm images were checked. Fracture reduction appeared to be anatomic. Suturing was carried out where needed with 4-0 Vicryl interrupted subcutaneous and 4-0 nylon interrupted sutures. Sterile dressings were applied. Vascular supply was noted to be satisfactory. Final frame tightening was carried out. What CPT codes should be reported?
A. 25600-LT, 20692-51
B. 25605- LT, 20690-51
C. 25606-LT
D. 25607-LT


17. The patient is a 66-year-old female who presents with Dupuytren’s disease in the right palm and ring finger. This results in a contracture of the ring digit MP joint. She is having a subtotal palmar fasciectomy for Dupuytren’s disease right ring digit and palm. An extensile Brunner incision was then made beginning in the proximal palm and extending to the ring finger PIP crease. This exposed a large pretendinous cord arising from the palmar fascia extending distally over the flexor tendons of the ring finger. The fascial attachments to the flexor tendon sheath were released. At the level of the metacarpophalangeal crease, one band arose from the central pretendinous cord-one coursing toward the middle finger. The digital nerve was identified, and this diseased fascia was also excised. What procedure code should be used?
A. 26123-RT, 26125
B. 26121-RT
C. 26035-RT
D. 26040-RT

18. Mike had a bicycle accident and suffered deep hematomas in both knees. He underwent a bilateral incision and drainage. How would you report the procedure?
a. 27301-50
b. 10040
c. 27303
d. 27301-59

19. PREOPERATIVE DIAGNOSIS: Medial meniscus tear, right knee POSTOPERATIVE DIAGNOSIS: Medial meniscus tear, extensive synovitis with an impingement medial synovial plica, right knee TITLE OF PROCEDURE: Diagnostic operative arthroscopy, partial medial meniscectomy and synovectomy, right knee The patent was brought to the operating room, placed in the supine position after which he underwent general anesthesia. The right knee was then prepped and draped in the usual sterile fashion. The arthroscope was introduced through an anterolateral portal, interim portal created anteromedially. The suprapatellar pouch was inspected. The findings on the patella and the femoral groove were as noted above. An intra-articular shaver was introduced to debride the loose fibrillated articular cartilage from the medial patellar facet. The hypertrophic synovial scarring between the patella and the femoral groove was debrided. The hypertrophic impinging medial synovial plica was resected. The hypertrophic synovial scarring overlying the intercondylar notch and lateral compartment was debrided. The medial compartment was inspected. An upbiting basket was introduced to transect the base of the degenerative posterior horn flap tear. This was removed with a grasper. The meniscus was then further contoured and balanced with an intra-articular shaver, reprobed and found to be stable. The cruciate ligaments were probed, palpated and found to be intact. The lateral compartment was then inspected. The lateral meniscus was probed and found to be intact. The loose fibrillated articular cartilage along the lateral tibial plateau was debrided with the intra-articular shaver. The knee joint was then thoroughly irrigated with the arthroscope. The arthroscope was then removed. Skin portals were closed with 3-0 nylon sutures. A sterile dressing was applied. The patient was then awakened and sent to the recovery room in stable condition. What CPT and should be reported?
A. 29880-RT
B. 29881-RT
C. 29881-RT, 29822-59-RT
D. 29880-RT, 29822-59-RT

20. Re-reduction of fracture during the postoperative period by the same physician is identified usingModifier
a) 58
b) 78
c) 76
d) 79

21. A 16-year-old patient undergoes excision of an aneurismal bone cyst of the proximal right humeruswith allograft.
a) 23155-22
b) 23156
c) 23146
d) 23220-63

22. Codes 20100 – 20103 do not include which of the following procedures?
a) exploration and enlargement of the wound
b) extension of dissection
c) debridement, removal of foreign body
d) thoracotomy / laparotomy

23. Patient underwent replantation of thumb after complete amputation from the distal tip to the MP joint
a) 20822
b) 20824
c) 20827
d) 20816

24. This 45 year-old male presents to the operating room with a painful mass of the right upper arm.  Upon deep dissection a large mass in the soft tissue of the patient's shoulder was noted. The mass appeared to be benign in nature.  With deep blunt dissection and electrocautery, the mass was removed and sent to pathology.  What CPT® code is reported?
a.  23076-RT
b.  23066-RT
c.   23030-RT
d.  23075-RT

25. Surgeon performed open repair of femoral neck fracture with internal fixation.
a) 27230
b) 27235
c) 27236
d) 27244

26. patient fell and fractured his left femoral shaft in three places. The fracture is treated with an ORIF of the left femur with an intramedullary nail and interlocking screws (peritrochanterically). The orthopedist also places the leg in a plaster splint prior to leaving the OR. What CPT® code(s) is/are reported?
a.  27245
b.  27507, 29505
c.   27506
d.  27513, 29505

27. A patient with compartment syndrome undergoes decompression fasciotomy of his right leg posterior compartment. The physician debrided all the nonviable tissue and nerve in that compartment. Code the procedure.
a) 27601
b) 27601, 10040
c) 27893
d) 27892, 27893

28. A 50 year-old male had surgery on his upper leg one day ago to remove an intramuscular tumor and presents with serous drainage from the wound. He was taken back to the operating room for evaluation of a hematoma. His wound was explored down to the rectus femoris muscle, and there was a hematoma which was very carefully evacuated. The wound was irrigated with antibacterial solution, and the wound was closed in multiple layers. What CPT® and ICD-10-CM codes are reported?
a.  10140-79, M96.810
b.  27603-78, T81.4XXA
c.   10140-76, T81.9XXA
d.  27301-78, M96.840

29. The type of fracture determines the type of treatment
a) True
b) False

30. Patient underwent reconstruction of the mandibular rami due to blunt trauma, undergoing C osteotomy with bone graft.
a) 21195
b) 21188
c) 21193
d) 21194

31. Codes for external fixation
a) can be used always when it is mentioned
b) should not be billed separately
c) can be billed if it is part of the basic procedure
d) can be billed if it is not part of the basic procedure

32. Surgeon performs removal of Harrington rod in a patient suffering from chronic irritation in the region of insertion.
a) 22850
b) 22850, 22851-59
c) 22850-62, 22851-59
d) 22852, 22849-59

33. Ultrasound guided trigger point injection in the deltoid, biceps and trapezius.
a) 20553
b) 20552
c) 20553, 76942
d) 20552, 76942

34. A  patient was seen in the office for trigger point injection involving the trapezius and lattismus muscle groups.
a) 20551
b) 20552
c) 64614
d) 64613

35. A 42 year-old with chronic right trochanteric bursitis is scheduled to receive an injection at the Pain Clinic. A 22-gauge spinal needle is introduced into the trochanteric bursa, and a total volume of 8 cc of normal saline and 40 mg of Kenalog is injected. What are the CPT® codes?
a.  20550-RT
b.  20610-RT
c.   20611-RT
d.  27093-RT

36. A doctor performs an open procedure of ankle arthrodesis for a patient with ankle arthritis. After arthrodesis, the doctor fits a small bone graft obtained from the fibula into the ankle. Code this procedure.
a) 27870, 20900
b) 27870, 20900-51
c) 27860
d) 27860, 20900

37. A 22 year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened with a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and the skin was closed with sutures.  What CPT® code is reported?
a.  20670-F4
b.  20680-F4
c.   10121-F4
d.  10120-F4

38. A 31 year-old secretary returns to the office with continued complaints of numbness involving three radial digits of the upper left extremity. Upon examination, she has a positive Tinel’s test of the median nerve in the left wrist. Anti-inflammatory medication has not relieved her pain. Previous electrodiagnostic studies show sensory mononeuropathy. She has clinical findings of carpal tunnel syndrome. She has failed physical therapy and presents for injection of the left carpal canal. The left carpal area is prepped sterilely. A 1.5 inch 25-gauge needle is inserted radial to the palmaris longus or ulnar to the carpi radialis tendon at an oblique angle of approximately 30 degrees. The needle is advanced a short distance about 1 or 2 cm observing for any complaints of paresthesia or pain in a median nerve distribution. The mixture of 1 cc of 1% lidocaine and 40 mg of Kenalog-10 is injected slowly along the median nerve. The injection area is cleansed and a bandage is applied to the site. What codes are reported?
a.  20526
b.  20550
c.   20551
d.  20605

39. A 22 year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture while on vacation. The patient was given general anesthesia and the elbow was reduced and was stable. The medial epicondyle was held in the appropriate position and was reduced in acceptable position and elevated. A long arm splint was applied. The patient is referred to an orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported?
a.  24565-54-RT, 24605-54-51-RT
b.  24577-54-RT, 24600-54-51-RT
c.   24575-54-RT, 24615-54-51-RT                               
d.  24576-54-RT, 24620-54-51-RT

40. A young man with left tibial shaft fracture is provided open treatment without intramedullary implant.After the procedure the leg was placed in a short leg cast. Give the appropriate CPT codes.
a) 27758
b) 27758, 29425
c) 27758, 29405
d) 27759, 29425




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