AAPC CPC Ch. 13 Review
A 52-year-old patient is scheduled for surgery for a right ovarian mass. Through an open incision, the surgeon finds a healthy left ovary. A right ovarian mass is visualized, and the decision is made to remove the mass and the right ovary. What CPT® code is reported?
Answer: A. 58940 Rationale: The right ovary was removed which is an oophorectomy. Code 58925 reports removal of an ovarian cyst. Code 58920 reports removal of a wedge (triangular piece) of an ovary or of both ovaries. Code 58720 reports the removal of tube and ovary, unilateral or bilateral. Look in the CPT® Index for Ovary/Excision/Total 58940-58943. Code 58940 is reported for the removal of an ovary. Verify in the numeric section.
Which of the following are also known as the greater vestibular glands?
Answer: A. Bartholin's glands Rationale: Bartholin's glands are the large glands located on either side of the vaginal introitus or opening. Another name for these glands is greater vestibular glands.
Physician performs an incision and drainage of an abscess located on the labia majora. What CPT® code is reported?
Answer: B. 56405 Rationale: The vulva consists of the external female genitalia, which includes the labia minora and majora, clitoris, and vestibule. Code 56405 reports the I&D of the abscess of the vulva or perineal abscess. Because there is a specific code for an I&D of an abscess of the vulva, do not code 10060. Look in the CPT® Index for Incision and Drainage/Abscess/Vulva 56405 Verify in the numeric section.
A 63-year-old patient has severe intramural fibroids. The surgeon performs an open total abdominal hysterectomy with removal of the fallopian tubes and ovaries. What CPT® code is reported?
Answer: B. 58150 Rationale: This is an open total abdominal hysterectomy, not a vaginal hysterectomy 58262. The procedure was not performed laparoscopically 58548. It does not mention that a partial vaginectomy with para-aortic and pelvic lymph node sampling was performed 58200. Look in the CPT® Index for Hysterectomy/Abdominal/Total 58150, 58200, 58956. The correct code is 58150. Verify in the numeric section.
A pregnant patient presents to the ED with cramping and bleeding. On examination, the cervix is dilated and there are no retained products of conception. The physician documents an abortion at 10 weeks. What is the type of abortion?
Answer: B. Spontaneous abortion Rationale: ICD-10-CM and CPT® recognize three types of abortions, spontaneous (also called a miscarriage), induced or therapeutic (TAB) caused by a deliberate procedure, or missed. A missed abortion occurs when the fetus dies but the products of conception are retained.
The two structures that make up the uterus are:
Answer: B. The cervix and uterine fundus Rationale: The uterine tubes, vulva, and vagina are not part of the uterus. The uterus is made up of the cervix (cervix uteri) and the fundus (corpus uteri).
A patient delivers twins at 32 weeks gestation for her first pregnancy. The first baby is delivered vaginally, but during the delivery, the second baby turns into a breech position. The physician decides to perform a cesarean delivery for the second baby. The physician also provided antepartum and postpartum care. How would the deliveries be reported?
Answer: C. 59510, 59409-51 Rationale: Only one baby is delivered vaginally making 59400, 59409-51 incorrect. Only one baby was delivered by cesarean section making 59510 incorrect. Because this is the patient's first pregnancy, do not report codes 59618, 59612. Look in the CPT® Index for Cesarean Delivery/Routine Care 59510 and Vaginal Delivery/Delivery Only 59409. Modifier 51 is appended to indicate additional procedures during the same session. The code with the highest value is sequenced first. Verify codes in the numeric section.
Which of the following structures in the female reproductive system is not bilateral?
Answer: C. Cervix Rationale: The ovaries and salpinges (fallopian tubes) are found on both sides of the uterus. The Bartholin's glands are found on both sides of the vaginal introitus. The cervix is singular, connecting the uterus to the vagina.
If you know that the suffix -scopy means to use a scope to examine a body structure, what word means a scope procedure to examine the vagina?
Answer: C. Colposcopy Rationale: The root word colp/o means vagina; colposcopy is examination of the vagina using a scope.
Choose the code for VIN III.
Answer: C. D07.1 Rationale: VIN III is coded as cancer in situ and VIN indicates a vulvar lesion. Look in the ICD-10-CM Alphabetic Index for VIN and you are directed to see Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for Neoplasia/intraepithelial/vulva/grade III referring you to D07.1. Verify in the Tabular List.
A woman with a long history of essential hypertension is managed throughout her pregnancy and delivers today. The hypertension has not resolved after the delivery. How is this coded?
Answer: C. O10.03 Rationale: It is important to assess if a condition existed prior to pregnancy, developed during, or due to the pregnancy in order to assign the correct code. In this case, the hypertension is pre-existing. Look in the ICD-10-CM Alphabetic Index for Hypertension/complicating/puerperium, pre-existing/pre-existing/essential O10.03. Puerperium is the time period immediately after the birth of the baby and up to six weeks following childbirth. Hypertension (I10) is not reported separately; it is included in O10.03.
Which one of the following is not part of the definition of code O80?
Answer: C. With forceps Rationale: Code O80 is for a normal delivery requiring minimal or no assistance, with or without episiotomy, without fetal manipulation [eg, rotation version] or instrumentation [forceps] of a spontaneous, cephalic, vaginal, full-term, single, live-born infant. Forceps delivery is found in the ICD-10-CM Alphabetic Index under Delivery/failed/forceps directing you to O66.5.
Patient comes in with uterine bleeding. Physician performs a diagnostic dilation and curettage by scraping all sides of the uterus. What CPT® code is reported?
Answer: D. 58120 Rationale: The D&C is performed in the uterus. Look in the CPT® Index for Dilation and Curettage/Corpus Uteri 58120. There is no mention that the patient is postpartum, so you do not report 59160. Verify in the numeric section.
The uterine adnexa refers to which two structures of the female reproductive system?
Answer: D. Fallopian tubes and ovaries Rationale: The word adnexa means appendages. Uterine appendages are the tubes and ovaries.
A 68-year-old female presents with vaginal bleeding. It has been five years since her last period. Choose the code to describe her bleeding.
Answer: D. N95.0 Rationale: This bleeding is after the end of the woman's menses and is described as postmenopausal. Look in the ICD-10-CM Alphabetic Index for Bleeding/postmenopausal N95.0. Verify in the Tabular List.
CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75-year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She is back for a pessary fitting today. FINDINGS: She has a third-degree cystocele, and after examination we've determined she actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse. Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved, but much less thin than prior appointment. DESCRIPTION OF PROCEDURE: After her exam, I started with a #4 ring pessary with support. This was clearly not large enough and the cystocele was coming around it. I then went to a #5 ring pessary with support with the same problem. I went to the #6 ring pessary with support.(The provider indicates the size of the pessary that he is fitting.) It did not lodge behind her pubic bone very well, but it definitely reduced all o
Correct Answer: [a] 57160 Correct Answer: [b] N81.3 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. The procedure performed is an insertion of a pessary. A pessary is a device placed in the vagina as supportive structure for the uterus. In the CPT® Index, look for Pessary/Insertion. Don't report the stage II uterine prolapse diagnosis you see in the Diagnoses header. In the Findings see "thirddegree uterine prolapse." Third-degree prolapse is considered complete uterine prolapse. Use this information in selecting the ICD-10-CM code. Look in the ICD-10-CM Alphabetic Index for Cystocele/female/with prolapse of uterus referring you to see Prolapse, uterus. Pay careful attention to the 4th character.
Patient has a LEEP conization for CIN II. What are the CPT® and ICD-10-CM codes reported for this procedure?
Correct Answer: a. 57522, N87.1 Rationale: In the CPT® Index, look for Conization/Cervix directing you to codes 57461, 57520, 57522. Code 57461 is LEEP performed with a colposcopy, but a colposcopy was not performed in this case. LEEP stands for loop electrode excision procedure and is reported with CPT® code 57522.In the ICD-10-CM Alphabetic Index look for CIN, which directs you to see Neoplasia, intraepithelial, cervix. Look for Neoplasia/intraepithelial/cervix/grade II directing you to code N87.1. Tabular List confirms CIN II is coded N87.1. Moderate dysplasia of cervix is another name for CIN II.
CASE 2 Indications: 21-year-old, G3, P1-0-2-1,(Patient has been pregnant three times, has given birth to a term infant one time, has had two abortions/miscarriages and has one living child.) found to have an abnormal cervical Pap test (Abnormal cervical Pap smear is the diagnosis.) with possible LGSIL.(Low-Grade Squamous Intraepithelial Lesion (LGSIL) is documented as possible so it is not coded.) She presents for follow-up pap and colposcopy. EXAM: Pubic hair is shaved. Negative inguinal adenopathy. The urethra, the introitus, and anus are grossly normal. Vagina is long, and an extra-long Pederson speculum is needed. Cervix is posterior, parous. Uterus anteverted, normal size. Some tenderness of the adnexa to deep palpation. No cervical motion tenderness. Normal discharge. Pap test was performed.(Pap test is performed.) COLPOSCOPIC PROCEDURE: Speculum was inserted for the colposcopy. An extra-long, narrow Pederson speculum was required and the cervix was visualized. 3% acetic acid was placed and the T-zone is large and bleeds to touch. The 3% acetic acid was placed, and several aceto-white lesions were noted, particularly at the 12- and 11 o'clock positions. Lugol solution was placed, a
Correct Answer: [a] 57460 Correct Answer: [b] R87.619 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. A colposcopy with a loop electrosurgical excision procedure (LEEP) biopsy is performed. Start in the CPT® Index with LEEP Procedure and verify the procedure listed. The Indications header shows an abnormal cervical Pap test is the reason for the procedure. You can't report "possible LGSIL." In the ICD-10-CM Alphabetic Index. Look for Abnormal/Papanicolaou (smear)/cervix to report the correct diagnosis code.
CASE 4 PREOPERATIVE DIAGNOSIS: Severe cervical dysplasia. POSTOPERATIVE DIAGNOSIS: Severe cervical dysplasia. PROCEDURE PERFORMED: Cold knife conization.(A cold knife conization is a biopsy performed to sample abnormal tissue from the cervix.) ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 25 cc. FLUIDS: 500 cc crystalloid. DRAINS: Straight catheter x 1. INDICATIONS: All risks, benefits and alternatives of this procedure were discussed with the patient and informed consent was obtained. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. She was prepped and draped in the normal sterile fashion after being placed in the dorsal lithotomy position. Attention was turned to the patient's pelvis where a weighted speculum was placed inside the patient's vagina.(A vaginal approach is performed.) The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 10 units of Pitressin and 20 cc of normal saline. A #2-0 Vicryl stitch was used at the 3 o'clock and 9 o'clock positions on the cervix to ligate the cervical branch of the uterine artery. PROCEDU
Correct Answer: [a] 57520 Correct Answer: [b] D06.9 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. A cold knife conization is performed for cervical dysplasia. The surgical approach and method of the conization will determine the proper CPT® code. In the CPT® Index look for Conization/cervix. The diagnosis listed is severe cervical dysplasia. In the ICD-10-CM Alphabetic Index look for Dysplasia/cervix (uteri)/severe.
CASE 10 DIAGNOSES: 1. Complete procidentia PROCEDURES: 1. Vaginal hysterectomy 2. Anterior and posterior colporrhaphy 3. Cystoscopy 4. Vaginal vault suspension SPECIMENS: Uterus and cervix. FINDINGS: A thick hypertophic ulcerated cervix was noted. The adnexa were small and atrophic. Complete procidentia with cystocele and rectocele. Cystoscopy done after indigo carmine was administered, at the end of the case, revealed bilateral strong ureteral jets. INDICATIONS: Her cervix was found to be ulcerated, erythematous and hypertrophic. Cervical biopsy was negative for neoplasia. She desires surgical management of these problems. OPERATION: The patient was taken to the operating room and placed in lithotomy position while awake. The patient has a history of bilateral knee replacements and cannot bend her legs. We put her in lithotomy position using Yellofin stirrups, keeping her legs without any bend and positioning her while she was awake in a comfortable way. The patient was then placed under general anesthesia. An exam under anesthesia was done with findings of a complete procidentia with ulcerations posteriorly. The vagina and perineum was prepped in the usual sterile fashion. A tenaculum
Correct Answer: [a] 58260 Correct Answer: [b] 57260-51 Correct Answer: [c] 57283-59 Correct Answer: [d] N81.3 Correct Answer: [e] N32.89 Response Feedback: There are three CPT® codes and two ICD-10-CM codes reported. 1. When a hysterectomy is performed, and the uterus is not weighed, it is coded with the lower weight. In the CPT® Index, look for Hysterectomy/Vaginal. 2. A combined anteroposterior colporrhaphy repairs the vaginal wall. An enterocele repair was not performed with this procedure. In the CPT® Index, look for Colporrhaphy/Anteroposterior. Report a modifier on this code to indicate more than one procedure is being performed in the surgery. 3. The next code to report is the vaginal colpopexy. The cystoscopy is not reported separately because it is included in the procedure to make sure there are no urinary tract complications from the procedure. In the CPT® Index, look for Colpopexy/Vaginal 4. There is a modifier required on the third procedure to indicate it is a separate procedure and medically necessary. You are not expected to look up the NCCI Edits. There are two diagnoses codes to report. The first one is for the cystocele with complete uterine prolapse. In the ICD-10-CM Alphabetic Index, look for Cystocele/with prolapse of uterus; the second code is for the trabeculation of the bladder.
CASE 9 CHIEF COMPLAINT: Contraceptive placement of IUD INDICATIONS: Ms. Barrett is coming into the office for placement of an IUD. She is a 29-year-old, gravida 1, para 1-0-0-1 who is status post a normal spontaneous vaginal delivery of a male infant weighing 4,086 grams. She has not had intercourse since delivery. She is interested in an IUD at this time. PROCEDURE: After obtaining consent, the patient is placed in the dorsal lithotomy position. A speculum was placed in the vagina to visualize the cervix. The cervix was cleaned three times with Betadine. Following this, a single-tooth tenaculum was placed on the anterior lip of the cervix. The uterus was sounded to approximately 6.5 cm. The Skyla IUD 13.5 mg, was then placed in the usual fashion and the strings cut to 2.5 cm. The lot number is TU003SL. The patient tolerated the procedure well, and hemostasis was achieved at the tenaculum site after removal. The patient tolerated the procedure well and was provided instructions to return if she should have any difficulties. What are the CPT® and ICD-10-CM codes? CPT® codes: [a], [b] ICD-10-CM code: [c]
Correct Answer: [a] 58300 Correct Answer: [b] J7301 Correct Answer: [c] Z30.430 Response Feedback: There is one CPT® code, one HCPCS Level II code, and one ICD-10-CM code reported. An insertion of an intrauterine device (IUD) is performed. For the procedure, look in the CPT® Index for Insertion/Intrauterine Device (IUD). A HCPCS Level II code is also reported for the type of intrauterine device inserted used. In the HCPCS Level II codebook, locate the Table of Drugs and Biologicals and look for Skyla 13.5 mg. The diagnosis is a Z code for the IUD insertion. Look in the ICD-10-CM Alphabetic Index for Intrauterine contraceptive device/insertion.
CASE 8 ABC Hospital Indication: 30 year-old G0P0Ab0 with irregular periods. She is infertile and requires hysterosalpingogram for evaluation to see if there is a cause for the infertility. PROCEDURE NOTE: The patient was brought to the outpatient surgical suite. After written consent was obtained and written final verification, the cervix was visualized with a Pedersen speculum, anesthetized with Cetacaine spray and swabbed with three swabs of Betadine scrub and an endocervical prep. A single-tooth tenaculum was placed on the anterior lip of the cervix without problems. An HSG catheter was introduced through the cervix. At this point the balloon was insufflated with 1 ml of normal saline within the cervix, speculum was then removed. Ethiodol contrast, approximately 8 ml, was instilled under fluoroscopic guidance. Under fluoroscopic guidance, the uterus shape was found to be normal. The tubes filled and spilled on the left. The right tube filled normally but no spill could be documented due to exuberant spill from the left. The patient was instructed to roll completely for two revolutions. An additional film was taken which showed normal dispersion. Plan: Follow-up as scheduled. What are
Correct Answer: [a] 58340 Correct Answer: [b] 74740-26 Correct Answer: [c] N97.9 Response Feedback: There are two CPT® codes and one ICD-10-CM code reported. A hysterosalpingography involves insertion of a catheter into the cervical opening and injection of contrast material into the endometrial cavity. Radiographic pictures are taken of the uterus and fallopian tubes. In the CPT® Index, look for Hysterosalpingography/Injection Procedure. This code has a parenthetical note to list another code for the radiological supervision and interpretation. This is the second CPT® code. You will need a professional component modifier on the radiology code to indicate the physician service. Look in CPT® Appendix A for the Professional Component modifier. The hysterosalpingogram is performed for infertility. Look in the ICD-10-CM Alphabetic Index for Infertility/female.
Patient with genital warts has cryotherapy of an extensive number of lesions on her mons pubis, labia and perineum. How is this procedure coded?
Correct Answer: d. 56515 Rationale: The mons pubis and labia are part of the vulva. In the CPT® Index look for Destruction/Lesion/Vulva/Extensive and you are referred to 56515. The extensive code is reported due to the extensive number of lesions. Verify the code in the numeric section.
CASE 3 ANESTHESIA: General with LMA. PREOPERATIVE DIAGNOSIS: Patient requesting sterilization. POSTOPERATIVE DIAGNOSIS: Sterilization.(Select a code from the postoperative diagnosis.) PROCEDURE PERFORMED: Tubal ligation with bilateral Falope-ring application.(Indicates the tubal ligation by Falope ring. This method of sterilization uses a small silastic ring shaped band placed around a loop of each fallopian tube.) COUNTS: Needle, sponge and instrument counts were correct. INTRAOPERATIVE MEDICATIONS: 0.25% Marcaine with epinephrine. OPERATIVE FINDINGS: The left ovary was mildly adhered to the side of the uterus. The right ovary appeared normal. Both tubes appeared normal. The upper abdomen appeared normal. There was a small subserosal fibroid approximately 1 to 1.5-cm on the left upper aspect of the uterus. DESCRIPTION OF PROCEDURE: After informed consent, Ms. Mathews was taken to operating suite #4 and a general anesthetic was administered. She was placed in the dorsal lithotomy position. She was sterilely prepped and draped in the usual manner. A sponge stick was placed vaginally. An infraumbilical incision(The incision is made below the navel.) was made and a non-bladed trocar and she
Correct Answer: [a] 58671 Correct Answer: [b] Z30.2 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. This is a sterilization in which a tubal ligation is performed with placement of Falope rings on the right and left fallopian tubes. It is a laparoscopic procedure. In the CPT® Index look for Fallopian Tube/Occlusion/Endoscopic. A Z-code is required for the diagnosis. Look in the ICD-10-CM Alphabetic Index for Encounter (with health service) (for)/sterilization to report the correct code.
CASE 7 PROCEDURE PERFORMED: Amniocentesis. INDICATIONS: The patient is a 28 year-old G4 P2103 at 36 weeks, here in the office today for amniocentesis for FLM secondary to Rh isoimmunization to D antigen. Following informed consent she elected to proceed with the amniocentesis. PROCEDURE: An ultrasound was carried out that revealed a single intrauterine gestation of 36+2 weeks in vertex presentation. A site for amniocentesis was identified in the left upper uterine segment which did not transgress the placenta and a image was retained for the record. The amniocentesis site was sterilely prepped and draped with a sterile towel and an alcohol based solution. Following this using direct ultrasound guidance a 22-gauge amniocentesis needle was sharply inserted in the amniotic fluid cavity. This returned clear amniotic fluid. 20 cc was easily aspirated and 10cc sent for FLM and 10cc held for possible OD450 if needed. The patient tolerated the procedure very well and normal fetal cardiac activity was seen following the procedure. The patient will be sent for a follow-up NST. Rhogam is not indicated as the patient is already sensitized. What are the CPT® and ICD-10-CM codes? CPT® codes: [a], [b]
Correct Answer: [a] 59000 Correct Answer: [b] 76946 Correct Answer: [c] O36.0130 Correct Answer: [d] Z3A.36 Response Feedback: There are two CPT® codes and two ICD-10-CM codes reported. In the CPT® Index, look for Amniocentesis/Diagnostic. There was ultrasonic guidance used during the procedure. There is a parenthetical note in the numeric listing instructing to report another code. The procedure is performed in the clinic office. You don't need to append a modifier for the professional component to the second code. The Indications header shows the reason for the procedure is a pregnancy complicated by Rh immunization. This is the first diagnosis. Look in the ICD-10-CM Alphabetic Index for Pregnancy/complicated by/RH immunization, incompatibility or sensitization NEC/anti-D antibody. The 6th character is determined by the trimester and the 7th character is determined by the fetus affected. This information is found in Indications. Check the notes at the beginning of ICD-10-CM Chapter 15 for choosing the 1st, 2nd, or 3rd trimester. A Z code will identify the weeks of gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation. This is your last code.
CASE 6 OB DELIVERY NOTE Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has been followed in the OB clinic with 12 normal antenatal visits. Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly progressed to 5 cm dilation. She had SROM at 0330 which showed light meconium. She continued to labor and reached the end of stage I at 1000, a period of 10 hours. FHTs showed some periods of reactivity but responded to stimulation. Stage II: Duration of Stage II (from pushing to delivery) was approximately 3 hours. A pediatric team was present. There was slight meconium staining present at delivery. Presentation was OP with right shoulder anterior shoulder. There was no nuchal cord. The cord was clamped x2 and cut and the baby was handed to pediatric team. Gender: Male Weight: 3772 grams. Apgars 8 /9 Stage III: Placenta delivered spontaneously with gentle traction and fundal massage and was intact. Vagina and cervix examined for lacerations. Inspection revealed a small second degree perineal laceration which was repaired with 3.0 Polysorb in the usual sterile fashion in layers. Another small lateral cutaneous tear was repaired with 3.0 polysorb and a figure-
Correct Answer: [a] 59400 Correct Answer: [b] O70.1 Correct Answer: [c] O77.0 Correct Answer: [d] Z37.0 Correct Answer: [e] Z3A.39 Response Feedback: There is one CPT® code and four ICD-10-CM codes reported. This patient is admitted in labor and delivers vaginally. She received her prenatal care and will be provided with postpartum care. In the CPT® Index look for Vaginal Delivery/Routine Care. The delivery has two separate complications. The first complication is a 2nd degree perineal laceration. The second complication is the meconium. In the ICD-10-CM Alphabetic Index, look for Delivery/complicated/by/laceration/perineum, perineal/ second degree. Next, look in the Alphabetic Index for Delivery/complicated/by/meconium in amniotic fluid. The 3rd and 4th ICD10-CM codes are Z codes; one for the outcome of delivery and one for the weeks of gestation. In the Alphabetic Index, look for Outcome of delivery/single NEC/liveborn. and Pregnancy/weeks of gestation/39 weeks. Verify code selections in the Tabular List. Refer to ICD-10-CM guideline Section I.C.15.b.5.
CASE 5 DIAGNOSIS: Intrauterine pregnancy at 18 weeks with multiple fetal anomalies. PROCEDURE: D&E(Dilation and evacuation.) ANESTHESIA: Moderate sedation. INDICATIONS: The patient is a 29 year-old gravida 1(Gravida represents number of pregnancies the woman has had. Thus, gravida 1 means this is her first pregnancy.) at 18 weeks with multiple fetal anomalies, who desires a termination of pregnancy.(The number of weeks of the pregnancy and the desire to terminate the pregnancy.) DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and moderate sedation was administered by the anesthesia team.(The anesthesia was handled by an anesthesiologist, who will bill separately for their services.) The patient then placed in the dorsal lithotomy(This position is common in female reproductive procedures. The patient is lying supine with legs bent at the knees and elevated in stirrups.) position and was prepped and draped in usual sterile fashion. The laminaria and prostaglandin suppositories were removed. The patient's cervix was dilated to 5-6 cm.( Vaginal suppositories and cervical dilation were performed.) There was a bulging bag that ruptured during vaginal prep. A speculum w
Correct Answer: [a] 59855 Correct Answer: [b] Z33.2 Correct Answer: [c] O35.9XX0 Response Feedback: There is one CPT® code and two ICD-10-CM codes reported. The Indications header in the report documents what will be performed and the reason for the procedure. The patient is seen for an induced abortion by vaginal suppositories. In the CPT® Index look for Abortion/Induced/by Vaginal Suppositories. Refer to your MCT Textbook in Chapter 13 under the Abortions heading. This is a legal abortion due to fetal abnormalities. The first diagnosis is a Z code for the termination of the pregnancy. Refer to ICD-10-CM guideline, I.C.21.c.16. Next report the pregnancy complicated by fetal abnormality. Per ICD-10-CM guideline I.C.21.c.11, Z3A codes are not assigned for pregnancies with abortive outcomes.
A patient has ovarian cancer of both ovaries. She has removal of her ovaries with peritoneal washings and assessment of the abdomen for any metastases, including inspection of omentum, diaphragm and multiple biopsies. Lymph nodes in the pelvic and peri-aortic areas were also biopsied. She has previously had a hysterectomy. What are the CPT® and ICD-10-CM codes reported for this service?
Correct Answer: a. 58943, C56.3 Rationale: Patient has ovarian cancer in which there was an open approach for removal of her ovaries only (total bilateral oophorectomy) along with biopsies performed on the peritoneal, pelvic and peri-aortic lymph nodes. Look in the CPT® Index for Ovary/Excision/Total guiding you to codes 58940-58943. 58943 is correct and includes the oophorectomy for malignancy and the biopsies. This is used for with or without salpingectomy and with or without omentectomy.To report the diagnosis, ovarian cancer, look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/ovary/Malignant Primary column referring you to C56.-. In the Tabular List a 4 th character is reported for laterality. Both ovaries are cancerous reporting C56.3.
A woman presents for hysterectomy after ECC (endocervical curettage) and EMB (endometrial biopsy) indicates endometrial cancer. Transabdominal approach (incision) is chosen for exposure of all structures possibly affected. The abdomen is thoroughly inspected with no gross disease outside the enlarged uterus but several lymph nodes are enlarged and the decision is made to perform a hysterectomy with bilateral removal of tubes and ovaries and bilateral pelvic lymphadenectomy with periaortic lymph node sampling. Specimens sent to pathology confirm endometrial cancer but find normal tissue in the lymph nodes. What are the CPT® and ICD-10-CM codes reported for this service?
Correct Answer: a. 58210, C54.1 Rationale: An open approach is performed to remove the uterus, cervix, tubes, ovaries and bilateral pelvic lymph nodes along with sampling (biopsy) the peri-aortic lymph nodes. In the CPT® Index look for Hysterectomy/Abdominal/Radical referring you to 58210. The key to choosing this code from the other choices is the removal of the pelvic lymph nodes and a biopsy of the peri-aortic lymph nodes (radical procedure) which is located in the description for code 58210.Because the lymph nodes were benign, the endometrial cancer is the only diagnosis to report. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/endometrium/Malignant Primary column referring you to C54.1. Verify in the Tabular List.
Ultrasound indicates a 20-week fetus has a distended bladder and the decision is made to perform vesicocentesis. The procedure is successful and the bladder is emptied. What CPT® is code reported for this procedure?
Correct Answer: a. 59074 Rationale: In the CPT® Index look for Fetal Procedure/Fluid Drainage directing you to 59074. Verify in the numeric section.
A 26-year-old gravida 2 para 1 female has been spotting and has been on bed rest. She awoke this morning with severe cramping and bleeding. Her husband brought her to the hospital. After examination, it was determined she has an incomplete early spontaneous abortion. She is in the 12th week of her pregnancy. She was taken to the OR and a dilation and curettage (D&C) was performed. There were no complications from the procedure. She will follow-up with me in the office. She has had four antepartum visits during her pregnancy.
Correct Answer: a. 59812, 59425, O03.4 Rationale: This procedure was performed on a pregnant patient (obstetrical) for an incomplete spontaneous abortion. The first procedure to report is the dilation and curettage (D & C). Look in the CPT® Index for Abortion/Incomplete referring you to 59812. Report the antenatal care service because the patient had four antepartum visits before the abortion occurred. In the CPT® Index look for Obstetrical Care/Antepartum Care referring you to 59425, 59426. 59425 is correct for 4-6 prenatal visits.Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous) referring you to O03.4. Weeks of gestation would not be coded. ICD-10-CM guideline 1.C.21.c.11, category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08).
What is the code for ultrasound evaluation of a fetus and mother, usually performed early in pregnancy (first trimester), to confirm fetal age, set an anticipated delivery date, for qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa?
Correct Answer: a. 76801 Rationale: The service performed in this question is an ultrasound to evaluate the fetus and mother in the first trimester. In the CPT® Index look for Ultrasound/Obstetrical/Pregnant Uterus referring you to 76801, 76802, 76805, 76810-76817. Code 76801 is correct to report the evaluation of both the fetus and the mother in her first trimester. This scenario does not qualify for a non-stress test; there is no monitoring of the fetal heart.
What ICD-10-CM code is reported for VIN III?
Correct Answer: a. D07.1 Rationale: Look in the ICD-10-CM Alphabetic Index for VIN - See Neoplasia, intraepithelial, vulva. Look in the Alphabetic Index for Neoplasia/vulva/grade III (severe dysplasia) referring you to D07.1. Verify in the Tabular List. The Alphabetic Index listing for Dysplasia/vulva/severe NEC also directs you to D07.1. VIN III is listed as carcinoma in situ in the Tabular List.
A 40-year-old presents with vaginal bleeding for several weeks. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter?
Correct Answer: a. N93.9 Rationale: There is no indication that the vaginal bleeding is associated with her menstrual cycle and there is no indication of menopause. Look in the ICD-10-CM Alphabetic Index for Bleeding/vagina, vaginal (abnormal) directing you to N93.9.
Patient wishes permanent sterilization and elects laparoscopic tubal ligation with Falope ring. What is the CPT® code reported for this service?
Correct Answer: b. 58671 Rationale: Patient is having a laparoscopic tubal ligation; her fallopian tubes (oviducts) are surgically blocked off (occlusion) with a Falope rings to prevent pregnancy (permanent sterilization). In the CPT® Index, look for Laparoscopy/Ovary/Oviduct/Oviduct Surgery, which guides you to codes 58670, 58671, 58679. Review the codes and 58671 is the correct code for the procedure performed.
What procedure is performed to treat vaginal prolapse?
Correct Answer: b. Colpopexy Rationale: Vaginal prolapse occurs when the vaginal wall is stretched out and there is no support in the pelvic structure and the pelvic organs fall downward protruding through the vaginal canal. To correct this disorder, a suturing of the prolapsed vagina to its surrounding structures is performed.All the choices have the prefix colpo- which means vagina. The suffix -pexy means surgical fixation. The suffix -scopy means examination of. The suffix -ectomy means removal of. The suffix -otomy is to make an incision or cut into. The correct answer is colpopexy.
If a non-Medicare patient has an age and gender appropriate preventive medicine exam (i.e., a breast and pelvic exam) this is coded with the age appropriate Preventive Medicine codes from the E/M chapter of CPT®. If a Medicare patient has a breast and pelvic exam, how is this coded?
Correct Answer: b. G0101 Rationales: Medicare Part B requires that for pelvic examination (including clinical breast examination), use HCPCS Level II code G0101 when ordered by a physician. This information can be found on the CMS website at this link: http://www.cms.gov/manuals/downloads/Pub06_PART_50.pdf, under the CHAPTER II - COVERAGE ISSUES APPENDIX, 50-20.1. In your HCPCS Level II Index look for Screening/cancer/cervical or vaginal and you are directed to code G0101.
What does the abbreviation IVF mean?
Correct Answer: b. In vitro fertilization Rationale: In the CPT® Index, look for IVF and you are directed to See Artificial Insemination; In Vitro Fertilization. IVF stands for in vitro fertilization.
If a woman is hospitalized with severe pre-eclampsia in the 30th week of her pregnancy what is the diagnosis code for her daily visits?
Correct Answer: b. O14.13, Z3A.30 Rationale: In the ICD-10-CM Alphabetic Index look for Pre-eclampsia/severe directing you to O14.1-. Verification in the Tabular List indicates that a 6th character is reported for the trimester of the pregnancy. 30 weeks of pregnancy places the patient in her third trimester reporting O14.13. The Tabular List at the beginning of Chapter 15 defines how many weeks are in the first, second and third trimesters. You will also see an instructional note to report a code from category Z3A to indicate the weeks of pregnancy. In the Alphabetic Index look for Pregnancy/weeks of gestation/30 weeks referring you to Z3A.30. Verify in the Tabular List.
What ICD-10-CM codes are reported for an encounter for full-term uncomplicated delivery of a single live birth at 41 weeks of pregnancy?
Correct Answer: b. O80, Z37.0, Z3A.41 Rationale: Code O80 is assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications during the delivery, or postpartum during the delivery episode. Look in the ICD-10-Alphabetic Index for normal referring you to O80. Code O80 is always a principal diagnosis and is not used if any other code from Chapter 15 is needed. Additional codes from other chapters may be used with code O80 if they are not related to or are in any way complicating the pregnancy. Z37.0 for single live birth, is the outcome of delivery and this code is indicated in an instructional note in the Tabular List to use as an additional code with O80. The instructional note at the beginning of Chapter 15 states to also use a code from Z3A to identify the weeks of gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation/41 weeks referring you to Z3A.41.
The patient presents with a recurrent infection of the Bartholin's gland which has previously been treated with antibiotics and I&D. At this visit her gynecologist incises the cyst, draining the material from it and tacks the edges of the cyst open creating an open pouch to prevent recurrence. How is this procedure coded?
Correct Answer: c. 56440 Rationale: Marsupialization is a procedure where a scalpel is used to cut an opening in the top of the abscess pocket. The leaflets created by this procedure are pulled away from the pocket and attached to the surrounding skin with stitches or glue. This creates an open pouch to help prevent recurrence of the abscess. Look in the CPT® Index look for Bartholin's Gland/Cyst/Marsupialization or Marsupialization/Cyst/Bartholin's Gland directing you to code 56440. Marsupialization of Bartholin's gland cyst is reported with CPT® code 56440.
What CPT® code is used to report 50% removal of the vulva and deep subcutaneous tissues?
Correct Answer: c. 56630 Rationale: In the CPT® Index look for Vulvectomy/Radical, directing you to codes 56630, 56631, 56633-56640. Removal of 50% of the tissue is a partial vulvectomy and removal of deep subcutaneous tissue is radical. Read the definitions in CPT® codebook at the beginning of the section: Vulva, Perineum, and Introitus.
An 88-year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment elects to receive colpocleisis (LeFort type) to prevent further prolapse and avoid more significant surgery such as a hysterectomy. The treatment is successful. What are the CPT® and ICD-10-CM codes reported for this procedure?
Correct Answer: c. 57120, N81.4 Rationale: This surgical procedure of a colpocleisis is performed to prevent uterine prolapse. In this procedure, the walls of the vagina are sewn together. This obliterates the vagina and prevents uterine prolapse. It is only performed in patients not sexually active. In the CPT® Index, look for Colpocleisis or LeFort Procedure/Vagina referring you to code 57120.The reason for the operation is uterine prolapse. In the ICD-10-CM Alphabetic Index look for Prolapse, prolapsed/uterus (with prolapse of vagina) referring you to code N81.4. Verify in the Tabular List.
A 62-year-old woman with a history of urinary incontinence and incomplete bladder emptying presents for sling urethropexy and repair of a cystocele. The sling urethropexy is performed using a prosthetic mesh. The anterior repair is also performed without difficulty and both repairs are performed vaginally. What are the CPT® codes reported for this service?
Correct Answer: c. 57288, 57240-51 Rationale: The patient has urinary incontinence and her bladder is bulging downward through the anterior vaginal wall (cystocele). First a sling is placed under the junction of the urethra and bladder for suspension to correct the urinary incontinence. Look in the CPT® Index for Sling Operation/Vagina referring you to 57287, 57288. 57288 is correct as 57287 is for removal or revision of the sling. Next is the repair of the cystocele by tightening the front (anterior) wall of the vagina (colporrhaphy or anterior repair). Look in the CPT® Index for Vagina/Repair/Cystocele referring you to 57240, 57260. The insertion of the mesh, code 57267, is not coded for this scenario because it was used for the sling operation not the colporrhaphy. It is included in 57288. Modifier 51 is appended to 57240 to indicate additional procedures performed during the same session.
A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles. What are the CPT® and ICD-10-CM codes reported for this procedure?
Correct Answer: c. 57308, N82.3, N81.89 Rationale: The physician is closing a rectovaginal fistula (abnormal passage between the rectum and vagina). The repair is performed by a transperineal approach by reconstructing the perineal body (pertaining to the vulva and anus area between the thighs) by using a levator muscle plication. In the CPT® Index look for Fistula/Closure/Rectovaginal referring you to 57300, 57305, 57307, 57308. Code 57308 includes closure of rectovaginal fistula via a transperineal approach, with perineal body reconstruction, with or without levator plication.Two diagnoses are reported for this scenario. The first diagnosis is rectovaginal fistula. Look in the ICD-10-CM Alphabetic Index for Fistula/rectovaginal referring you to N82.3. Your second diagnosis is perineal scarring. Look for Laceration/perineum/female/old (postpartal) referring you to code N81.89. Verify codes in the Tabular List.
A patient with severe adenomyosis has a vaginal hysterectomy with bilateral salpingo-oophorectomy. After the uterus is removed it is weighed at 300 grams. What is the CPT® code reported for this procedure?
Correct Answer: d. 58291 Rationale: A vaginal hysterectomy code can be selected based on the weight of the uterus and additional procedures included with the hysterectomy. In the CPT® Index look for Hysterectomy/Vaginal/Removal Tubes/Ovaries directing you to codes 58262, 58263, 58291, 58292, 58552, 58554. A vaginal hysterectomy for a uterus greater than 250 grams is reported from code range 58290-58294. Further selection of removal of tubes and ovaries defines code 58291.
A 37-year-old woman presents with abdominal pain, bleeding unrelated to menses and an abnormal pap showing LGSIL (low grade squamous intraepithelial lesion). Treatment is hysteroscopy with thermoablation of the endometrium and cryocautery of the cervix. This is performed without difficulty. What are the CPT® and ICD-10-CM codes reported for this procedure?
Correct Answer: c. 58563, 57511-51, R87.612 Rationale: The endometrium is destroyed with thermoablation under the guidance of the hysteroscope. In the CPT® Index, look for Hysteroscopy/Ablation/Endometrial, guiding you to code 58563. The LGSIL is treated with cryocautery. In the CPT® Index, look for Cervix/Cauterization/Cryocautery referring you to code 57511. Verify the codes in the numeric section. Modifier 51 is appended to 57511 to show multiple procedures performed in the same session.In the ICD-10-CM Alphabetic Index look for Abnormal/Papanicolaou (smear)/cervix/low grade squamous intraepithelial lesion (LGSIL) guiding you to code R87.612. Verify in the Tabular List.
A patient with uterine prolapse presents for laparoscopic hysterectomy and colpopexy. After induction of general anesthesia, the laparoscope is introduced into the abdomen with separate placement of ports for visualization. The surgeon began to tie off the uterine artery when the patient had a sudden drop in blood pressure and could not be stabilized. The procedure was discontinued. No procedures were completed. What are the CPT® and modifier code(s) for this service?
Correct Answer: c. 58570-53 Rationale: After general anesthesia was initiated and the surgery for the laparoscopic hysterectomy began, the patient's blood pressure dropped and could not be stabilized. There are two ways to find the code for a laparoscopic hysterectomy. Start by looking in the CPT® Index for Hysterectomy/Laparoscopic/Total or Laparoscopy/Hysterectomy/Total. Both refer you to 58570-58573. 58570 is correct for the laparoscopic hysterectomy. Modifier 53 is the correct modifier to append because there was a threat to the well-being of the patient during the surgery. You do not code for the colpopexy (57425) because the colpopexy surgery had not begun.
What is a root word for vagina?
Correct Answer: c. Colp/o Rationale: Colp/o refers to the vagina.
A 32-year-old woman with a previous vertical incision for cesarean delivery presents in spontaneous labor with the baby in cephalic presentation. She has had an uneventful pregnancy and after laboring for 10 hours she delivers a single female child with brief use of a vacuum extractor over an episiotomy that is repaired by the delivering physician. There are no complications. What are the diagnosis codes for this delivery?
Correct Answer: c. O66.5, O34.212, Z3A.00, Z37.0 Rationale: Rationale: You do not code a normal delivery, code O80, because a vacuum extractor is used to deliver the baby. In the ICD-10-CM Alphabetic Index look for Delivery/complicated/by/attempted vacuum extraction and forceps referring you to code O66.5. ICD-10-CM guidelines, I.A.14., state the word "and" should be interpreted as "and" or "or" when appearing in the title. The second code reports the previous cesarean delivery. In the Alphabetic Index look for Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, guiding you to code O34.212. Instructional note in the beginning of Chapter 15 indicates a code from Z3A is reported with the pregnancy codes. Z3A.00 indicates unspecified weeks. This is found in the Alphabetic Index by looking for Pregnancy/weeks of gestation/not specified. Your last code to report is the outcome of the delivery. Look in the Alphabetic Index for Outcome of delivery/single NEC/liveborn referring you to code Z37.0. Verify all codes in the Tabular List.
Procedures involving which of the following structures found in the vulva are NOT coded in the female reproductive system section of CPT®?
Correct Answer: c. Skene's gland Rationale: Procedures on the Skene's glands are coded in the urinary system
A pregnant patient presents to the ED with bleeding, cramping, and concerns of loss of tissue and material per vagina. On examination, the physician discovers an open cervical os with no products of conception seen. He tells the patient she has had an abortion. What type of abortion has she had?
Correct Answer: c. Spontaneous Rationale: There is no indication this was an induced abortion. A missed abortion does not occur with passage of material and tissue; it is silent, meaning that the body does not recognize the pregnancy loss or expel the pregnancy tissue. This case is considered a spontaneous abortion or miscarriage.
Vulvar cancer in situ can also be documented as:
Correct Answer: c. VIN III Rationale: Vulvar intraepithelial neoplasia stage III or VIN III is coded as cancer in situ. The other VINs listed are coded as hyperplasia and adenocarcinoma is a primary malignancy. In ICD-10-CM Alphabetic Index go to the Table of Neoplasms and look for Neoplasm, neoplastic/vulva/Ca in situ column directing you to D07.1. Verification of this code in the Tabular List confirms D07.1 is reported for VIN III.
What ICD-10-CM category is used to report the weeks of gestation of pregnancy?
Correct Answer: c. Z3A Rationale: When a code from Chapter 15 is reported, an additional code is reported to identify the specific week of the pregnancy. This is reported from category Z3A Weeks of gestation.
A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis including a chocolate cyst (endometrioma) of the right ovary, right fallopian tube and peritoneum. The endometriomas are all small, less than 5 cm, and laser is used to ablate them, except the ovarian cyst, which is excised. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?
Correct Answer: d. 49203, 58611, N80.111, N80.211, N80.30, Z30.2 Rationale: The exploratory laparotomy is not a separately billable service because it is no longer just examination of the intraabdominal organs; it became a surgical procedure in which the endometriomas were destroyed by laser. Remember a surgical laparotomy always includes a diagnostic (exploratory) laparotomy. Look in the CPT® Index for Endometrioma/Abdomen/Destruction/Excision referring you to 49203-49205. 49203 is correct for destruction for 1 or more tumors with the largest less than 5 cm in diameter.The second procedure is a tubal ligation (female sterilization in which the fallopian tubes are sealed or severed). Look in the CPT® Index for Fallopian tube/Ligation referring you to 58600, 58611. Add-on code 58611 is correct to report because the tubal ligation was performed at the same time as another intra-abdominal surgery. Modifier 51 is not appended because 58611 is an add-on code.The endometriosis included the ovary and the right fallopian tube. Look in the ICD-10-CM Alphabetic Index for Endometriosis/ovary/superficial guiding you to code N80.11-. Next look in the Alphabetic Index for Endometriosis/fallopian tube/superficial referring you to code N80.21-. Both codes will report the 6th character 1. Then look for Endometriosis/peritoneal directing you to code N80.30. Reporting a diagnosis for the tubal ligation is found by looking in the Alphabetic Index for Encounter (with health service) (for)/sterilization guiding you to code Z30.2. Verify all codes in the Tabular List.
A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins vaginally. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure?
Correct Answer: d. 59400, 59409-51 Rationale: The delivery is vaginal. Look in the CPT® Index for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care and will provide the postpartum care, the vaginal delivery for twin A is the global service described by 59400. The delivery of twin B is coded with 59409 with modifier 51 appended indicating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and not to both deliveries.
A 27-year-old woman's regular obstetrician delivers twins by cesarean delivery. Both are delivered without complications. Patient will have postpartum care in two weeks. What is/are the CPT® code(s) reported for this service?
Correct Answer: d. 59510 Rationale: When reporting a procedure code for an uncomplicated twin delivery by cesarean delivery, you code the global cesarean code once, because there is only one incision to deliver both babies by a cesarean delivery. Many payers will not provide additional reimbursement for a twin delivery by cesarean. Look in the CPT® Index for Cesarean Delivery/Routine Care referring you to 59510. Verify in the numeric section.
If a physician obtains a Pap smear specimen from a non-Medicare patient and incurs the cost for it to be transferred to an outside laboratory. How is this coded?
Correct Answer: d. 99000 Rationale: Look to the CPT® Index for Specimen Handling and you are directed to 99000, 99001. CPT® code 99000 is reported when the physician incurs cost for collection, handling and/or conveyance of a specimen for transfer from the office to a laboratory. This is a non-Medicare patient, the HCPCS Level II code Q0091 is only reported for a Medicare patient.
What is a bilateral structure of the female reproductive system?
Correct Answer: d. All of the above Rationale: The Bartholin's glands (also called the greater vestibular glands) are located slightly below and to either side of the vaginal introitus. The Fallopian tubes are two tubes, one on either side of the uterus, leading from the bilateral ovaries into the uterus.
A 23-year-old woman delivers her second child by cesarean delivery. Her first child was delivered by cesarean (vertical incision) and the decision is made early in her pregnancy for a repeat cesarean. The patient started her antenatal (prenatal) care in Arizona and then moved to Wisconsin when her husband was transferred to a new job. She had two antenatal visits during the first trimester in Arizona and 10 more antenatal visits with her new provider in Wisconsin before the repeat cesarean delivery was performed. She delivered a healthy baby girl. She will follow up with her Wisconsin physician after discharge for postpartum care. What are the procedure and diagnosis codes for her Arizona physician and her Wisconsin physician including her antenatal care, delivery and postpartum care procedures?
Correct Answer: d. Arizona: 2 E/M codes, one for each visit - Z34.81; Wisconsin: 59515- O34.212, Z3A.00, Z37.0, 59426 - Z34.81 Rationale: According to CPT®, if the physician does not provide all the antepartum care, you cannot report a global obstetric service. Instead, you must itemize the services provided using either E/M codes or the codes for antepartum care only and delivery with postpartum care only. Not all insurers follow CPT® rules. The Arizona provider may bill two visits with E/M codes depending on the documentation of the visits because she only had 2 antenatal visits. The Wisconsin provider delivered the baby and will be providing the postpartum care. Look in the CPT® Index for Cesarean Delivery/Delivery with Postpartum Care and you are referred to 59515. Next in the CPT® Index look for Obstetrical Care/Antepartum Care and you are directed to 59425, 59426. The Wisconsin physician provided 10 antenatal visits, so 59426 is reported.Look in the ICD-10-CM Alphabetic Index for Pregnancy/prenatal care only/specified Z34.8-. This is not her first pregnancy and the encounters occurred during the first trimester so Z34.81 is reported for both the Arizona and Wisconsin physicians for the antenatal visits. For code 59515 the Wisconsin physician will report diagnosis code O34.212 , Z3A.00 to indicate unspecified weeks of pregnancy and Z37.0 for the single birth. In the ICD-10-CM Alphabetic Index look for Cesarean delivery, previous, affecting management of pregnancy/classical (vertical) scar and you are referred to O34.212. In the Alphabetic Index look for Pregnancy/weeks of gestation/unspecified weeks and you are directed to Z3A.00. Next look in the Alphabetic Index for Outcome of delivery/single NEC/live born, referring you to code Z37.0. Verify all codes in the Tabular List.
What modifier is appropriate for a separately billable antenatal service during the global OB package period?
Correct Answer: d. No modifier is needed Rationale: An antenatal service is performed before the baby is delivered. According to the notes in the Maternity Care and Delivery subsection in the CPT® codebook "Antepartum care includes the initial prenatal history and physical examinations; recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery."
A patient is seen for three extra visits during the third trimester of her 30-week pregnancy because of her history of pre-eclampsia during her previous pregnancy which puts her at risk for a recurrence of the problem during this pregnancy. No problems develop. What diagnosis code(s) is/are reported for these three extra visits?
Correct Answer: d. O09.893, Z3A.30 Rationale: Because the patient had pre-eclampsia in her previous pregnancy she is being monitored for three additional visits because she is at a high risk of getting pre-eclampsia during this current pregnancy. Due to the patient being high-risk, she will not be coming in for supervision of a normal pregnancy, eliminating Z34.83. Code O14.03 is incorrect because she is just being monitored for possible pre-eclampsia. O09.893 is used for supervision of pregnancy of other high risk. Look in the ICD-10-CM Alphabetic Index for Pregnancy/supervision of/high-risk/due to (history of)/specified NEC directing you to O09.89-. In the Tabular List, a 6th character is needed to indicate the trimester. Report code O09.893 for the third trimester. Instructional note in the beginning of Chapter 15 indicates a code from Z3A is reported with the pregnancy codes. The weeks of pregnancy is 30 weeks. Look in the Alphabetic Index for Pregnancy/weeks of gestation/30 weeks and you are directed to Z3A.30. Verify in the Tabular List.
A pregnant patient presents to labor and delivery with the baby in a breech presentation. During the delivery the doctor attempts to turn the baby (version of the breech presentation) while it is still in the uterus. The baby turns but then immediately resumes his previous breech position. Can this service (the version of the breech) be billed? If so, what is the code?
Correct Answer: d. Yes, because the doctor did the work, even though the outcome was unsuccessful. Report this procedure with code 59412 Rationale: The physician can bill for this service separately. Look in the CPT® Index Version, Cephalic — see Cephalic Version. Look in the CPT® Index for Cephalic Version/of Fetus/External and you are referred to 59412. Verify in the numeric section.
