2019

Medical Auditing Training: CPMA®

Practical Application Workbook


Disclaimer
This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information
within these pages. The ultimate responsibility lies with readers to ensure they are using the codes, and following applicable
guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of
information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This
guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations.

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This product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer
software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense
by the American Medical Association, 330 N. Wabash, Chicago, Illinois, 60611. U.S. government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer
software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable,
for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject
to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable
agency FAR Supplements, for non-Department of Defense Federal procurements.

AMA Disclaimer
CPT® copyright 2018 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of
CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense
medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

Clinical Examples Used in this Book

AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees.
All examples and case studies used in our study guides, exams, and workbooks are actual, redacted office visit and procedure
notes donated by AAPC members.

To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the
stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or
to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

© 2018 AAPC
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Updated 10312018. All rights reserved.
ISBN 978-1-626886-841

CPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

ii 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
 Chapter
6

Case 1
Radiology
Re: Janine Perry Date of Service: January 5, 20XX
MR # 600-1

EXAM: X-ray hip with pelvis, 1 view, left

INDICATION FOR PROCEDURE:

Total hip arthroplasty.

TECHNIQUE
Single view of the left hip and single view of the pelvis with comparison to radiographs earlier the same day from 1547 hours,
which were intraoperative, and with June 20, 20XX.

FINDINGS
Interval left total hip arthroplasty changes with acetabular augmentation screws. No evidence of immediate postoperative compli-
cation. Expected postsurgical changes of the soft tissues. Right hip shows minimal degenerative changes. Minimal degenerative
changes of the bilateral sacroiliac joints. L5-S1 disk space narrowing is seen.

IMPRESSION
Left total hip arthroplasty without evidence of immediate postoperative complication.

Electronically signed by Thomas Butler, MD 1230

Radiology Department Coding Fee Ticket

Patient Name Janine Perry

Medical Record Number/Account Number 600-1
Radiologist Thomas B. Butler, MD
Insurance Company UHC Metrahealth
Comments

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
1/5/20XX AAPC Hospital 21 73500 V43.64 26, LT 1 $18.00
1/5/20XX AAPC Hospital 21 72170 V43.64 26 1 $18.00
Total $36.00

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 Chapter 6

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Coding fee ticket is correct with no coding error or discrepancies.

B. Date of service discrepancy.

C. Incorrect place of service.

D. Indication for service is unclear on why the X-rays are being done.

2. The documentation supports what CPT® and ICD-10-CM codes?

A 73502-26-LT; 72170-26; M16.12

B. 73501-26-LT; 72170-26; M16.12, Z96.642

C. 73501-26-LT; Z96.642

D. 73502-26-LT; T84.091, Z96.642

Case 2
Radiology
Re: Mark C. Kennedy Date of Service: January 5, 20XX
MR # 600-2

EXAM: X-ray thoracic spine

INDICATION FOR PROCEDURE:

Nontraumatic pain, back.

TECHNIQUE
Four views of the thoracic spine without comparison examination.

FINDINGS
Spinal alignment is normal, intervertebral disk spaces and vertebral body heights are maintained. No significant appearing
degenerative changes.

IMPRESSION
Unremarkable thoracic spine.

EXAM: X-ray lumbar spine, 2 views

INDICATION FOR PROCEDURE: Nontraumatic pain, back

TECHNIQUE
Three views of the lumbosacral spine without comparison

FINDINGS

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Chapter 6

Five non-rib bearing lumbar type vertebrae. Stranding of the lumbar spine, otherwise spinal alignment is unremarkable. Verte-
bral body heights and intervertebral disk spaces are maintained. No acute fracture or listhesis.

IMPRESSION
No acute or degenerative changes
Electronically signed by Janice Wise, MD; 01/05/20XX; 11:30 AM

Radiology Department Coding Fee Ticket

Patient Name Mark C. Kennedy

Medical Record Number/Account Number 600-2
Radiologist Janice Wise, MD
Insurance Company BCBS
Comments

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
11/5/20XX XYZ 22 72074 M54.9 26 1 $23.00
Outpatient
Hospital
11/5/20XX XYZ 22 72110 M54.9 26 1 $23.00
Outpatient
Hospital
Total $46.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Incorrect place of service and date of service

B. Date discrepancy and one of the radiology codes is incorrect

C. Indication for service is not clear and discrepancy with the number of views for both radiology codes

D. Radiology and diagnosis codes are correct.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 72072-26; 72100-26; M54.89

B. 72074-26; 72100-26; M54.9

C. 72072-26; 72110-26; M54.6, M54.5

D. 72074-26; 72110-26; M54.9

CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 151
 Chapter 6

Case 3
Radiology
Re: Marie Hamilton Date of Service: January 5, 20XX
MR # 600-3

EXAM: IRL RFS Thoracentesis Therapeutic RFS

INDICATION FOR PROCEDURE:

Dyspnea and pleural effusion.

The risks, benefits, and alternatives of the procedure were explained to the patient. Informed written consent was obtained.

FINDINGS
The right hemithorax was evaluated with ultrasound and demonstrates a moderate size pleural effusion. A posterior intercostal
approach was selected. The overlying skin was prepped and draped in usual sterile fashion. 1% local lidocaine was used as superfi-
cial and deep anesthetic. Using ultrasound guidance a Yueh centesis catheter was advanced into the pleural space and 1500 cc’s of
yellow straw-colored fluid was removed. The patient tolerated the procedure well without immediate complication.

Electronically signed by Jacinto Munez, MD; 01/05/20XX; 1305

Radiology Department Coding Fee Ticket

Patient Name Marie Hamilton

Medical Record Number/Account Number 600-3
Rad Tech Michael G Ray
Insurance Company Medicaid
Comments

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
1/5/20XX XYZ Outpa- 22 32555 J90 1 $1266.00
tient Hospital

Total $1266.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Coding fee ticket is correct with no coding errors or discrepancies.

B. Date discrepancy and indication for service

C. CPT® code and diagnosis codes are incorrect.

D. Rendering physician not correct on the coding fee ticket.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 32555, 76942-26, J91.8

B. 32555, J90

C. 32557, 76942-26, J90

D. 32557, J91.8

152 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 6

Case 4
Radiology
Re: Stephen P. Jordan Date of Service: January 5, 20XX
MR # 600-4

EXAM: X-ray lumbar spine

CLINICAL INDICATION:
Nontraumatic low back pain.

TECHNIQUE
Three views of the lumbosacral spine

FINDINGS
Five non-rib bearing lumbar type vertebrae. There is lumbar dextroscoliosis with a curvature of approximately 20 degrees. Disk
space narrowing and endplate sclerosis with spurring most pronounced at the L2-L3 and L3-L4 level on the left. Vertebral body
heights are maintained. Spinal alignment is normal.

IMPRESSION
1. Lumbar spondylosis with discogenic disease and dextroscoliosis worse at the L2-L3 and L3-L4 level.
2. No acute findings.

Electronically signed by Robert Hayes, MD; January 5, 20XX; 1324

Radiology Department Coding Fee Ticket

Patient Name Stephen P. Jordan

Medical Record Number/Account Number 600-4
Radiologist Robert Hayes, MD
Insurance Company Medicaid
Comments

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
1/5/20XX XYZ Outpatient 72100 M47.816 26, LT 1 $23.00
Hospital M51.26
M41.26
Total $23.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Place of service

B. Date discrepancy and indication for service

C. Indication for service

D. Physician service missing and date of service wrong

CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 153
 Chapter 6

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 72100-26, M47.817, M41.26

B. 72082-26, M47.817, M41.27

C. 72100-26, M47.816, M51.26, M41.26

D. 72082-26, M47.816, M51.26, M41.27

Case 5
Radiology
Re: Teresa Blake
MR # 600-5

EXAM: CT Abd/Pelvis w/o IV Contrast

Pain. Evaluate for stone.

TECHNIQUE
Unenhanced CT examination of the abdomen and pelvis per renal colic protocol.
Coronal and sagittal reformatted images.

COMPARISON
No prior CT.

FINDINGS
There is a less than 2 mm nonobstructing punctate stone is seen in the left kidney. There is a nonobstructing less than 2 mm stone
in the inferior pole of the right kidney. No right-sided hydronephrosis or hydroureter. Minimal left pelvic caliectasis.

There is diffuse hypodensity of the liver. The remaining unenhanced solid and hollow abdominal and pelvic organs are grossly
unremarkable. The appendix is normal. No free fluid in the pelvis. Multilevel discogenic bulges in the lower lumbar spine and
mild multilevel facet arthropathy in the lower thoracic spine. Otherwise, osseous structures are grossly unremarkable.

IMPRESSION
1 Bilateral nonobstructing punctate nephrolithiasis.
2. Pelvic caliectasis
3. Hepatic steatosis.

Findings discussed with Dr. Tomlinson in the emergency department at 1313 hours.

Electronically signed by TB Butler MD

154 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 6

Radiology Department Coding Fee Ticket

Patient Name Theresa Bradd

Medical Record Number/Account Number 600-5
Radiologist Thomas B. Butler, MD
Insurance Company Self Pay
Comments

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
1/5/20XX AAPC ER 23 74176 N20.0 26 1 $194.00
N28.89
K76.0
Total $194.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Place of service is not correct

B. Date of service missing and patient’s name discrepancy.

C. CPT® radiology code is not correct.

D. Diagnosis codes are not correct.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 74178-26, N20.9, N28.9, K76.89

B. 74174-26, N20.2, N28.9, K76.89

C. 74176-26, N20.0, N28.89, K76.0

D. 74150-26, N20.0, N28.89, K76.0

CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 155
 Chapter 6

Case 6
Radiology
Re: Jerry W. Sloan Date of Service: January 5, 20XX
MR # 600-6

EXAM: CT Head wo/w IV Contrast

INDICATION FOR PROCEDURE

Fall with possible head or brain injury.

TECHNIQUE
Pre and post contrast-enhanced examination of the head with coronal and sagittal reformatted images.

FINDINGS
No acute intracranial hemorrhage. No midline shift or mass effect. There is diffuse prominence of the ventricular system with
periventricular white matter hypodensity and diffuse sulcal prominence. 12 mm ovoid hypodensity in the left thalamus is noted.
There are also several smaller hypodensities in the anterior limbs of the bilateral internal capsules, bilateral caudate nuclei and
extreme capsules. Atheromatous calcifications in the bilateral vertebral arteries and bilateral ICA carotid siphon regions. Normal
opacification of the intracranial arterial vessels and visualized venous sinuses. Normal parenchymal enhancement without
evidence of vascular malformation or enhancing mass.

The calvaria is intact. Paranasal sinuses and mastoid air cells are clear.

IMPRESSION
1. Fall with no acute intracranial hemorrhage or mass effect.
2. Age-related involutional changes with degenerative brain parenchymal atrophy and findings suggestive of chronic small
vessel ischemic change.

EXAM: X-ray abdomen, 2 Views

INDICATION FOR PROCEDURE:

Abdominal distention.

TECHNIQUE
Supine and a left lateral decubitus view of the abdomen.

Comparison with the prior day. Correlation with CT examination of the prior day as well.

FINDINGS
Mild diffuse gaseous distension of the bowel without abnormal dilation. There is no free air on the lateral decubitus view. The
bilateral renal collecting systems and bladder are opacified with excreted contrast from the prior day’s CT examination. Multiple
surgical clips overlie the left upper abdomen and mid to lower abdomen. Senescent changes of the osseous structures and partially
visualized sternotomy wires noted.

IMPRESSION
No evidence of bowel obstruction. Probably mild colonic ileus.
Electronically signed by Thomas B Butler, MD; 01/05/20XX; 1934

156 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 6

Radiology Department Coding Fee Ticket

Patient Name Jerry W. Sloan

Medical Record Number/Account Number 600-6
Radiologist Thomas B. Butler, MD
Insurance Company Medicare
Comments

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
1/5/20XX AAPC 21 70470 G31.9 26 1 $132.00
Hospital W19.XXXA
1/5/20XX AAPC 21 74019 R14.0 26 1 $28.00
Hospital
Total $160.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Place of service and date of service are incorrect.

B. Date of service discrepancy.

C. CPT® and diagnosis codes are incorrect.

D. Coding fee ticket is correct with no coding errors or discrepancies..

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 70470-26, 74019-26, G31.9, R14.0, W19.XXXA

B. 70450-26, 70460-26, 74021-26, W19.XXXA, G31.9, R14.0

C. 70460-26, 70419-26, I67.82, R14.0

D. 70450-26, 70460-26, 74021-26, I67.81, R14.0

CPT® copyright 2018 American Medical Association. All rights reserved. www.aapc.com 157
 Chapter 6

Case 7
Radiology
Re: Pauline Jones Date of Service: January 5, 20XX
MR # 600-7

EXAM: X-RAY Abdomen 2 Views

INDICATION FOR PROCEDURE:

Bowel obstruction

TECHNIQUE
Supine and left lateral decubitus views of the abdomen with comparison to the prior day.

FINDINGS
Mildly dilated left upper quadrant and epigastric small bowel loops measuring up to 3.9 cm in diameter are not significantly
changed. Suggestion of mild bowel wall thickening again noted. No free air is seen on the lateral decubitus view. Stool and air
are present within the rectum. Multiple pelvic phleboliths. Right upper quadrant surgical clips and distal portion of enteric tube
overlying the gastric area noted.

IMPRESSION
Small bowel obstruction vs. ileus with bowel wall thickening most often secondary to inflammatory, infectious, or ischemic
etiologies, not significantly changed from prior.

Radiology Department Coding Fee Ticket

Patient Name Pauline Jones

Medical Record Number/Account Number 600-7
Physician
Insurance Company AAPC Insurance
Comments

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
1/5/20XX AAPC 21 74019 K56.2 26 1 $28.00
Hospital
Total $28.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. CPT® code is not correct.

B. No indication for service is provided.

C. Date of service is not correct on the fee ticket.

D. Provider signature missing.

158 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 6

2. What other problem areas were discovered during the audit?

A. The provider coded all services correctly; therefore, no problem areas need to be addressed.

B. Diagnosis is not correct.

C. Patient’s name discrepancy.

D. Any administered contrast agents were not documented clearly.

Case 8
Radiology
Re: Betty Davis Date of Service: January 5, 20XX
MR # 600-8

EXAM: MAMM Screen Bilateral Digital-CAD

INDICATION FOR PROCEDURE:

Breast screening. Two sisters with breast Ca. Benign right breast biopsy in 20XX. No current complaints.
Films are interpreted in conjunction with CAD.

FINDINGS
The breast parenchyma remains heterogeneously dense. Vascular and other benign-appearing calcifications are again seen. A
biopsy clip at the 4 o’clock position of the anterior right breast is again noted. A nodule with internal coarse calcifications at the 4
o’clock position of the anterior left breast is again seen. There is no architectural distortion identified.

IMPRESSION

Benign mammographic findings. Calcifications in both the right and left breasts. Advise routine screening to follow up.

BI-RADS CATEGORY 2 BENIGN FINDING

Your patient will be receiving a normal letter.

PLEASE NOTE
1. A negative mammogram report should not delay biopsy of a clinically suspicious mass, since approximately 10 to 15
percent of breast malignancies are not demonstrable mammographically.
2. Heterogeneously dense and very dense breast tissue decreases the sensitivity of mammography. In these patients, MRI
could be of benefit.
3. It is the patient’s responsibility to supply information about the date and place of her/his previous screening mammo-
graphic procedures.
4. The original images or films are being placed in the patient’s medical imaging record.
5. The American Cancer Society has determined screening mammograms are an important part of ongoing healthcare and
has established guidelines.

Electronically signed by Tanya Mars, MD; 01/05/20XX; 1934

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 Chapter 6

Radiology Department Coding Fee Ticket

Patient Name Betty Davis

Medical Record Number/Account Number 600-8
Physician Tanya Mars, MD
Insurance Company AAPC Insurance
Comments

Date of Facility Place of CPT® Diagnosis Modifier Quantity Fee

Service Service Code(s) Code(s)
1/5/20XX AAPC Hospital 21 77067 Z12.31 26 1 $255.00
Mammography Z80.3 R92.1
Center
Total $255.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Date of service discrepancy.

B. Diagnosis codes are not reported correctly.

C. Indication for service is unclear.

D. Place of service is incorrect.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 77067, R92.1

B. 77065-26 x 2, Z12.31, Z85.3, R92.1

C. 77067-26, Z12.31, Z80.3, R92.1

D. 77067-26-50, Z12.31, Z80.3, R92.1

160 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.
Chapter 6

Case 9
Radiology
Re: Jill Jones Date of Service: June 10, 20XX
MR # 600-9

EXAM: X-RAY Shoulder, Right

INDICATION FOR PROCEDURE:

Right shoulder pain.

TECHNIQUE
Three views of the right shoulder are obtained.

FINDINGS
There is no fracture or dislocation identified.

IMPRESSION
No fracture or dislocation seen.
Electronically signed by Haylee Abel, MD; 6/10/20XX; 1734

Radiology Department Coding Fee Ticket

Patient Name Jill Jones

Medical Record Number/Account Number 600-9
Physician Haylee Abel, MD
Insurance Company AAPC Insurance
Comments

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
6/10/20XX AAPC ER 23 73030 M25.511 26 1 $19.00
Total $19.00

1. When meeting with the radiologist post audit, which of the following needs to be addressed?

A. Place of service is incorrect.

B. Indication for service is unclear.

C. Date of service discrepancy.

D. Coding fee ticket is correct with no coding errors or discrepancies.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 73030-26-RT, M25.511

B. 73020-26-50, M25.111, M25.512

C. 73030-26 x 3, M25.111, S42.90XA

D. 73020-26 x 3, S42.90XA

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 Chapter 6

Case 10
Radiology
Re: Mary Black Date of Service: January 5, 20XX
MR # 600-10

EXAM: X-RAY Chest X-Ray 2 View

INDICATION FOR PROCEDURE:

Cough

TECHNIQUE
AP and lateral views of the chest are obtained without comparison study.

FINDINGS
The heart is normal in size. Small right upper lobe infiltrate is noted. No effusion or pneumothorax seen.

IMPRESSION
Small right upper lobe infiltrate. Consider follow up until resolution.

Electronically signed by Katelyn Jones, MD; 01/05/20XX; 1934

Radiology Department Coding Fee Ticket

Patient Name Mary Black

Medical Record Number/Account Number 600-10
Physician Katelyn Jones, MD
Insurance Company AAPC Insurance
Comments

Date of Facility Place of CPT® Code(s) Diagnosis Modifier Quantity Fee

Service Service Code(s)
1/5/20XX AAPC ER 23 71045 R91.8 26 1 $23.00
Total $23.00

1. What information is missing to validate the service provided?

A. Place of service is not correct.

B. Diagnosis code is not correct.

C. CPT® code is not correct.

D. Coding fee ticket is correct with no coding errors or discrepancies.

2. The documentation supports what CPT® and ICD-10-CM codes?

A. 71045-26, R91.8

B. 71046-26-TC, R05, R91.8

C. 71046-26, R91.8

D. 71045-TC, R05

162 2019 Medical Auditing Training: CPMA® CPT® copyright 2018 American Medical Association. All rights reserved.