CPC Test Case B

The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9 o'clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be approximately 1.5 - 2 cm in maximum dimension. Hemostasis was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished, the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the procedure and diagnosis codes. A. 19120, 611.72 B. 19301, 611.72 C. 19125, 610.8 D. 19101, 611.79

A. 19120, 611.72 One way to get to the correct answer is by the diagnosis. This patient is having the procedure performed due to a breast mass. The only two choices that have the ICD-9-CM code for breast mass are A and B. The diagnosis is indexed in the ICD-9-CM Index to Diseases under Mass/breast. CPT® subsection guidelines Breast Excision tells us that partial mastectomy procedures (eg, lumpectomy, tylectomy, quadrantectomy, or segmentectomy) describe open excision of breast tissue with specific attention to removal of adequate surgical margins surrounding the mass or lesion. There is no documentation supporting removal of surgical margins when removing the breast mass.

This 25-year-old male presents with deviated nasal septum. After intubation, a left hemitransfixion incision was made with elevation of the mucoperichondrium. Cartilage from the bony septum was detached and the nasoseptum was realigned and removed in a piecemeal fashion from the obstructed perpendicular plate of the ethmoid. Thereafter, 4-0 chronic was used to approximate mucous membranes. Next, submucous resection of the middle and inferior turbinates was handled in the usual fashion by removing the anterior third of the bony turbinate and lateral mucosal followed by bipolar cauterization of the posterior enlarged tip of the inferior turbinate as well as outfracturing. A small amount of silver nitrate cautery was used to achieve hemostasis. A dressing consisted of a fold of Telfa with a ventilating tube for nasal airway on each side achieved good hemostasis, patient went to recovery in good condition. What is the correct code for this procedure? A. 30520 B. 30420 C. 30620 D. 30450

A. 30520 The multiple choice answers are between a rhinoplasty and septoplasty for which you will need to know the difference. Rhinoplasties are performed on patients that are having cosmetic surgery, restorative, or reconstruction on the nose. This patient is coming in to correct a deviated septum, which falls under a septoplasty which is removing a portion of the deviated septum and straightening the septum to correct airway obstruction. You eliminate multiple choice answers B and D. C is incorrect since the patient is not coming in for a dermatoplasty, which is surgical replacement of destroyed skin.

Mr. Y presents to outpatient surgery for placement of a dual chamber pacemaker after multiple attempts to manage his bradycardia medically. Atrial and ventricular leads were placed under fluoroscopic guidance via the subclavian vein. Testing confirmed appropriate placement and conduction. The left chest was then infiltrated with Epinephrine and a pocket was opened for placement of the generator. The leads were attached to the generator and the generator was programmed. Appropriate pacing was confirmed. The skin pocket was closed in layers and dressing placed. Select the appropriate CPT® codes. A. 33208 B. 33213, 33217 C. 33235, 33208 D. 33214

A. 33208 This is an insertion of a new dual chamber pacemaker. The provider is inserting the pulse generator as well as two leads (atrial and ventricular) which is only reported with one code. There is no documentation that the patient had a removal of a pacemaker or is upgrading to a dual chamber system.

Mr. Jones is here today to receive an intercostal nerve block to mitigate the debilitating pain of his malignancy. His cancer has metastasized to his lungs. Select the appropriate ICD-9-CM codes. A. 338.3, 197.0 B. 162.9, 338.3 C. 338.3, 162.9 D. 197.0, 338.3

A. 338.3, 197.0 The reason for this encounter is pain management. According to ICD-9-CM guidelines (Section I.C.6.a.5) pain in neoplastic disease (338.3) should be the first listed diagnosis. The patient has metastatic cancer (secondary malignancy) of the lung, which is reported with 197.0 as a secondary diagnosis.

PREOPERATIVE DIAGNOSIS: History of prior colon polyps POSTOPERATIVE DIAGNOSIS: Colon polyps, diverticulosis, hemorrhoids PROCEDURE: A rectal exam was performed and revealed small external hemorrhoids. The video colonoscope was passed without difficulty from anus to cecum. The colon was well prepped. The instrument was slowly withdrawn with good views obtained throughout. There was a 3 mm polyp in the proximal ascending colon. This polyp was removed with hot biopsy forceps and retrieved. There was a 4 mm rectal polyp located 10 cm from the anus in the proximal rectum. The polyp was removed by hot biopsy forceps. There was also moderate diverticulosis extending from the hepatic flexure to the distal sigmoid colon. Code the CPT® procedure(s). A. 45384 B. 45385 C. 45388 D. 45384 x 2, 45378-59

A. 45384 This colonoscopy involved two polyps being removed by hot biopsy forceps which leads to code 45384. This is only coded once regardless of the number of polyps that was removed with this one technique. According to CPT® subsection guidelines for Endoscopy, a surgical endoscopy always includes diagnostic endoscopy. The diagnostic colonoscopy is not reported separately.

58-year-old female has lumbar degenerative spondylolisthesis with severe stenosis and instability. The spinous process of L4 and L5 are decompressed bilaterally by performing a laminectomies, right-sided forminotomies and then left-sided facetectomy completely decompressing the nerve roots as well as the dura. How is this procedure reported? A. 63047, 63048 B. 63030-50, 63035-50 C. 63017 D. 63047-50, 63048-50

A. 63047, 63048 A laminectomy is performed, eliminating multiple choice B. The laminectomy is performed with a facetectomy and foraminotomy. Modifier 50 is not reported with code 63047 since bilateral is included in the code description.

22-year-old has had no prenatal care. Fundal height indicates a term fetus and by dates it is determined she is 38 weeks pregnant. Few hours prior to admission to Labor and Delivery her membranes ruptured spontaneously. She does not have fever, but the physician performs a rapid antigen test for group B strep. An enzyme immunoassay method is performed. Physician obtains a lower vaginal swab, then observes that it visually shows the patient is negative for the antigen. If clinical risk factors appear, intrapartum antibiotics will be initiated. Which lab test is reported? A. 87802 B. 87653 C. 86317 D. 87450

A. 87802 The lab test ordered by the physician is to detect Streptococcus, Group B. The direct observation (observes the vaginal swab that visually showed the result) is important since her membranes are ruptured and an immediate result is needed.

Mary, who has food allergies, came to her physician for her weekly allergen immune therapy that consists of two injections prepared and provided by the physician. The correct code is: A. 95125 B. 95117 C. 95144 D. 95146

A. 95125 In this case the patient presents for allergen immune therapy for food allergies. The injections are prepared and provided by the physician, which is reported with 95125 for two injections. Code 95144 is reported when the antigen extract is prepared and supplied in a vial. The therapy is not for an insect which makes 95146 an incorrect answer. 95117 does not include the provision of the extract so it is also incorrect.

Physician performs a medical review and documentation on an 83-year-old patient who has been in the hospital for the last two days with confusion. Problem focused exam where she is alert and oriented x 3 today. Low medical decision making by ordering an echocardiogram and to continue IV fluids. Patient is not safe to return home. What CPT® code should be reported for this visit? A. 99231 B. 99221 C. 99224 D. 99234

A. 99231 The patient has been in the hospital for the last two days and is being seen by the physician reporting the visit as a subsequent hospital care. Documentation does not support the patient is in observation care or observation status. In the CPT® Index, look for Hospital Services/Inpatient Services/Subsequent Hospital Care. You are referred to 99231-99233. Two out of three key components are needed for subsequent hospital care codes. The physician documented a problem focused exam + Low MDM = 99231

While playing softball a 12-year-old boy sustains a blowout fracture. What is the anatomical location of a blowout fracture? A. Orbit B. Clavicle C. Patella D. Femur

A. Orbit A blowout fracture is a fracture of the walls or floor of the orbit. The orbit is the cavity or socket of the skull which the eye and its appendages are situated. In the ICD-9-CM Index to Diseases, look for Fracture/orbit/floor (blowout).

When coding for a patient who has had a primary malignancy of the thyroid cartilage that was completely excised a year ago, which of the following statements is TRUE? A. When the cancer is surgically removed with no further treatment provided and there is no evidence of any existing primary malignancy, code V10.87. B. When further treatment is provided and there is evidence of an existing metastasis, code first V10.87 and then 161.3. C. Any mention of extension, invasion, or metastasis to another site is coded as a 239.1, V10.87. D. When the cancer is surgically removed but the patient is receiving chemotherapy treatment report V10.87.

A. When the cancer is surgically removed with no further treatment provided and there is no evidence of any existing primary malignancy, code V10.87. According to ICD-9-CM Official Coding Guidelines (Section I.C.2.d.), when the patient has excised or eradicated the malignancy and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, select a personal history of malignancy by site. From the ICD-9-CM Index to Diseases, look for History/malignant neoplasm (of)/thyroid.

Indications: 55-year-old female had a sizeable 1.5 cm basal cell carcinoma on the right upper lip. She had a 2 cm defect. After excision, it was reconstructed in a first stage with a nasolabial cheek flap. The margins were clear and she is planned for the second stage. Operative Procedure: Under intravenous sedation, patient in supine position, the face was prepped and draped. Division performed to the bridge between the base of the flap of the upper lip. Unfurled the base of the flap that was excised until it was soft and pliable. It is defatted and laid back onto the cheek with interrupted 5-0 Monocryl and running 6-0 plain catgut. Similar procedure was performed on the redundant portion of the flap and permanently set into the upper lip. Steri-strips applied. Which CPT® should be used? A. 15758-79 B. 15630-58 C. 15758-76 D. 15630-78

B. 15630-58 You can start by looking at the modifiers to guide you to the correct answer. The keywords in the question are "planned" and "second stage" of the procedure. This indicates that a planned or anticipated (staged) related procedure is being performed. The patient is coming in for a division and inset of cheek flap to the right upper lip.

25-year-old male has a ruptured distal bicep tendon. An incision is made overlying the antecubital fossa. The biceps tendon was retrieved and tagged using #1 Vicryl-suture. The second incision made on the superior border of the ulna. The supinator was incised deep to expose the radial tuberosity. Threaded suture from the anterior incision through to the posterolateral incison and brought the biceps up to the radial tuberosity. A drill hole was made followed by a tap and seated 5mm corkscrew into the radial tuberosity. Two sutures placed in the biceps tendon in horizontal mattress type fashion separately to tie down the suture. Closure was then accomplished with sutures and staples. What is the correct code for this procedure? A. 24342 B. 24340 C. 23430 D. 23440

B. 24340 Tenodesis is suturing of the end a tendon to a bone. There is a ruptured distal bicep tendon which is a tendon injured around the elbow joint, eliminating multiple choice C. A long tendon bicep runs over the top of the humerus bone (upper arm) and attaches to the top of the shoulder. There is no documentation of a reinsertion, removal, or transplantation of a bicep tendon, eliminating multiple choices A and D.

55-year-old female presents to the office with ongoing history of diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetes on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. 785.4, 250.01, V58.67 B. 250.70, 785.4, V58.67 C. 250.71, 785.4, V58.67 D. 785.4, 250.70, V58.67

B. 250.70, 785.4, V58.67 According to ICD-9-CM guidelines (Section I.C.3.a.2): If the type of diabetes mellitus is not documented in the medical record the default is type II. Guidelines further say (Section I.C.3.a.3) that the use of insulin does not mean that a patient is a type I diabetic. This eliminates multiple choices A and C. When assigning codes for diabetes and its associated conditions, the code(s) from category 250 must be sequenced first then its associated condition. The primary code is indexed under Diabetes/with gangrene referring you to code 250.7x [785.4].

A Grade I, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement, including excision of devitalized bone. The patient was then reprepped, redraped, and repositioned. Intramedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure? A. 27506, 11044-51, 821.11, E814.7 B. 27506, 11012-51, 821.11, E814.7 C. 27507, 11012-51, 821.01, E814.7 D. 27507, 11044-51, 821.10, E814.7

B. 27506, 11012-51, 821.11, E814.7 One way to start finding the correct answer is to look up the diagnosis in the ICD-9-CM manual. It is indexed under Fracture/femur/shaft/open which refers you to code 821.11, eliminating codes C and D. The only difference between choices A and B are the second procedure codes. Code 11012 is the correct code because extensive debridement was performed all the way to the bone on an open fracture.

Patient with RUQ pain and nausea suspected of having a stone or other obstruction in the biliary tract is brought in for ERCP under radiologic guidance. Procedure: The patient was brought to the outpatient endoscopy suite and placed supine on the table. The mouth and throat were anesthetized. Under radiologic guidance, the scope was inserted through the oropharynx, esophagus, stomach, and into the small intestine. The ampulla of Vater was cannulated and filled with contrast. It was clear that there was an obstruction in the common bile duct. The endoscope was advanced retrograde to the point of the obstruction, which was found to be a stone that was removed with a stone basket. The rest of the biliary tract was visualized and no other obstructions or anomalies were found. The scope was removed without difficulty. The patient tolerated the procedure well. A. 47554, 74363-26 B. 43264, 74328-26 C. 43265, 74328-26 D. 43275, 74329-26

B. 43264, 74328-26 Patient is having an endoscopic retrograde cholangiopancreatography (ERCP), Radiological guidance was used for this procedure; there is a parenthetical note above code 43260 that informs you to use 74328, 74329, or 74330 for radiological supervision and interpretation. The catheterization went all the way into the biliary ductal system where a stone was found. Because the surgery is being performed in an outpatient hospital, the physician does not own the equipment so modifier 26 needs to be appended to the radiology code. 43264 is the correct code because there was a removal of a calculus (stone) from the common bile duct.

A patient comes in for surgery today to address complications from his previous partial enterectomy performed 5 months ago. Upon reopening the patient's previous incision the surgeon resected the ileum and a portion of the colon. An ileocolostomy was performed to complete the procedure with no complications. The appropriate CPT® code to report is: A. 44144 B. 44160 C. 44150 D. 44205

B. 44160 Documentation supports the physician removing portion of the colon (partial colectomy), the ileum and an ileocolostomy through an incision not laparoscopically.

Newborn male is scheduled for a circumcision. He is sterilely prepped and draped; a penile nerve block is performed. The circumcision is performed by a ring device. Hemostasis is achieved. Vaseline Gauze dressing applied. Patient tolerated the procedure well. How would this encounter be coded? A. 54160 B. 54150 C. 54161, 64450 D. 54150, 64450

B. 54150 The patient is having the circumcision performed with a ring device (other device), guiding you in selecting code 54150. It is inappropriate to code 64450 with 54150 since penile block is included and stated in the code description.

A laparoscopic assisted total hysterectomy is planned for a patient who has severe intramural fibroids. After inserting the laparoscope, extensive adhesions are noted to the extent that the ligaments supporting the uterus cannot be visualized. The physician decides to convert the procedure to an open abdominal hysterectomy in which the uterus and cervix are removed. What CPT® code(s) should be reported? A. 58262, 58570-53 B. 58150 C. 58260, 58550-22 D. 58570

B. 58150 Per CPT® when a provider converts a laparoscopic procedure to an open procedure you report the open procedure as the primary code and the laparoscopic procedure appending modifier 52 as the secondary code (CPT® Assistant March 2000). According to the National Correct Coding Initiative (NCCI) policy which is followed by most payers, only report the open procedure code; do not report the laparoscopic procedure code. On the CPC® exam, when a laparoscopic procedure is converted to an open procedure the NCCI policy is followed reporting only the open procedure code. The correct code to report is 58150 for the total abdominal hysterectomy.

The patient presents with burning urination and frequency. The physician performs a UA dipstick, which shows elevated WBC. He orders a urine culture with identification for each isolate to determine which antibiotic to give to the patient for the infection. What are the appropriate lab codes? A. 81000, 81007 B. 81002, 87088 C. 81001, 87086 D. 87086, 87088

B. 81002, 87088 First the physician performs a UA dipstick with no indication of a microscopic test. This test is reported with 81002. The urine culture is performed with identification for each isolate, which is reported with 87088. 87086 is a quantitative test for a colony which is incorrect.

In order to use the critical care codes, which of the following statements is TRUE? A. Critical care services can be provided in an internist's office B. Critical care services provided for more than 15 minutes but less than 30 minutes should be billed with 99291 and modifier 52. C. Time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor cannot be included in the determination of critical care time. D. Critical care services are never reported with endotracheal intubation (31500) E. Physician can provide services to another patient during the same time providing critical care services to a critically ill patient

B. Critical care services provided for more than 15 minutes but less than 30 minutes should be billed with 99291 and modifier 52. Critical care services can be provided at any site. If the patient is critically ill, the services provided can be coded with critical care regardless of where the services take place. A minimum of 30 minutes of critical care must be performed in order to report 99291. If less than 30 minutes, select the appropriate E/M code based on the three key components. Time spent reviewing results and discussing the critically ill patient with medical staff is included in the critical care time. Endotracheal intubation, code 31500, can be reported with critical care services. The subsection guidelines for critical care services in the CPT codebook does give what services can not be billed with critical care. A physician providing critical care services must devote full attention to the critically ill patient and cannot provide services to any other patient during the same period of time.

Which of the following services are covered by Medicare Part B? A. Inpatient chemotherapy B. Minor surgery performed in a physician's office C. Routine dental care D. Assisted living facility

B. Minor surgery performed in a physician's office Services performed by physicians are covered by Medicare Part B. Inpatient services are covered by Part A. Medicare does not cover routine dental care.

A healthy 11-month-old patient with bilateral cleft lip and palate undergoes surgery. The surgeon performs a bilateral cleft lip repair, single stage. Code the anesthesia service. A. 00170-P1, 99100 B. 00102-P1 C. 00102-P1, 99100 D. 00170-P1

C. 00102-P1, 99100 Anesthesia is performed for cleft lip repair. In the CPT® Index, look for Anesthesia/Cleft Lip Repair. You are referred to 00102. Refer to the code description to verify accuracy. The patient is healthy, which means P1 is the correct physical status modifier. 99100 is reported because the patient is under one year of age and the patient's age is not included in the CPT® code for the anesthesia service.

Angiograms reveal three artery blockages. The patient has COPD, which is a severe systemic disease. The patient undergoes a CABG X 3 venous grafts on cardiopulmonary bypass and cell saver. Code the anesthesia service. A. 00562-P3 B. 00560-P4 C. 00567-P3 D. 00566-P4

C. 00567-P3 In CPT® Index, look for Anesthesia/ Heart/ Coronary Artery Bypass Grafting. You are referred to 00566 and 00567. In the scenario it states that cardiopulmonary bypass is used, which indicates the code that includes pump oxygenator is the correct answer. The patient has COPD, which is a severe systemic disease, but there is no indication that is a threat to the patient's life. Append physical status indicator P3. Anesthesia physical status modifiers are listed in Appendix A in the CPT® codebook.

Indications: 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient's burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with xenograft (skin substitute graft), and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient's face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with xenograft. Finally a split thickness skin graft of 0.015 inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service? A. 15200, 15201 x 123, 15004, 15005, 15002, 15003 B. 15275, 15276 x 31, 15271, 15272 x 66, 15004, 15005 x 16, 15002, 15003 x 7 C. 15277, 15278 x 7, 15273, 15274 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040 D. 15130, 15131 x 7, 15135, 15136 x 16, 15004, 15005 x 7, 15002, 15003 x 16

C. 15277, 15278 x 7, 15273, 15274 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040 To first tackle this scenario, you need to find out what type of graft was used on this patient. It was a xenograft, which is a skin substitute graft. Multiple choice C reports the skin substitute graft codes. Add the group body areas together with their total sq cm. The first group to add is: Face, scalp, neck 500 cm + hands & feet 300 cm = 800 sq cm coded, 15277, 15278 x7. Your next group is the trunk 950 cm + arms & legs 725 = 1675 cm coded, 15273, 15274 x 16. Those took care of the xenograft codes. The next set of codes deal with the excision of the burn eschar to provide healthy skin onto which the skin graft will be placed. You would use the same sq cm totals that are grouped in the same body areas that you used for the xenograft codes. Face, scalp, neck, hand, and feet are coded 15004, 15005 x 7. Trunk, legs and arms are coded 15002, 15003 x 16. Code 15040 (Harvest of skin for tissue skin autograft, 100 sq cm or less) was performed when a split thickness skin graft was harvested using dermatome (skin harvesting) from a separate donor site (autograft).

A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was once beating on its own again, we attempted to induce an arrhythmia and this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for this service. A. 33512, 33254-51, 33508 B. 33535, 33254-51, 33508 C. 33512, 33257, 33508 D. 33512, 33257-51, 33508-51

C. 33512, 33257, 33508 The patient is having a coronary artery bypass graft (CABG) involving three venous grafts (33512), eliminating multiple choice B. A modified maze is performed, but according to CPT® guidelines instruct do not report code 33254 when performed at the same time as another procedure requiring median sternotomy or cardiopulmonary bypass. A parenthetical instruction lists the codes that are not to be reported with code 33254, eliminating multiple choice A. Add-on code 33257 is reported for a modified MAZE procedure performed at the same time of other cardiac procedures. Parenthetical instruction is under this code that lists which codes can be reported with it. Add-on code 33508 is correct to report since the saphenous vein is harvested endoscopically. Codes 33257 and 33508 are add-on codes which does not require modifier 51 to be appended.

Patient has consented for further testing to determine the extent of her cervical dysplasia. A cervical cone biopsy of endocervical tissue was cut using a laser. It was tagged with a single stitch. Dilation and curettage was performed. Small amount of tissue was obtained and sent to pathology. Which procedure code(s) should be used? A. 57520, 58120 B. 57461 C. 57520 D. 57500, 57505

C. 57520 Excision of endocervical tissue in a cone shape of the cervix is conization. The procedure was performed using a laser. The code description for code 57520 includes fulguration, dilation and curettage, or repair when performed and are not reported separately.

Physician is performing an intracapsular cataract extraction. The anterior chamber of the eye is entered performing an anterior capsulotomy using forceps. The lens nucleus was hydrodissected and loosened. Using phacoemulsification unit, the lens nucleus was divided and emulsified. Cortical and capsular fragments were removed. The anterior chamber and capsule bag inflated. Using lens inserter an intraocular lens prosthesis, Cystalens, was inserted and rotated to the horizontal position. Topical solution applied, conjunctiva repositioned over the wound with wet field cautery and patch applied. Which CPT® code(s) should be reported? A. 66984, 66985 B. 66983, 66985 C. 66985 D. 66983

D. 66983 An intracapsular catatract extraction is being performed. An intraocular lens prosthesis (Cystalens) was inserted in the same surgery session with the cataract extraction. Code 66985 is reported when only an intraocular lens is being inserted on a patient who had previously undergone cataract removal.

Operation: Replacement of shunt valve with medium pressure ventriculo-peritoneal shunt assembly with in-line 0-25 Aesculap Shunt Assistant Implant ICP Monitor. Procedure: After obtaining general anesthesia, patient prepped and draped. Right parietal scalp incision was reopened and shunt catheter identified. The shunt reservoir was delivered from the wound and the distal catheter freed from it. Abdominal incision reopened, shunt passer was used to bring the distal catheter from the head wound to the abdominal wound. The old ventricular catheter was removed. A new ventricular-catheter was inserted into the tract of the old catheter and fed, good flow seen. It was then attached to the shunt reservoir that was then seated after attaching a 0-25 shunt assistant valve to it. The distal catheter was then fed into the peritoneal cavity. Subcutaneous tissues were closed in multi-layer fashion and skin with staples. Patient tolerated the procedure well and taken to PICU in stable condition. Code this procedure. A. 62223, 62225-51 B. 62258, 62160 C. 62230, 62225-51 D. 62256, 62225-51

C. 62230, 62225-51 Patient already has a shunt; a new one is not being created, eliminating multiple choice A. There is a replacement of the valve and ventricular catheter; not a removal of the whole shunt system.

32-year-old delivered a baby girl one week ago via cesarean section. She is in the obstetrician's office with complaint of her cesarean wound bleeding. The wound is cleaned, the edges pulled with steri-strips, and a clean dressing is applied. What ICD-9-CM code(s) should be reported? A. 674.32 B. 666.22 C. 674.34 D. 669.71, V24.0

C. 674.34 Patient is in the post-partum period since she delivered the baby a week ago. This eliminates multiple choices B and D. According to ICD-9-CM guidelines (Section I.C.11.i.4) states when a complication occurs during the admission of the delivery or the patient has remained in the hospital after the delivery, not yet discharged you assign the fifth digit 2. When encounters for post-partum complications happens after the delivery when the patient has been discharged from the hospital and is coming back for a subsequent visit then you assign the fifth digit 4. Code V24.0 is only assigned when there are no complications noted after the delivery.

A 78-year-old with lower back pain and leg pain is scheduled for a MRI of lumbar spine without contrast. Following the MRI, the patient is diagnosed with spinal stenosis of the lumbar region. What are the procedure and diagnosis codes? A. 72020-26, 724.2, 729.5, 724.02 B. 72149-26, 724.03 C. 72148-26, 724.02 D. 72158-26, 724.02, 724.2, 729.5

C. 72148-26, 724.02 Codes for Magnetic resonance imaging (MRI) are determined by anatomical site and whether contrast is used. In this case, the MRI is of the lumbar spine. From the CPT® Index, look for Magnetic Resonance Imaging (MRI)/Spine/Lumbar. You are referred to 72148-72158. Option A is an X-ray so it is not the correct answer. 72148 is without contrast, which is the correct code. According to ICD-9-CM Official Coding Guidelines, do not report signs and symptoms of a definitive diagnosis. In this case the patient complains of lower back pain and leg pain. He is diagnosed with lumbar spinal stenosis. The symptoms he presents with are symptoms associated with his diagnosis and should not be reported. From the ICD-9-CM Index to Diseases, look for Stenosis/spinal/lumbar, lumbosacral (without, neurogenic claudication). You are referred to 724.02. Verify the code in the Tabular List.

42-year-old male was previously treated with external fixation of a trimalleolar fracture. He is now presenting with a nonunion fracture of the medial and lateral malleoulus. What are the ICD-9-CM codes to report? A. 905.4, 733.82 B. 905.4, 824.6 C. 733.82, 905.4 D. 824.6, 733.82, 905.4

C. 733.82, 905.4 According to ICD-9-CM guidelines on Late Effect codes (Section I.A.12): The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect. This eliminates multiple choices B and D. The same guidelines also states: Coding of the late effects generally requires two codes sequenced in the following order: The conditions or nature of the late effect is sequenced first. The late effect code is sequenced second.

Which of the following coding combinations is an example of unbundling? A. 80048, 80061 B. 80076, 80300 C. 80061, 83718, 84478 D. 82310, 82355, 82374

C. 80061, 83718, 84478 Unbundling is reporting components of a code separately that can be reported with one code. In this case 80061 includes 83718 and 84478. It is unbundling to report lab tests that are included in a panel separately.

A patient presents to the ED with crushing chest pain radiating down the left arm and up under the chin. There are elevated S-T segments on EKG. The cardiologist sees and admits the patient to CCU. He orders three serial CPK enzymes levels with instructions that the tests are also to be done with isoenzymes if the initial tests are elevated for that date of service. The CPK enzyme levels were elevated, the lab codes would be: A. 82550, 82552, 82550-76 x 2, 82552-76 x 2 B. 82550, 82552, 82552-91 x 2 C. 82550, 82550-91 x 2, 82552, 82552-91 x 2 D. 82550 x 3, 82554 x 3

C. 82550, 82550-91 x 2, 82552, 82552-91 x 2 In this scenario, three CPK enzyme levels are performed. Modifier 91 is appended to the second, and third CPK CPT® code to indicate the services were repeat clinical diagnostic tests. because each of the CPK enzymes were elevated, the isoenzymes were also tested, which is reported with 82552. Modifier 91 is appended to the second and third tests to indicate the tests are repeat clinical diagnostic tests.

69-year-old female has been having chest tightness. Cardiologist orders percutaneous transluminal coronary angioplasty (PCTA) of the right coronary artery and left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel of the left anterior descending coronary artery and right coronary artery. Stents were inserted in both arteries to keep the arteries opened. Patient was placed under moderate conscious sedation during the procedure for a total of 30 minutes. What CPT® codes should be reported for this procedure? A. 92928-LT, 92929-RT B. 92928-LD, 92929-RC, 99144 C. 92928-LD, 92928-RC D. 92928-LD, 92928-RC, 99144

C. 92928-LD, 92928-RC Stents were placed in the left anterior descending coronary artery (LD) and right coronary artery (RC) which are both major coronary arteries, and reported with base code 92928 twice. There is a bull's-eye symbol in front of code 92928 which indicates moderate sedation is included in the code and is not reported separately.

A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that arrived with multiple facial fractures that may need surgery. Patient was in an automobile accident and an opinion is needed for reconstructive surgery. The plastic surgeon arrives at the ED, obtains detailed history and performs a detailed exam. The plastic surgeon performs a moderate medical decision making, in deciding that the patient needs major surgery to repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with findings in the ED chart. The E/M service reported by the plastic surgeon is: A. 99284-57 B. 99243-32 C. 99243-57 D. 99284-32

C. 99243-57 The E/M service is reported as a consultation because the request of the ED physician to have a plastic surgeon render an opinion on whether the patient needs surgery. A written report of the findings is documented in the ED chart. According to CPT® coding guidelines, the requirements for a consultation have been met. The consultation service is provided in the ED, which is an outpatient setting. The plastic surgery performs a detailed history, a detailed exam, and a moderate MDM. For an outpatient consultation three of the three key components are required. 99243 is the appropriate code. During this encounter, the plastic surgeon made the decision to perform a major surgery, which is scheduled for the next day. Modifier 57 is appended to the E/M service. Modifier 32 is not appropriate to report because there is no documentation that the consultation was requested by a third party, such as an insurance company.

Which of the following statements regarding advanced beneficiary notices (ABN) is TRUE? A. ABN must specify only the CPT® code that Medicare is expected to deny. B. Generic ABN which states that a Medicare denial of payment is possible, or the internist is unaware whether Medicare will deny payment or not is acceptable. C. An ABN must be completed before delivery of items or services are provided. D. An ABN must be obtained from a patient even in a medical emergency when the services to be provided are not covered.

C. An ABN must be completed before delivery of items or services are provided. An ABN must include the service that may be denied, an estimated cost of the patient's responsibility if Medicare denies the service and the response for the potential denial. Generic ABNs are not allowed. Signing of the ABN cannot be obtained during a medical emergency. The patient must be stable. The ABN must be signed prior to providing the service.

70-year-old had fallen breaking her jaw. She has had difficulty eating after having her jaw wired. Her doctor ordered a stationary parenteral nutrition infusion pump for her TPN. A seven day supply of a parenteral home mix nutrition supply kit was also given. What HCPCS Level II codes are reported? A. B9000, B4220 x 7 B. B9004, B4222 C. B9006, B4222 x 7 D. B9006, B4172

C. B9006, B4222 x 7 The nutrition pump is stationary and a supply kit given for seven days. HCPCS codes B4220-B4224 are reported per day.

A patient has an insulin pump of 100 units. The pump is filled. Which code reports the supply? A. J1817 B. J1815 x 20 C. J1817 x 2 D. J1835

C. J1817 x 2 In this scenario we are selecting a code to report the refill of insulin pump. J1815 reports insulin but not for a pump. J1817 is insulin through a pump which is the correct code. J1817 reports 50 units. Two units are reported to account for 100 units of the insulin.

A pediatrician examines an adolescent that has a thoracic curvature of the spine which is called: A. Sclerosis B. Osteochondrosis C. Kyphosis D. Neurofibromatosis

C. Kyphosis Kyphosis is an exaggerated thoracic (upper back) curvature of the spine, sometimes referred to as a hunchback. Kyphosis is indexed to code 737.10. This code falls under category code 737 Curvature of spine.

Patient is admitted in labor for delivery. She received a labor neuraxial epidural for a vaginal delivery. The baby goes into fetal distress and a cesarean section is performed. Following delivery the patient starts to hemorrhage. The physician decides, with family approval, to perform a hysterectomy. Code the anesthesia services. A. 01967, 00840 B. 01962 C. 01968 D. 01967, 01969

D. 01967, 01969 The patient received a neuraxial epidural for labor for a planned vaginal delivery, which is reported with 01967. During the course of labor the patient requires a caesarean section. The patient begins to hemorrhage requiring a hysterectomy. The add-on code 01969 is used to report the anesthesia for the caesarean and hysterectomy.

Patient complains of chronic/acute arm and shoulder pain following bilateral carpal tunnel surgery. Patient is followed by pain management for over a year. Physician finally diagnoses patient with reflex dystrophy syndrome (RSD). Physician performs six trigger point injections into four muscle groups. Code the procedure(s). A. 20552 B. 20553 x 6 C. 20551 x 6 D. 20553

D. 20553 Trigger point is your key term in this scenario, eliminating choice C. Trigger points are coded by the number of muscles that the injections are performed on, not by the number of trigger point injections. The scenario tells you that six trigger points were injected into four muscle groups which lead you to the procedure code 20553.

A 67-year-old female has CAD, atrial fibrillation, claudication and several chronic conditions that have been marginally controlled with medication. The doctor decided that the benefits outweigh the risks for her having a single vessel cardiopulmonary bypass using an arterial graft. Her medication Heparin has been stopped for several days. She was admitted in the hospital a day before the surgery. In the operating room, general anesthesia was administered. After the chest is opened the patient begins to hemorrhage and drops in blood pressure. The decision is made to stop the procedure and close the chest. How should this service be coded? A. Service is not coded due to not completing the procedure B. 33533-52 C. 33533-74 D. 33533-53

D. 33533-53 The procedure code with an appropriate modifier needs to be reported since the patient had been prepared for surgery, received anesthesia, and the procedure had already started. An indication in guiding you to choose the correct modifier is that the procedure was stopped due to the patient's drop in blood pressure, which threatens the well-being of the patient. Procedure was not performed in the out-patient hospital or ambulatory surgery center setting.

A patient with esophageal cancer is brought to the OR for subtotal esophagectomy. A thoracotomy incision is made and the esophagus is identified. The tumor is carefully dissected free of the surrounding structures. No invasion of the aorta or IVC is identified. The cervical esophagus is controlled with pursestring sutures and then transected above the sternal notch. The esophagus is then dissected free of the stomach and the entire specimen is removed from the chest cavity and sent to pathology. The stomach is then pulled into the chest cavity and anastomosed to the remaining cervical esophageal stump. The anastomosis is tested for patency and no leaks are found. Hemostasis is assured. The chest is examined for any signs of additional disease but is grossly free of cancer. The chest is closed in layers and a chest tube is place through a separate stab incision. The patient tolerated the procedure well and was taken to the PACU in stable condition. A. 43101 B. 43117 C. 43107 D. 43112

D. 43112 You first need to look at the approach of the surgery, which the physician is incising the chest (thoracotomy) to expose the esophagus, eliminating multiple choice answer C. The physician is not removing a lesion from the esophagus; the physician is removing the esophagus (esophagectomy) and replacing it with the stomach, eliminating multiple choice answer A. The next key term to help you choose between procedure codes 43112 and 43117 is "cervical". Code 43112 is correct because the stomach is pulled through the middle of the chest into the neck and the stomach is connected to the stump of the esophagus in the neck (cervical).

22-year-old driver loss control of her car and crashed into a light pole on the highway. She arrived to the hospital by ambulance in an unconscious state. She had CT scans without contrast of the brain and chest. She had X-rays of AP and PA views of her left ribs and AP and PA views of her right ribs with a posterioanterior view of the chest. The CT scan of the brain showed a fracture of the skull base with no hemorrhage of the brain. The CT of the lung showed no puncture of the lungs. The X-ray showed fractures in her second, third, and fifth ribs. What CPT® and ICD-9-CM codes should be reported. A. 70450-26, 71250-26, 71101-26, 803.02, 807.03, E815.0, E849.5 B. 70460-26, 71260-26, 71110-26, 801.02, 807.13, E815.0, E849.5 C. 70450-26, 71250-26, 71111-26, 71010-26, 801.06, 807.03, E815.0, E849.5 D. 70450-26, 71250-26, 71111-26, 801.06, 807.03, E815.0, E849.5

D. 70450-26, 71250-26, 71111-26, 801.06, 807.03, E815.0, E849.5 The first radiology code is for the computed tomography (CT) of the head or brain without contrast. Second radiology code is for the CT of the thorax without contrast. The last radiology code is a total of four views of both (bilateral) sides of the ribcage and includes the posteroanterior chest view. ICD-9-CM codes: Fracture of the skull base with no hemorrhage is indexed under Fracture/skull/base referring you to code 801.0x. Documentation has the patient being unconscious, but no time frame on how long was documented. The fifth digit is 6. Three ribs are fractured, this is indexed under Fracture/rib(s) (closed) referring you to code 807.03. E codes are found in the Alphabetic Index to External Cause under Collision/motor vehicle/object referring you to code E815.x. The patient was the driver, fourth digit being a 0. Accident occurred on the highway. This is indexed under Accident/occurring/highway referring you to code E849.5.

The physician orders an ultrasound on a patient 25 weeks pregnant with twins to access fetal heart rate and fetal position. Select the code(s). A. 76805, 76810 B. 76811, 76812 C. 76816 x 2 D. 76815

D. 76815 In the beginning of the obstetric ultrasound subsection in CPT®, there are descriptions of what is required for the OB ultrasound codes. In this case the ultrasound is limited because only two elements are examined the fetal heart rate and fetal position. This type of ultrasound is reported with 76815. In the code description it states "1 or more" which means the code is only reported once whether it is a single fetus or multiple fetuses.

A two-month-old returns for a well check up and several shots (Rota, DTaP/Hib, PCV) with her pediatrician. He offers suggestions to the mom, completes the exam, and counsels her on the vaccinations. How should this be coded? A. 99391-25, 90460, 90461 x 2, 90680, 90721, 90669 B. 99381-25, 90471, 90472 x 2, 90474, 90680, 90700, 90648, 90669 C. 99381-25, 90471, 90472 x3, 90680, 90700, 90645, 90669 D. 99391-25, 90460 x 3, 90461 x 3, 90680, 90721, 90669

D. 99391-25, 90460 x 3, 90461 x 3, 90680, 90721, 90669 We know this patient is established because she is "returning to her pediatrician." The well check up is coded as a preventive service. The patient is two-months-old. The proper code is 99391. According to NCCI, modifier 25 is appended when a significant and separately identifiable E/M service is performed with other services at the same encounter. In this case vaccinations are performed. A vaccine administration for each is coded as well as the vaccine itself. In this case three vaccines are performed; rotavirus (90680), combination vaccine DTaP/Hib (90721) and Pneumococcal (90669). The physician counsels the patient's mother regarding the vaccinations. This eliminates multiple choices B and C. Add-on-code 90461 is reported when a combination vaccine is given. DTaP/HIB is a combination vaccine that has a total of four components (diphtheria, tetanus, accellular pertussis, Hemophilus influenza B). Code 90460 is reported three times for the administration of the rotavirus, diphtheria (first component of the combination vaccine), and pneumococcal. Add-on-code 90461 is reported three times for the remaining three components (tetanus toxoids, acellular pertussis and Hemophilus influenza B) in the combination vaccine

At the request of the mother's obstetrician, a neonatologist is called to attend the birth of an infant being delivered at 29 weeks gestation. During delivery, the neonate was pale and bradycardic needing resuscitation. Neonatologist performs the suctioning and bag ventilation on this 1000 gram neonate was performed with 100 percent oxygen. Brachycardia worsened; endotracheal intubation was performed and insertion of an umbilical line for fluid resuscitation. Later this critically ill neonate was moved from the delivery room and admitted to the NICU with severe respiratory distress and continued hypotension. What are the appropriate procedure codes reported by the neonatologist? A. 99465, 99468 B. 99465, 99464, 99468-25, 31500-59, 36510-59 C. 99468, 99464 D. 99465, 99468-25, 31500-59, 36510-59

D. 99465, 99468-25, 31500-59, 36510-59 Parenthetical instrustruction states that code 99464 cannot be reported with 99465. Because the baby needed resuscitation report 99465. The critically ill neonate is admitted to critical care. According to CPT® coding guidelines, 99468 can be reported with 99465. The guidelines also state "other procedures performed as a necessary part of the resuscitation are also reported separately when performed as part of the pre-admission delivery room care". In this scenario the intubation (31500) and the umbilical line (36510) were performed pre-admission to the NICU for resuscitation so they are both reported. Modifier 59 is appended to indicate that these procedures were performed before the baby was admitted to NICU. Failing to append modifier 59 on the procedure codes, will allow both services to be bundled with 99468. Modifier 25 is reported to indicate a separate and significant E/M service.

According to the CPT® Appendix L, when performing a selective vascular catheterization, which vessels would you pass through to place the catheter into the right middle cerebral artery? A. Innominate, right common carotid, right exteranl carotid B. Innominate, right subclavian & axillary C. Left common carotid, left internal carotid D. Innominate, the right common, and internal carotid

D. Innominate, the right common, and internal carotid Using Appendix L in your CPT® codebook as a guide for the vascular families, we begin in the Innominate artery (first order). Then from there you will enter R. (right) common carotid (second order). Next you will pass through the R. internal carotid (third order) ending up at the R. a. cerebral artery.

The root metr/o means: A. Menstruation B. Breast C. Mammary gland D. Uterus

D. Uterus The root word metr/o or metr/i means uterus. In the ICD-9-CM Index to Diseases look for a word that starts with metro. You will see the medical term Metrorrhexis - see Rupture, uterus.