Medical Coding Training CPC Chapters 1-20 Review

____ is a term standing for enlargement of the heart.

Cardiomegaly Cardio = heart, megaly = enlargement

Which structure is not a true endocrine structure?

Carotid body The carotid body is not a true endocrine structure, but is made of both glandular and nonglandular tissue.

What is the name of the structure made of bone and cartilage separating the nostrils?

Nasal septum A septum is a partition. The nasal septum separates the nostrils.

The ____describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare.

National Coverage Determinations Manual The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures or technologies are considered medically necessary under Medicare.

What is included in all vascular injection procedures?

Necessary local anesthesia, introduction of needles or catheters, injection of contrast media with or without automatic power injection and/or necessary pre-and post-injection care specifically related to the injection procedure. CPT® guidelines for Vascular Injection Procedures indicate the above listed in D as being included.

What is a laminotomy?

Partial excision of one or more lamina. A laminotomy is partial excision of a vertebral lamina (placing a hole in the lamina). It is also referred to as a hemilaminectomy. A laminectomy is complete excision of a lamina.

What is a default code? Refer to ICD-10-CM guideline I.A.18.

The code that represents the condition most commonly associated with the main term. The default code represents that condition is the most commonly associated with the main term, or is the unspecified code for the condition.

Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?

There are separate codes for carbuncles and furuncles. There are separate codes for a furuncle versus a carbuncle.

Supplementary words enclosed in parentheses in the ICD-10-CM coding manual have what affect on the coding? Refer to ICD-10-CM guideline I.A.7.

They do not affect code assignment. Parentheses are used in both the ICD-10-CM Alphabetic Index and Tabular List to enclose supplementary words that may be present in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.

How are ambulance modifiers used?

They identify ambulance place of origin and destination. Transportation (ambulance) services utilize modifiers made up of two letters identifying the origin and the destination according to the HCPCS Level II guidelines at the beginning of section A, Transportation Services Including Ambulance A0021-A0999.

What is also referred to as the "Windpipe?"

Trachea The trachea carries air from the mouth and throat down to the lungs and is often referred to as the windpipe.

Urine is transported from the kidneys to the urinary bladder by which structure?

Ureter

What type of code is assigned when the provider documents a reason for a patient seeking healthcare that is not an injury or disease?

Z code (Z00-Z99) ICD-10-CM guideline IV.E indicates to use codes from Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99). These codes are also known as Z codes and are provided to record healthcare encounters for circumstances other than a disease or injury. ICD-10-CM Chapter 21 states Z codes provide codes to deal with encounters for circumstances other than a disease or injury.

Which of the following is true about the function of the cochlea?

It transmits sound only

Arthritis is an inflammation of what?

Joint

" " What ICD-10-CM code is reported for nausea and vomiting?

" R11.2 Look in the ICD-10-CM Alphabetic Index for Nausea/with vomiting which directs you to R11.2. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for Ataxia telangiectasia?

" G11.3 In the ICD-10-CM Alphabetic Index, look for Ataxia/telangiectasia directing you to code G11.3. Verification in the Tabular List confirms code selection.

"CASE 10 Preoperative diagnosis: Severe two-vessel coronary artery disease and moderate valve aortic stenosis. Postoperative diagnosis: Same. Operation: Triple-vessel coronary artery bypass grafting: Left internal mammary artery to the left anterior descending coronary artery, reverse saphenous vein to the first diagonal branch, and a ramus intermedius. Aortic valve replacement with a 23 mm bovine pericardial bioprosthesis. Anesthesia: General. Indications: This is a 66 year-old white male who presented with unstable angina pectoris. He underwent coronary angiography and had a 70 percent occlusion in the distal left main, an 80 percent occlusion in the proximal left anterior descending coronary artery (LAD), a 95 percent occlusion of the proximal ramus intermedius, and a 70 percent occlusion in the proximal diagonal branch. The right coronary artery had no significant lesions. His aortic valve gradient was 40mm Hg by catheter and echocardiogram. He presented with a new onset of angina pectoris and significant coronary artery disease, surgery was warranted. Procedure: While monitoring the intra-arterial blood pressure and EKG, the patient was anesthetized without incident. The entire chest, abdomen, and both legs were prepared and draped into the usual sterile field. A median sternotomy was performed. The left internal mammary artery was dissected off the chest wall. Simultaneously, the greater saphenous vein was endoscopically harvested from the left leg and the layers were closed with Vicryl and Dermabond. A sterile compressive dressing was applied. The pericardium was opened and tacked up to form a cradle. After heparinization, the ascending aorta and the right atrial appendage were cannulated and connected to cardiopulmonary bypass using a membrane oxygenator with an initial flow of 4.9 liters/min. Antegrade and retrograde cardioplegia catheters were inserted. On bypass, a left ventricular vent was placed through the right superior pulmonary vein. The coronaries were dissected out and found to be suitable for grafting although the circumflex branches were less than 1 mm in diameter. The ramus intermedius was identified as well as the diagonal branch which was small. The heart was then arrested with cold enriched blood cardioplegia, given antegrade after cross-clamping the ascending aorta. Once diastolic arrest was obtained, the heart was cooled with cold blood cardioplegia given initially antegrade and subsequently retrograde. Additional doses were given retrograde as well as down the vein graft. At the end, a hot shot was given. Systemic temperature was lowered to 32 degrees. Myocardial temperature was maintained around 20 degrees. The ramus intermedius was opened first. This was found to be a 1.5-2.0mm vessel. An end-to-end anastomosis using a segment of reverse saphenous vein was then performed with running 7-0 Prolene suture technique. This was felt to be a good graft with flow of 90 ml/min. Next, the first diagonal branch was grafted in a similar manner with a second segment of reverse saphenous vein with a resultant flow of 50 ml/min. The left internal mammary artery was anastomosed to the left anterior descending coronary artery in an end-to-end fashion using the in situ left mammary with running 8-0 Prolene suture technique. The diagonal branch was a 1.5mm vessel and the LAD was a 1.5-2.0mm vessel. Next, the aorta was opened in an oblique transverse fashion and a moderately calcified trileaflet aortic valve was examined. The left ventricle was irrigated with saline. The annulus sized to a 23mm pericardial tissue valve (Model #3000, Serial # 55555555). The valve was sutured; in a supra-annular fashion with interrupted 2-0 Ethibond valve sutures placed in the pledgets on the left ventricular out-flow tract side. The valve was seated and tied down securely. The aortotomy was then closed in two layers with running 4-0 Prolene reinforced with in the corners pledgets. During the same cross-clamp time, the proximal vein grafts were then anastomosed to the ascending aorta to two separate circular openings using 6-0 Prolene suture technique. After filling the heart with blood and evacuating the air from the apex of the left ventricle with an 18-gauge needle, the cross-clamp was removed and the vein graft deaired. Rewarming had begun while constructing the proximal anastomoses. While rewarming continued, two temporary atrial, temporary ventricular, and temporary ground pacing wires were placed, as well as two Blake drains for mediastinal drainage. Once the patient reached a rectal temperature of 36 degrees, he was weaned off cardiopulmonary bypass without any inotropic support and without any difficulties. The venous cannula was removed, the heparin was reversed with protamine, and the aortic cannula was removed. The mediastinum was irrigated with copious amounts of saline and Bacitracin solution, using the pulse lavage irrigator. The sternum was reapproximated with the surgical Pioneer Sternal Cable System using four figure-of-eight cables. After pulse irrigating and pulse lavaging the fascia and subcutaneous tissue, the incision was closed in layers with Vicryl and the skin reapproximated with a subcuticular closure and Telfa sterile dressing was applied. There were no difficulties and the patient was taken to the ICU in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c], [d] ICD-10-CM codes: [e], [f]

" 33405, 33533-51, 33518, 33508, I35.0, I25.110

"CASE 7 Preoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis. Postoperative Diagnosis: Cholelithiasis, chronic cholecystitis, and acute pancreatitis, pathology pending. Procedure Performed: Laparoscopic cholecystectomy, with intra-operative fluoroscopic cholangiography. Anesthesia: General anesthesia and 0.5% Marcaine (10 cc/s). Estimated Blood Loss: minimal. Drains: None. Specimen: Gallbaldder. Operative indications: This is a 49-year-old female with the above diagnosis who presents for elective laparoscopy, cholecystectomy and intra-operative cholangiography. Operative Procedure: The patient was brought to the OR suite with PAS stocking in place. She was transferred to the operative table, given a general anesthetic, positioned supine on the table, and the operative field was sterilely prepped and draped. A vertical incision was made in the base of the umbilicus and deepened through the fascia. Stay sutures of 0-Proline were placed, and the abdomen was entered under direct vision. A Hassan cannula was anchored in place with the stay sutures and the abdomen was insufflated to 15 mm Hg with CO2 gas. A 10 mm, 30-degree scope was assembled, focused, weight-balanced, and placed into the abdomen. Cursory evaluation revealed no other obvious pathology with the exception of the gallbladder. Under direct vision, 3-5 mm ports were placed in the epigastrium, right upper quadrant, and right lower quadrant. The patient was placed in reverse Trendelenberg position, with the right side up. The fundus of the gallbladder was grasped and retracted over the dome of the liver. Adhesions to the gallbladder were taken down with sharp and blunt dissection while carefully maintaining hemostasis with electrocauterery. The ampulla of the gallbladder was grasped with a second instrument and retracted downward and laterally, displaying the angle of Calot distracted from the portal structures, The cystic duct and artery were dissected circumferentially. A single clip was placed on the distal cystic duct and an opening created just proximal to it. The cholangiogram apparatus was introduced into the abdomen via the 5 mm RUQ port and the 5-French whistle-tip ureteral catheter was threaded into the common bile duct through the opening in the cystic duct. The cholangiogram was performed under fluoroscopy and was normal, demonstrating filling of the duct with defects and prompt flow into the duodenum. The cholangiogram apparatus was withdrawn from the abdomen, and the cystic duct was clipped twice proximally, and divided. The cystic artery was clipped once distally, twice proximally, and divided. The cystic duct and artery were dissected circumferentially, clipped once distally, twice proximally and divided. Care was taken not to encroach upon the common bile duct or portal structures. The gallbladder was taken down from the liver using the hook-dissector and cautery carefully maintaining hemostasis during the process. The right upper quadrant was irrigated with saline and suctioned dry. Hemostasis was confirmed. There was no bile drainage from the gallbladder bed in the liver. A 5 mm, 30-degree scope was assembled, focused, white-balanced, and placed into the epigastric port. The gallbladder was removed under direct vision through the umbilical port. The other ports were removed under direct vision, and hemostasis was achieved. The abdomen was de-insufflated. The fascia in the umbilical incision was closed with a figure of eight suture of 0 vicryl. The wounds were infiltrated with a total of 10 cc's of 0.5% marcaine. The skin incisions were closed with subcuticular sutures of 4.0 vicryl. Steri-strips and sterile dressings were applied. After a correct sponge, instrument, and needle count, the patient was awakened, extubated, and taken to the recovery room in good condition. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 47563, K80.10, K85.90

"CASE 2 Preoperative diagnosis: Prostate cancer. Postoperative diagnosis: Prostate cancer.(This is the diagnosis to report for the surgery. The pre and post-operative diagnoses match and are supported in the statement of medical necessity.) Procedure: Radical retropubic prostatectomy with bilateral pelvic lymph node dissection. Statement of Medical Necessity: The patient is a very pleasant 58-year-old gentleman with Gleason 7 prostate cancer. He understood the risks and benefits of radical retropubic prostatectomy including failure to cure, recurrence of cancer, need for future procedures, impotence and incontinence. He understood these risks, and he elected to proceed. Statement of Operation: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate general endotracheal anesthesia was accomplished, he was put in the dorsal lithotomy position and was prepped and draped in the usual sterile fashion. A 20 French Foley catheter was introduced in the patient's urethra, and the balloon was inflated with 20ml of sterile water. Made a mid-line infraumbilical incision and dissected down to the rectus fascia. Then transected the rectus fascia between the bellies of the rectus muscle and dissected into the retropubic space.(This indicates the surgery is performed by an open approach into the retropubic area.) Placed a Bookwalter retractor to aid in visualization and to protect the surrounding structures. Performed a bilateral pelvic lymph node dissection,(Bilateral pelvic lymphadenectomy.) taking care to avoid the hypogastric and obturator nerves bilaterally. The node packets were sent off the field for permanent section and frozen section. Then dissected the prostate free from its lateral side wall and dorsal attachments superficially and placed a right-angle clamp behind the dorsal venous complex and tied off the dorsal venous complex with two free ties of #1 Vicryl. Sewed some back bleeding sutures over the prostate and we placed a right-angle again behind the dorsal venous complex and then transected it with a long handled blade. Carefully inspected the dorsal venous complex for any bleeding and no bleeding was noted. Then placed a right angle clamp behind the urethra and transected the anterior aspect of the urethra, exposing the Foley catheter. We grasped this with a tonsil and then cut off the Foley catheter at the urethral meatus and pulled the Foley catheter into the urethral incision that had been made. Then transected the posterior urethra, freeing the prostate from its apical attachment. This allowed us to apply upward retraction to the prostate and dissect it free from the rectal anterior wall. Then clipped and cut the lateral pedicles to free the prostate up to the level of the bladder neck. Then transected Denonvilliers' fascia and identified the bilateral vas deferens, which were clipped and cut accordingly. Also, dissected the seminal vesicles leaving the tips of the seminal vesicles in place in the hopes of improving his incontinence.(Radically removing the entire prostate.) Once this was complete, dissected the prostate free from the bladder neck using electrocautery.(Radically removing the entire prostate.) Opened the anterior aspect of the bladder, able to identify the bilateral ureteral orifices effluxing indigo carmine that had been administered about 10 minutes earlier by the anesthesiologist. Once the prostate was sent off the field for permanent section, attention was turned to recapitulating the bladder neck. Everted the bladder mucosa with 4-0 Monocryl and then closed the bladder neck in a tennis racquet closure using 2-0 Vicryl. Then placed a Roth sound in the patient's urethra after ensuring adequate hemostasis in the pelvis and placed five anastomotic sutures of 2-0 Monocryl surrounding the urethra. Then placed them in the corresponding location in the bladder neck after a Foley catheter, 20 French in size, had been placed through the urethra and into the bladder, and the balloon was inflated with 20ml of sterile water. Then cinched down these anastomotic sutures and tied them off. Irrigated the Foley catheter and ensured that there was no bladder leak. Then placed a JP drain in the patient's left lateral quadrant, taking care to avoid the epigastric vessels. Stitched the drain in place with a 2-0 silk. Closed the fascia with #1 Vicryl in a running fashion and closed the subcutaneous tissues with 3-0 Vicryl. The skin was stapled closed and a sterile dressing was applied. His catheter was again irrigated with return of blue urine. No clots. The patient was extubated, and taken to the recovery room in good condition. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code(s): [a] ICD-10-CM code(s): [b]

" 55845, C61

"CASE 8 PREOPERATIVE DIAGNOSIS: Right otosclerosis. POSTOPERATIVE DIAGNOSIS: Right otosclerosis. TYPE OF PROCEDURE: Right stapedectomy. ANESTHESIA: General endotracheal. FINDINGS: There was otosclerosis on the anterior footplate of the stapes with preoperative conductive hearing loss in the right ear. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. Following induction of general endotracheal anesthesia, the head was turned to the left and the right ear was prepped and draped in the usual fashion. Then 1% Xylocaine with 1:100,000 epinephrine was infiltrated in the skin along the posterior ear canal wall and the skin over the tragus. After a short waiting time, an incision was made over the tragus and a piece of posterior tragal perichondrium was harvested for a graft and set aside to dry. A speculum was then placed in the canal. The canal was quite large. An incision was made along the posterior canal wall, and a tympanomeatal flap was elevated and laid forward to include the fibrous annulus without perforation. The middle ear was inspected. The ossicular chain was palpated and otosclerosis appeared to be fixing the stapes. The chorda tympani nerve was very carefully preserved and not manipulated and was kept moist throughout the procedure. No curetting of bone was necessary in order to access the footplate. A control hole was made in the footplate with a straight pick. The incudostapedial joint was separated with an IS joint knife. The stapedius tendon was severed, and the superstructure of the stapes was fractured over the promontory and removed. The footplate was then picked out with a 45-degree pick, completely removing all fragments. Great care was taken not to suction in the vestibule. The distance between the incus and the oval window was then measured. The tragal perichondrial graft was then taken and laid over the oval window with complete coverage. A 3.75 Shea platinum Teflon cup piston was then chosen. The platinum wires were opened and the shaft was placed down against the graft and into the oval window niche. The cup was placed under the long process of the incus by gently lifting the incus, and the platinum wires were snugly crimped around the long process of the incus. An excellent round window reflex was achieved upon palpation of the ossicular chain at this point. Small, dry, pressed Gelfoam pledgets were then placed around the shaft of the prosthesis and over the graft. The tympanomeatal flap was replaced. The lateral surface of the drum was covered with Gelfoam, and the canal was filled with antibiotic ointment. The incision over the tragus was closed with running, interlocking 5-0 plain, fast-absorbing gut. A cotton ball was placed in the canal, and the patient was awakened, extubated, and returned to recovery in satisfactory condition. He will be discharged when fully awake and will return to my office in two weeks. He will avoid strenuous activity, keep the ear dry, keep a clean cotton ball in the ear, apply antibiotic ointment to the tragal incision, avoid driving while dizzy, and he was given prescriptions for Lorcet Plus, Keflex, and Xanax. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 69660-RT, 21235-51-RT, H80.81

"New Patient History & Physical CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44 year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. MEDICATIONS: Advair. ALLERGIES: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. LYMPH NODES: None. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear to auscultation. HEART: Regular rhythm with no murmur. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number, and he will call and arrange the operation. What CPT® and ICD-10-CM codes are reported?

" 99203, K40.90

"CASE 5 CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.) MODE OF ARRIVAL: Private vehicle. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain. REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough. All other systems have been reviewed and are negative except as noted. PHYSICAL EXAMINATION: General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance. Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air. HEENT: The head is normocephalic and atraumatic. Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles. Heart: Regular rate and rhythm without murmurs Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand symmetrically. Thorax/Chest Wall: Demonstrates mild tenderness anteriorly and demonstrates distinct tenderness posteriorly along the medial aspect of the scapula. No bruising or ecchymosis is noted on the skin of the chest wall. Patient keeps his right shoulder lowered. There is no deformity noted. There is no tenderness over the right clavicle. No bony deformity is noted there. There is no subcutaneous emphysema of the chest wall. Extremities: Warm and dry without clubbing, cyanosis or edema. Grip strength is 5/5 bilaterally. Patient can flex and extend all fingers without difficulty. He can pronate and supinate at the elbow. He complains of pain in the shoulder when he flexes and extends at the elbow. Normal radial and ulnar pulses are appreciated in the bilateral upper extremities. Capillary refill is brisk. Sensation is normal in all nerve distributions in the bilateral arms. Abdomen: Soft, non-distended. Non-tender. Diagnostics: Two views of the chest, PA and lateral, and three views of the right shoulder were obtained. ED course: The patient received a total of 2 mg of Dilaudid for pain, 1 mg of sublingual Ativan. His arm was placed in a sling This was well tolerated and the patient was discharged home. Medical Decision Making: It appears the patient has an anterior chest wall and a posterior chest wall contusion. The exact reasoning why he has so much difficulty moving the shoulder is unclear at this time, as he is completely neurologically intact from what I can tell. He can adduct and abduct at the shoulder, as I have seen him do it as he was moving around to be examined. X-rays demonstrate no evidence of fracture or dislocation. At this point, I am discharging the patient home, having him use ice packs, doing prescriptions for pain medications and having him return for new or worsening symptoms. IMPRESSION: 1 Anterior and posterior chest wall contusion. 2 Right shoulder injury. (Report codes for the definitive diagnosis.) PLAN: Discharge home. Return for new or worsening symptoms. Sling for comfort. What diagnosis code(s) are reported? [a] [b] [c] [d] [e]

" S20.211A, S20.221A, S49.91XA, W23.0XXA, Y92.512

What agency maintains and distributes HCPCS Level II codes?

CMS CMS maintains and distributes HCPCS Level II codes.

What disease is characterized by enlarged skeletal parts?

Acromegaly Acromegaly is characterized by enlarged skeletal parts, especially the nose, ears, jaws, fingers and toes. It is caused by hypersecretion of growth hormone (GH) from the pituitary gland.

Chapter 5 Questions

Answers Rationale:

" Chapter 14 Questions

Answers Rationale

Which of the following best describes constituent components of the human lymphatic system?

Lymph nodes, lymphatic vessels, spleen, thoracic duct

What are the different parts of Medicare?

Part A, B, C, D

A covered entity does NOT include

Patients Image

What is medical necessity?

Relates to whether a procedure or service is considered appropriate in a given circumstance.

The acronym BKA means:

below knee amputation BKA is the acronym for below-knee amputation.

The prefix meaning lip

cheil/o An/o means anus, cec/o means cecum, col/o means colon.

What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges?

ABN An Advanced Beneficiary Notice (ABN) is used when a Medicare beneficiary requests or agrees to receive a procedure or service that Medicare may not cover. This form notifies the patient of potential out of pocket costs for the patient

Select the TRUE statement regarding ABNs.

ABNs may not be recognized by non-Medicare payers. ABNs may not be recognized by non-Medicare payers. Providers should review their contracts to determine which payers will accept an ABN for services not covered.

An anesthesiologist is medically supervising six cases concurrently. What modifier is reported for the anesthesiologist's service?

AD In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. An anesthesiologist who is medically supervising more than four concurrent anesthesia procedures uses modifier AD to report for the anesthesiologist supervision services. The anesthesia services performed by the CRNA are reported separately. The anesthesia modifier for the anesthesiologist depends on the number of concurrent cases.

What is Bowman's capsule?

C-shaped structure partially surrounding the glomerulus

After a routine and uncomplicated appendix surgery, the patient began bleeding post-operatively. What ICD-10-CM code is reported?

" K91.840 In the ICD-10-CM Alphabetic Index look for Complication/hemorrhage/postprocedural directs you to see Complication, postprocedural hemorrhage. Look for Complication/postprocedural /hemorrhage (hematoma) (of)/digestive system/following procedure on digestive system which directs you to code K91.840. Verify code selection in the Tabular List.

" The patient presents to the clinic today for a follow up of his hospitalization for pneumonia. He was placed back on Singulair® and has been improving with his breathing since then. He has no complaints today. What is the level of history?

" Problem focused History HPI Location Severity Timing Modifying Factors Quality Duration Context Assoc Signs & Symptoms Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more) ROS Const GI Integ Hem/lymph Eyes GU Neuro All/Immuno Card/Vasc Musculo Psych All other negative Resp ENT, mouth Endo None Pertinent to problem (1 system) Extended (2-9 systems) Complete PFSH Past history (current meds, past illnesses, operations, injuries, treatments) Family history (a review of medical events in the patient's family) Social history (an age appropriate review of past and current activities) None None Pertinent (1 history area) Complete (2 (est) or 3 (new) history areas) Problem Focused Expanded Problem Focused Detailed Comprehensive CC: Follow-up of hospitalization for pneumonia. HPI: Modifying Factor: He was placed back on Singulair® and has been improving with his breathing since then. ROS: None PFSH: None

" Mr. Yates loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Yates. When EMS reached the hospital Emergency Department, Mr. Yates is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour in critical care stabilizing the patient and performing CPR. The time the provider spent on CPR was 15 minutes (the CPR time was included in the one-hour critical care time). What are the appropriate procedure codes for this encounter?

" " 92950, 99291, 99288 Documentation describes physician direction of the paramedics (99288). In the CPT® Index look for Physician Services/Direction, Advanced Life Support. He spends another hour stabilizing the patient. Refer to the CPT® guidelines under Critical Care Services. The time for the CPR must be deducted from the 1 hour of critical care, making the critical care time 45 minutes reported with critical care code 99291. CPR is not a service included in the critical care codes and may be reported separately with 92950. In the CPT® Index look for CPR (Cardiopulmonary Resuscitation).

"CASE 6 CRNA performed anesthesia Anesthesiologist medically directing two cases Anesthesia Time: 9:30 to 10:06 Physical Status 3 PREOPERATIVE DIAGNOSIS: Cyst on knee POSTOPERATIVE DIAGNOSIS: Baker's Cyst PROCEDURE: Excision of Baker's Cyst, knee ANESTHESIA: Monitored Anesthesia Care What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® code: [c] ICD-10-CM code: [d] What is the time reported for this service? [e] minutes

" "01400-QK-QS-P3, M71.20, 01400-QX-QS-P3, M71.20, 36 Look in the CPT® Index for Anesthesia/Knee, referring you to a large selection of codes. Other than 00400 (used for Integumentary), the codes directed fall within the range 01320-01444 (Knee and Popliteal Area). An excision is an open procedure, so you would find the code specific to open procedures on the knee. There is not a specific anesthesia code for excision of a Baker's cyst, so CPT® 01400 is reported. The physical status is reported as level 3 (P3). QK is used to indicate the anesthesiologist is directing 2-4 concurrent cases. QX is used to indicate the services reported by the CRNA. QS reports Monitored Anesthesia Care (MAC) services.ICD-10-CM: The post-operative diagnosis is Baker's Cyst. In the ICD-10-CM Alphabetic Index, look for Cyst/Baker's, referring you to M71.2-. In the Tabular List, 5th character 0 is reported for unspecified knee. Time: The anesthesia time is noted as 9:30-10:06, which is 36 minutes.

"Operative Report PREOPERATIVE DIAGNOSIS: Diabetic foot ulceration. POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration. OPERATION PERFORMED: Debridement and split thickness autografting of left midfoot. ANESTHESIA: General endotracheal. INDICATIONS FOR PROCEDURE: This patient with multiple complications from type 2 diabetes developed skin ulcerations which were debrided with homograft last week. The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting. DESCRIPTION OF PROCEDURE: After informed consent the patient is brought to the operating room and placed in the supine position on the operating table. Anesthetic monitoring was instituted; general anesthesia was induced. The left lower extremity is prepped and draped in a sterile fashion. Staples were removed and the homograft was debrided from the surface of the wounds. One wound appeared to have healed; the remaining two appeared to be relatively clean. We debrided this sharply with good bleeding in all areas. Hemostasis was achieved with pressure, Bovie cautery, and warm saline soaked sponges. With good hemostasis a donor site was then obtained on the left anterior thigh, measuring less than 100 cm 2. The wounds were then grafted with a split-thickness autograft that was harvested with a patch of Brown dermatome set at 12,000 of an inch thick. This was meshed 1.5:1. The donor site was infiltrated with bupivacaine and dressed. The skin graft was then applied over the wound, measured approximately 60 cm 2 in dimension on the left midfoot. This was secured into place with skin staples and was then dressed with Acticoat 18's, Kerlix incorporating a catheter, and gel pad. The patient tolerated the procedure well. The right foot was redressed with skin lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition. What CPT® and ICD-10-CM codes are reported?

" "15120-58, 15004-58-51, E11.621, L97.421 The wound was prepped with sharp debridement. Look in the CPT® Index for Creation/Recipient Site and you are referred to codes 15002-15005. Code selection is based on location and size resulting in 15004 as the correct code for the foot. Then a split-thickness graft was harvested. Look in the CPT® Index for Skin Graft and Flap/Split Graft referring you to codes 15100, 15101, 15120, 15121. The measurement applies to the recipient area, which is 60 cm². A split thickness autograft to the foot for the first 100 sq cm is coded with 15120. The operative note states, "The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting," indicating this is a staged procedure and modifier 58 is appended. Modifier 51 is appended to the second procedure to indicate the same surgeon performed more than one procedure during the same operative session. In the ICD-10-CM Alphabetic Index complications of diabetes are reported with combination codes. Diabetes is specific to the type of diabetes, and documentation supports this as type 2, with midfoot skin ulcer. Look in the Alphabetic Index for Diabetes/type 2/with/foot ulcer referring you to E11.621. The Tabular List instructs to use an additional code to identify the site of the ulcer L97.1-L97.9, L98.41-L98.49. The graft is performed on the left midfoot for the skin ulcer, L97.421.

"CASE 10 Preoperative Diagnosis: Left lower eyelid basal cell carcinoma Postoperative Diagnosis: Left lower eyelid basal cell carcinoma Operation: Excision of left lower eyelid basal cell carcinoma with flaps and full thickness skin graft and tarsorrhaphy. Indication for surgery: The patient is a very pleasant female who complains of a one-year history of a left lower eyelid lesion. This was recently biopsied and found to be basal cell carcinoma. She was advised that she would benefit from a complete excision of the left lower eyelid lesion. She is aware of the risks of residual tumor, infection, bleeding, scarring and possible need for further surgery. All questions have been answered prior to the day of surgery. She consents to the surgery. Operative Procedure: The patient was placed supine on the operating table and an intravenous line was established by hospital staff prior to sedation and analgesia. Throughout the entire case, the patient received monitored anesthesia care. The patient's entire face was prepped and draped in the usual sterile fashion with a Betadine solution and topical tetracaine and corneal protective shields were placed over both corneas. A surgical marking pen was used to mark the tumor. Markings that were 3 mm were obtained around the tumor. The tumor was noted to encompass approximately 1/3 of the left lower eyelid. A wedge resection was performed and this was marked and 2% Xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:100,000 epinephrine was infiltrated around the lesion. This was excised with a #15 blade. This was sent for intraoperative fresh frozen sections. Intraoperative fresh frozen sections revealed persistent basal cell carcinoma at the medial margin. Another 2mm of margin was discarded and a revised left lower eyelid medial margin was sent for permanent sections. The area could not be closed primarily, thus a tarsoconjunctival advancement flap was advanced from the left upper eyelid to fill the defect. This was sutured in place with multiple 5-0 Vicryl sutures. The anterior lamella defect of skin was closed by harvesting a full-thickness skin graft from the left upper eyelid and placing it in the left lower eyelid defect. This was sutured in place with multiple interrupted 5-0 chromic gut sutures. The eyelids were sutured shut both on the medial aspect of the Hughes flap as well as the lateral aspect of the Hughes flap with a 4-0 silk suture. A pressure dressing and TobraDex ointment were applied. The patient tolerated the procedure well and was transported back to the recovery area in excellent condition. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c], [d] ICD-10-CM code: [e]

" "15260-E2, 67966-51-E2, 67971-51-E2, 67875-51, C44.1192 In this case, an excision of a basal cell carcinoma is performed. More than 1/3 of the lower eyelid is excised. A full thickness graft as well as a flap (adjacent tissue transfer) is required for the closures. A full-thickness skin graft from the left upper eyelid which was placed on the left lower eyelid defect. Skin grafts are always reported according to the recipient site. Look in the CPT® Index for Skin Graft and Flap/Free Skin Graft/Full Thickness referring you to 15200-15261. The size is not reported, so 15260 is assigned. In the CPT® Index, look for Excision/Lesion/Eyelid. Refer to the codes referenced in the index. Under code 67840, there is a parenthetical note which states, "For excision and repair of eyelid by reconstructive surgery, see 67961, 67966." Code 67961 is for an excision and repair of the eyelid including preparation for skin graft or flap with adjacent tissue transfer or rearrangement involving up to one-fourth of the lid margin. Code 67966 reports the excision and reconstruction with a flap or an excision over one-fourth of the lid margin which is one of the correct code for this case. This can also be found by looking in the CPT® Index for Repair/Eyelid/Excisional. For the reconstructive procedure, look for Reconstruction/Eyelid/Tarsoconjunctival Flap Transfer 67971 in the CPT® Index. Code 67971 indicates it is for a full thickness reconstruction of the eyelid with a flap from the opposing eyelid of up to two-thirds of the eyelid. A tarsorrhaphy (eyelids sewn shut) is performed. Look in the CPT® Index for Tarsorrhaphy, referring you to 67875. Review the code description for accuracy. When multiple procedures are performed, they are sequenced in order from the most labor intensive (highest RVUs) to the lowest. In this case, the proper sequence is 15260, 67966, 67971, 67875. The procedure codes 15260, 67966, and 67971 are performed on the left lower eyelid, which is reported with HCPCS modifier E2. Code 67875 is reported with HCPCS modifiers E1 and E2 because both eyelids were closed shut. When multiple procedures are performed, modifier 51 is appended to the procedure codes that are listed after the first listed CPT® code. ICD-10-CM code: To determine the ICD-10-CM code, look in the ICD-10-CM Alphabetic Index for Carcinoma/basal cell. There is guidance to - see also Neoplasm, skin, malignant. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/eyelid/basal cell carcinoma and report the code from the Malignant Primary column C44.11-. In the Tabular List, a 6th character 9 and 7th 2 is reported for the lower left eyelid.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Nausea and vomiting

" R11.2 Nausea and vomiting are both main terms. In the ICD-10-CM Alphabetic Index, look for Nausea/with vomiting or Vomiting/with nausea. You are referred to R11.2. Review the code in the Tabular List to verify the code accuracy.

" A patient with a diagnosis of chronic sphenoidal sinusitis undergoes a bilateral sinusotomy. While the provider examines the diseased sphenoid sinus, she takes a biopsy of the sphenoidal masses and removes the mucosa with several polyps. Transseptal sutures are placed and the intraoral incision is closed in a single layer. The nose is packed and external nasal dressings are placed. What CPT® and ICD-10-CM codes are reported?

" "31051-50, J32.3, J33.8 In the CPT® Index look for Sinusotomy/Sphenoid Sinus directing you to codes 31050, 31051. 31051 is appropriate for the reporting of biopsies taken in the sphenoids as well as removal of mucosa and polyps. The procedure was an open procedure; it was not performed endoscopically. Modifier 50 is appended to indicate the procedure was performed bilaterally. Look in the ICD-10-CM Alphabetic Index for Sinusitis/sphenoidal directing you to code J32.3 (this is for chronic) and Polyp, polypus/sinus (sphenoidal) is J33.8. Verification in the Tabular List confirms code selection.

" " A patient with laryngeal spasms undergoes therapeutic injection of the vocal cords. Topical anesthesia is administered to the oral cavity, pharynx and larynx. Using an operating microscope, a direct laryngoscope is inserted into the patient's mouth. The interior larynx is examined and the surgeon injects the vocal cords at two sites with glycerin. What CPT® and ICD-10-CM codes are reported?

" "31571, J38.5 In the CPT® Index look for Laryngoscopy/Direct directing you to 31515-31571. 31571 is appropriate for the injection into the vocal cords using an operating microscope. There is a parenthetical instruction note that states, "Do not report code 69990 in addition to code 31571". In the ICD-10-CM Alphabetic Index look for Spasm(s), spastic, spasticity/larynx, laryngeal which directs you to code J38.5. Verify code selection in the Tabular List.

" A 78 year-old patient with bilateral, lower lobe lung cancer has been in the hospital for seven days with a tunneled chest tube in place to drain fluid from the pleural space. The chest tube currently is inserted between the 4 th and 5 th intercostal space on the left side. There is a very bad infection at the insertion site. The provider removes this chest tube and inserts another chest tube between the 5 th and 6 th intercostal space on the left side to continue fluid drainage. The tube placed today is just the same as the one removed, only sterile. What CPT® and ICD-10-CM codes are reported?

" "32550, 32552-51, T85.79XA, C34.31, C34.32 Code 32552 represents the indwelling tunneled chest tube removal and code 32550 the insertion of a new indwelling catheter/tube. In the CPT® Index look for Catheterization/Pleural Cavity which directs you to 32550-32552. Read both codes to confirm the selections. The infection is at the insertion site of the chest tube. Look for Complication/prosthetic device or implant /infection or inflammation referring you T85.79. Verification in the Tabular List indicates seven characters is required for a complete code. Add placeholder X for the 6 th character and A, initial encounter, for the 7 th character. The ICD-10-CM code for the lung cancer is found in the Table of Neoplasms. Look for Neoplasm, neoplastic/lung/lower lobe and select from the Malignant Primary column directing you to code C34.3-. Verification in the Tabular List indicates the need for a 5 th character to identify right or left. The patient has bilateral lower lobe lung cancer there is no bilateral code choice, report code C34.31 for right and C34.32 for the left. (See ICD-10-CM guideline I.B.13.)

"CASE 8 Preoperative diagnosis: Ischemic cardiomyopathy. Intraventricular block delay. Congestive heart failure. The patient has a dual-system pacemaker in place. Postoperative diagnosis: Same Operation: Insertion of left ventricular epicardial pacemaker lead with generator change Indications: Ischemic cardiomyopathy with intraventricular conduction delay in a patient experiencing congestive heart failure; status post failed attempt at placement of transvenous coronary sinus lead. Procedure: The patient was brought to the operating room and, after having the appropriate monitoring devices placed, was intubated and general endotracheal anesthesia was achieved. The patient was prepared and draped in the usual sterile fashion. The chest was entered via a small left posterior thoracotomy. The left anterior chest generator pocket was opened, and the generator explanted. The left lung was collapsed. The pericardium was opened, and two unipolar epicardial leads were placed in the posterolateral left ventricle. Thresholds were checked and found to be adequate. The leads were tunneled subcutaneously to the generator pocket. A new St. Jude biventricular pacemaker generator was then reconnected to the transvenous atrial and ventricular leads as well as to the epicardial lead. The generator was again interrogated, and the thresholds and impedances of all leads were found to be adequate. The generator was replaced in the pocket. The pocket was irrigated with antibiotic saline and closed in layers with Vicryl suture. A single left pleural drain was placed, and a single pericostal suture was utilized to reapproximate the ribs. The fascia and subcutaneous tissue were closed with layered Vicryl suture, and the skin was closed with a subcuticular stitch. The patient was transferred to the coronary care unit in stable condition, having tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d], [e]

" "33202, 3224-51, I25.5, I45.4, I50.9 For this case, the provider opened the chest (thoracotomy), placed two epicardial leads on surface of the ventricle. The Indications for Surgery cite a failed transvenous approach to placing the third lead in the left ventricle. Look in the CPT® Index for Insertion/Electrode/Heart, directing you to a list of codes. Code 33202 represents insertion of epicardial electrode(s) by thoracotomy. See the subsection guidelines in CPT® for the subheading Pacemaker or Implantable Defibrillator, look in second paragraph and jump to the last sentence. The last sentence directs the coder to use CPT® codes 33202 and 33203 for epicardial placement of a left ventricular lead. The second procedure performed is replacement of the pacemaker pulse generator. You must also code for the insertion of the pacing electrode for the left ventricular pacing at the time of the upgrade of the dual pacemaker to a multi-system pacemaker. See notes in second paragraph of CPT® for Pacemaker or Implantable Defibrillator. Look in the CPT® Index for Insertion/Electrode/Heart directing you to a long list of codes. Report 33224, which includes insertion of the pacing electrode for left ventricular pacing, with attachment to a previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator). Check the notes under 33224 and you will see it is reported in conjunction with 33202. 33224 includes the replacement of the pulse generator, so it is not reported separately. The correct order of the codes is 33202, 33224-51. Modifier 51 is needed to show an additional procedure performed during the same session. ICD-10-CM Codes: Look in the ICD-10-CM Alphabetic Index for Cardiomyopathy/ischemic, directing you to I25.5. For the conduction diagnosis, look in the Alphabetic Index for Block/intraventricular (nonspecific), and you are referred to I45.9, which is conduction disorder, unspecified. This was specified as intraventricular conduction delay. Report I45.4. Nonspecific intraventricular block. For the last diagnosis, look in the Alphabetic Index for Failure, failed/heart/congestive, directing you to I50.9. Verify code selection in the Tabular List.

" A 56 year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally. The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review. What are the CPT® and ICD-10-CM codes reported for this procedure?

" "56640-50, C51.9, C77.4, C77.5 The patient has her vulva removed to treat malignancy (vulvectomy, radical complete). She also has removal of inguinofemoral, iliac and pelvic lymph nodes. In the CPT® Index, look for Vulvectomy/Radical/Complete/with Inguinofemoral, Iliac, and Pelvic Lymphadenectomy referring you code 56640. All areas removed are listed in the code description for code 56440. There is a parenthetical note under this code to report 56640 with modifier 50 for a bilateral procedure. This scenario needs three ICD-10-CM codes. The first one is to show the carcinoma of the vulva. Look in the ICD-10-CM Alphabetic Index for Carcinoma - see also Neoplasm, malignant by site. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/vulva/Malignant Primary column referring you to C51.9. The second diagnosis code is for the metastasis of the cancer to the lymph nodes. Look in the Table of Neoplasms for Neoplasm, neoplastic/lymph, lymphatic channel NEC/gland (secondary)/inguina, inguinal/Malignant Secondary column, guiding you to code C77.4. Also look under gland (secondary) in the Malignant Secondary column for iliac C77.5 and pelvic C77.5. Verify all codes in the Tabular List.

"Operative Report Diagnosis: Basal Cell Carcinoma Procedure: Mohs micrographic excision of skin cancer. Site: Face left lateral upper canthus eyelid Pre-operative size: 0.8 cm Indications for surgery: Area of high recurrence, area of functional and/or cosmetic importance. Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient's questions were answered. Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape. Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site. Repair: Complex repair. Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days What CPT® and ICD-10-CM codes are reported?

" 17311, 13152-51, C44.1191 In the CPT® Index look for Mohs Micrographic Surgery directing you to codes 17311-17315. Code selection is based on location and stages. This operative note indicates the location is on the face and only one stage is performed, making 17311 the correct code choice. According to category guidelines for Mohs micrographic surgery, repairs are coded separately. This is a complex repair on the eyelid measuring 3.4 cm making 13152 the correct code choice. Modifier 51 is used to indicate multiple procedures. In the ICD-10-CM Alphabetic Index, look for Carcinoma/basal cell and there is a note to see also Neoplasm, skin, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/canthus (eye) (inner) (outer)/basal cell carcinoma/Malignant Primary column referring you to C44.11-. In the Tabular List the code is C44.1191 for left upper eyelid.

" " Mrs. Smith is visiting her mother and is 150 miles away from home. She is in the 26th week of pregnancy. In the late afternoon she suddenly feels a gush of fluids followed by strong uterine contractions. She is rushed to the hospital but the baby is born before they arrive. In the ED she and the baby are examined and the retained placenta is delivered. The baby is in the neonatal nursery doing okay. Mrs. Smith has a 2nd degree perineal laceration secondary to precipitous delivery which was repaired by the ED physician. She will return home for her postpartum care. What ICD-10-CM and CPT® codes are reported by the ED physician?

" "59414, 59300-51, O73.0, O70.1, Z3A.26, Z37.0 The ED physician did not deliver the baby. The ED physician performed the removal of the retained placenta after the delivery. Look in the CPT® Index for Placenta/Delivery referring you to 59414. The ED physician repaired the perineal laceration. Look in the CPT® Index for Repair/Vagina/ Postpartum referring you to code 59300. Verify the codes in the numeric section. Modifier 51 is appended to 59300 for additional procedures during the same session. The first diagnosis code to report is delivery of the retained placenta. In the ICD-10-CM Alphabetic Index, look for Delivery/complicated/by/placenta, placental/retained/without hemorrhage referring you to O73.0. The second diagnosis code to report is for the second-degree perineal laceration. Look in the Alphabetic Index for Laceration/perineum/female/during delivery/second degree O70.1. Next, code the weeks of pregnancy. Look in the Alphabetic Index for Pregnancy/weeks of gestation/26 weeks Z3A.26. The last code to report is the outcome of the delivery. 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.

"CASE 5 OPERATION PERFORMED: Right-sided decompressive hemicraniectomy with duraplasty.(This is the planned operation. Review the operative report to confirm it is the procedure performed.) COMPLICATIONS: None. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Approximately 400 ml INDICATIONS: is a 56-year-old male with significant past medical history who came in this evening with an ischemic infarct(Ischemic infarct is the initial diagnosis.) to his right middle cerebral artery (Specificity of where the infarction occurred.) territory which converted to a subarachnoid hemorrhagic(The infarct converted to a subarachnoid hemorrhage.) transformation. The significant shift was following commands on the right side and hemiplegia on the left side. After a thorough discussion with the family, we explained to them that this would be a life-saving procedure and we could not ensure that there would be any further neurological improvement from the state that he was in. They understood these risks and wanted to proceed ahead. OPERATION PERFORMED: After informed consent was obtained, the patient was taken to the operating room and induced under general endotracheal anesthesia without incident. TEE monitor was placed due to the patient's significant cardiac history. At this point, a roll was placed underneath the right shoulder and the head was placed in a horseshoe reverse question mark. This area was sterilely prepped and draped in usual fashion. A #10 blade was used to make an incision sharply. Raney clips were applied to the skin edges. The temporalis fascia and muscle were then resected with the cutaneous flap anteriorly. This was done until the keyhole could be identified. The musculocutaneous flap was then retracted with towel hooks, rubber bands and Allis clamps. The perforator was then used to make several burr holes (approximately six) and a footplate was then applied to perform the hemicraniectomy.(Documentation supports performance of the hemicraniectomy.) We ensured that we were off midline to make certain that we did not get into the sagittal sinus or any draining veins associated with this. Once the bone was removed, hemostasis was obtained, the dura was opened in the C-shaped fashion. and a large piece of Durepair was placed underneath this. There was a small subdural clot which was also evacuated and the large piece of Durepair was then used to create a duraplasty.(The performance of the duraplasty is described.) This was stitched in several points with 4.0 nylon. Hemovac was then tunneled through as well. At this point, the galea and the temporalis fascia were then reapproximated with 0 Vicryl in interrupted fashion, and the overlying galea was reapproximated with 0 Vicryl in interrupted fashion. The overlying skin was closed with staples and the Hemovac drain was secured with 2-0 nylon. At the end of the case, all counts of the needles and sponges were correct. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "61322, I60.11 The surgeon is performing a decompressive hemicraniectomy with duraplasty. Burr holes, the placement of which are included in the procedure, are used to facilitate the decompressive hemicraniectomy. A dural opening is made to remove the subdural clot. Then, a reconstructive operation on the dura mater (duraplasty) is performed using the Durepair for closure. This procedure is indexed under Craniectomy. In the CPT® Index, look for Craniectomy/Decompression referring you to codes 61322-61323, 61340, and 61343. Confirm code 61322 in the numeric section as the correct code choice. ICD-10-CM Code: The diagnosis is ischemic infarct to the middle cerebral artery territory. However, this converted to a subarachnoid hemorrhage. Look in the ICD-10-CM Alphabetic Index for Hemorrhage, hemorrhagic/intracranial/subarachnoid/intracranial (cerebral) artery/middle cerebral referring you to I60.1-. Verify code selection in the Tabular List. This was the right middle cerebral artery so report I60.11.

" A patient receives a paravertebral facet joint injection at three levels on both sides of the lumbar spine using fluoroscopic guidance for lumbalgia. What CPT® and ICD-10-CM codes are reported?

" "64493-50, 64494 x 2, 64495 x 2, M54.5 In the CPT® Index, look for Injection/Paravertebral Facet Joint/Nerve with Image Guidance directing you to 64490-64495. Code selection is based on the location of the spine (lumbar) and the levels injected. Modifier 50 is appended to 64493 to indicate it is bilateral. Modifier 50 is not appended to add-on codes. 64494 and 64495 are reported twice to indicate they were performed bilaterally. Depending on the payer, modifiers RT and LT may be appended.

" A CT study of the lumbar spine (L2-L4) was performed with IV contrast in the hospital outpatient radiology department and the interpretation of the images is performed by the radiologist. What CPT® code(s) should be reported by the radiologist who is not an employee of the hospital?

" "72132-26 Look in the CPT® Index for CT Scan/with Contrast/Spine/Lumbar which directs you to 72132. Modifier 26 is appended to the radiological service for the professional service. The hospital would also bill the radiological service for the technical component as the hospital owns the equipment used for the service.

"CASE 7 Location: Regional Hospital CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX. COMPARISON: CT chest Regional Hospital 7/8/20XX. HISTORY: Non-small-cell lung cancer. TECHNIQUE: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast. FINDINGS: Chest CT shows left upper lobe and pulmonary mass which appear centrally necrotic abutting the posterior pleural surface and mediastinum without definitive invasion, 83 x 64 mm, prior 76 x 56 mm, image 15. Stable lingular and left basilar, right middle lobe and right lower lobe superior segment pleural-parenchymal opacity suggesting scarring. New mild subsegmental infiltrate left upper lobe. No pneumothorax or pleural fluid. No thoracic adenopathy. Heart size normal, no pericardial effusion. Left coronary arteriosclerotic calcification present. No osseous neoplasm. Abdomen CT shows normal liver, gallbladder, biliary ducts, pancreas, spleen, adrenal glands and kidneys. Stomach and duodenum within normal limits. Aortoiliac arterial sclerosis without aneurysm. No retroperitoneal adenopathy. Pelvis CT shows no mass, adenopathy or ascites. No bowel obstruction. No hernia. No osseous neoplasm. Lumbar spine degenerative change present. Left-sided muscle atrophy and brace noted. Conclusion: 1. Increasing size left upper lobe pulmonary mass with central cavitation suggested. 2. No thoracic adenopathy or distant metastatic disease demonstrated. 3. Coronary arteriosclerosis. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" "74177-26, 71260-26, C34.12, I25.10 In the CPT® Index, look for CT Scan/with Contrast/Abdomen and CT Scan/with Contrast/Pelvis. Code 74177 is a combination code reported for the abdomen and pelvis. Next, look for CT Scan/with Contrast/ Thorax referring you to 71260. Modifier 26 is appended to show the professional component only; the hospital will report the technical component. ICD-10-CM codes: The patient has non-small cell lung cancer. The mass/tumor is specified in the report as being in the left upper lobe. In the ICD-10-CM Alphabetic Index, look for Cancer - see also Neoplasm, by site, malignant. In the Table of Neoplasms, look for Neoplasm, neoplastic/lung/upper lobe/Malignant Primary referring you to subcategory C34.1-. In the Tabular List, 5th character 2 is reported for the left lung. The radiologist also notes a secondary diagnosis of coronary arteriosclerosis. Look in the Alphabetic Index for Arteriosclerosis/coronary (artery) or Disease, diseased/artery/coronary referring you to I25.10. Verify code selection in the Tabular List.

" "CASE 5 CLINICAL INDICATIONS: The patient is a 28 year-old female for routine lab tests part of her yearly physical exam. COLLECTED: 04/14/XX 13:29 PATIENT NUMBER: xxxxxxxxxxxxx ID: verified SITE: right antecubital venipuncture DISPOSITION: outpatient, fasting TEST: metabolic (Metabolic Panel is a set of tests performed as a panel in CPT®. Review the two metabolic panels to see if one includes the tests performed.) & CBC (CBC is not included in either metabolic panels and is reported separately.) RESULTS: SODIUM BLOOD: 141 mEq/L (135-145) POTASSIUM BLOOD: 4.0 mEq/L (3.3-4.8) CHLORIDE BLOOD: 105 mEq/L (95-105) CARBON DIOXIDE BLOOD: 24 mmol/L (23-30) UREA NITROGEN BLOOD: 12 mg/dL (5-25) CREATININE BLOOD: 0.86 mg/dL (0.70-1.50) GLUCOSE BLOOD: 93 mg/dL (70-110) CALCIUM BLOOD (TOTAL): 9.3 mg/dL (8.5-10.5) (The calcium is total instead of ionized.) CBC: (automated) (CBC is automated with no differential.) WBC: 6.9 thou/uL (3.9-10.3) HEMOGLOBIN BLOOD: 14.5 g/dL (11.8-16.0) PLATELET COUNT: 235 thou/uL (135-370) RED BLOOD CELLS: 5.02 mil/uL (4.00-5.50) IMPRESSION: Normal labs HCT: 40% (38%-46%) What are the CPT® and ICD-10-CM codes for the pathologist?

" "80048 85027 Z00.00

"CASE 1 R/O MRSA - Central line catheter Clinical Indications:(Clinical indications provide medical necessity when there are no other findings.) Patient with fever not responsive to antibiotics Collected: 03/30/XX 17:45 Accession Num: TXXXXX Status: Authenticated Method: Single nucleic acid sequence (Note the method used to identify the infectious agent and/or resistance.) Culture: Methicillin Resistant Staphylococcus aureus (MRSA) isolated (Select the diagnosis code based on the findings.) What are the CPT® and ICD-10-CM codes?

" "87641 A49.02

" "CASE 6 Requested by R Simon, MD CYTOLOGY (Report indicates type of procedure performed.) REPORT Collected: 1/26/2011 Received: 1/27/2011, Pathologist performing the service is an employee of the lab. SPECIMEN SOURCE: A. Peritoneal Fluid SPECIMEN DESCRIPTION: 100mls yellow fluid CYTOPREPARATION: 2 ccf PERTINENT CLINICAL DATA AND CLINICAL DIAGNOSIS: 26 year-old female with end-stage renal disease (ESRD) due to type 1 diabetes presents for elective kidney transplant. (Use clinical diagnostic information to assign ICD-10-CM codes because the findings are negative.) CYTOLOGIC IMPRESSION: Peritoneal dialysis drain fluid: No cytologically malignant cells are identified. (Cytology is performed on the fluid obtained.) COMMENT: 100 mls yellow fluid is received from which two Papanicolaou stained cytocentrifuged slides are made. Slides contain mesothelial cells with a spectrum of reactive changes and histiocytes. No malignant cells are identified. What are the CPT® and ICD-10-CM codes?

" "88108 E10.22 N18.6 Z99.2

" "CASE 8 Requested by R Williams, MD SURGICAL PATHOLOGY REPORT Collected: 2/1/20XX Received: 2/2/20XX. The pathologist is employed by the lab providing the service. CLINICAL DATA: 26 year-old with end-stage renal disease(ESRD) due to type 1 diabetes, status post kidney, pancreas transplant with subsequent pancreas allograft removal, now with disseminated intravascular coagulation and decreased urine output and kidney allograft showing no flow to the kidney. GROSS DESCRIPTION: A) Received fresh designated ""ureteral stent - gross only"" is a 15 cm x 0.2 cm piece of plastic tubing with a 1.5 cm hairpin turn at either end. There are 0.05 cm holes at every 2 cm of the device. B) Received fresh in a container labeled ""removed kidney-gross and micro"" is a 138 gram, 11 x 7 x 3 cm kidney. The specimen has a smooth, glistening, pink capsule with lightly adherent fibrous tissue. There are multiple surgical clips within the hilum and perihilar fat. The specimen is bivalved to reveal a sharp but irregular demarcation at the cortex and the medullary interface. No masses, nodules or lesions are grossly appreciated. There is probable intravascular thrombus. Representative sections are submitted as follows: B1 - renal vein, renal artery and ureteral margins; B2-B5 - representative sections of kidney parenchyma in relation to capsule. FINAL DIAGNOSIS: A) Medical device, removal: Pigtail catheter (gross only). B) Kidney, allograft resection: 1. Widespread acute coagulative necrosis/infarct of renal parenchyma in the setting of multifocal microvascular thrombi (clinical history of disseminated intravascular coagulation). 2. Focal renal arterial thrombosis. 3. No evidence of humoral or cellular rejection. What are the CPT® and ICD-10-CM codes ?

" "88307 88300 T86.19 N28.0

" "CASE 7 Requested by D Smith, MD. The pathologist providing the service is an employee of the lab. SURGICAL PATHOLOGY REPORT CLINICAL DATA: Chronic infected skin ulcer status post amputation of first and third toes, current mid transmetatarsal amputation. GROSS AND MICROSCOPIC DESCRIPTION: A) Received in formalin designated ""right mid transmetatarsal amputation"" is a distal right foot including second, fourth, and fifth toes, measuring 9.0 x 9.0 x 4.0 cm. Also in the container is a piece of tan bone measuring 2.4 x 1.3 x 1.3 cm. The skin and subcutaneous tissue recedes up to 4.0 cm from the smooth bony margins of resection. The skin is tan-white. The first and third toes are missing. The remaining toes are slightly flexed and with a thickened irregular nail of the second toe. There is a round, deep ulcer at the bottom of the foot proximal to the second toe, measuring 1.5 x 1.5 x 0.7 cm. No other lesions are identified. The piece of bone is submitted for decalcification. Representative sections are submitted in A1 and A2, including skin and soft tissue margins. FINAL DIAGNOSIS: A) Right foot, mid-transmetatarsal amputation: 1. Right foot with ulceration 2. Status post amputation of first and third toes. 3. Skin and soft tissue margins histologically viable. 4. Bone section pending decalcification, addendum report to follow. COMMENT: Geographic fibrinoid necrosis associated with ulcer raises the possibility of a rheumatoid nodule. MICROSCOPIC DESCRIPTION: Microscopic examination was performed. Findings of decalcified specimen (A3). Sections of the bone demonstrate chronic reactive changes. No evidence of active osteomyelitis is identified. What are the CPT® and ICD-10-CM codes? 88307 88311

" "88307 88311 L97.511

" "CASE 3 Requested by P Norris, MD SURGICAL PATHOLOGY REPORT MATERIALS RECEIVED: Referred slides of inguinal lymph node CLINICAL DATA: History of Merkel cell carcinoma. FINAL DIAGNOSIS: Lymph node, left inguinal, excision: 1. High grade neuroendocrine carcinoma involving one of four lymph nodes (1/4); see Comment. 2. No extranodal extension identified. COMMENT: The neoplasm consists of sheets of small round blue cells with powdery chromatin, scant cytoplasm, and indistinct cell borders. Numerous mitotic figures and areas of single cell necrosis are seen. The morphologic findings are consistent with a high grade neuroendocrine carcinoma and the differential diagnoses include metastatic Merkel cell carcinoma or small cell carcinoma. Given the patient's reported history (slides not reviewed at UMMM), the features are consistent with metastatic Merkel cell carcinoma. Correlation with clinical findings is advised. What are the CPT® and ICD-10-CM codes?

" "88321 C7A.1

" "CASE 2 Requesting Provider: CI, MD SURGICAL PATHOLOGY REPORT Collected: Received: 3/4/2011, the pathologist providing the service is an employee of the lab. Materials Received for Consultation: Three referred specimens described as left base of tongue, left tonsil and right tonsil (There are three specimens.) CLINICAL DATA: Slides are prepared and reviewed in conjunction with the patient being seen for Radiation Oncology consultation for carcinoma of base of tongue (Use this diagnosis as consultation on referred materials is negative.) FINAL DIAGNOSIS: Eight slides prepared and reviewed A - H Left base of tongue (part A) and right tonsil, biopsies (parts B, C, G): Squamous mucosa and tonsillar tissue; no carcinoma identified. Left tonsil, biopsies (parts D, E, F, H): Tonsillar tissue with no carcinoma identified. (A total of eight slides are prepared and reviewed for a single case.) What are the CPT and ICD-10-CM codes

" "88323 C01

" "CASE 4 SURGICAL PATHOLOGY ORDERING PHYSICIAN: Karen Smith, MD PROCEDURES: Surgical pathology procedure performed by a pathologist. CLINICAL INDICATIONS: Patient presents to her gynecologist for follow-up of an abnormal Papanicolaou (Pap) smear. (Diagnosis used for lab.) The physician refers patient for repeat Pap smear. The specimen is sent for interpretation and report by the pathologist providing consultative services. SPECIMENS: Pap smear, cervix. METHODOLOGY: Morphometric analysis Fluorescent In Situ Hybridization (FISH) using computer-assisted technology, professional component. (Procedure performed.) RESULTS: The pathologist reviews images from the slides. The pathologist does not identify any copies of the 3q26 (Initial stain.) and 5p15 (Additional stain.) genes in the stained slide images. This report is consistent with the patient's HPV results and the patient is not at presently at risk to develop severe dysplasia. A 41 year-old female presents to her gynecologist to review her abnormal Pap results. The physician reviews her Pap results which indicates that this patient is at risk for cervical cancer. The gynecologist recommends the patient have a repeat Pap smear and FISH studies to evaluate the tissue for the 3q26 and 5p15 genes which are associated with increased risk to develop cervical dysplasia. FISH studies may be ordered by gynecologist to evaluate the presence of copies of the 3q26 and 5p15 genes. The presence of these genes is associated with an increased risk to develop severe cervical dysplasia, and place the patient at a higher risk to develop invasive cervical cancer. The patient decides to have these studies and the physician performs a Pap smear on the same day. The specimen is sent for both HPV testing and probe studies for the 3q26 and 5p15 genes. Pathologist does the review and the interpretation and report of the FISH probes and reports that the probes 3q26 and 5p15 are not present in this patient's cervical Pap smear specimen. Referring physician sends the patient's Pap smear results and FISH studies which include the pathologist's interpretation and report. What are the CPT® and ICD-10-CM codes reported? [a][b][c]

" "88367 88373 R87.619

"CASE 1 Preoperative diagnosis: Malignant neoplasm glottis Postoperative diagnosis: Malignant neoplasm glottis(Diagnosis to report for the procedure.) Procedure: An incision is made low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage. A tracheostomy(This is the performed procedure.) tube is inserted and secured with sutures. The patient tolerated the procedure well and was sent to recovery without complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 31600, C32.0

" "CASE 5 Pre-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures Post-procedure Diagnosis: Analysis of Vagal Nerve Stimulator (VNS), epilepsy with history of seizures(Post procedural diagnosis) Procedure: Vagal Nerve Stimulator Analysis(VNS analysis) Patient here for VNS implant analysis with possible adjustments. The programming head was placed over the implanted neurostimulator located within the patient's neck-left side. Impedance was verified insuring parameters within normal limits. Parameters charted on flowchart within medical record. Operating status of neurostimulator reflects on. Estimated time for analysis/interrogation was 20 minutes in duration. Patient denies questions at this time. Will repeat analysis in three months. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" "95970, Z46.2, G40.909 Look in the CPT® Index, for Neurostimulators/Analysis/Cranial Nerve, referring you to 95974, 95975. These codes are both intraoperative which does not apply to this case. Look for Neurostimulators/Analysis/Brain referring you to 95970, 95978, 95979. The vagus nerve is a cranial nerve. The correct code is 95970 for without reprogramming. ICD-10-CM code: The purpose of the visit is for the analysis of the neurostimulator. Look in the ICD-10-CM Alphabetic Index for Interrogation/neurostimulator referring you to Z46.2. Next, in the ICD-10-CM Alphabetic Index, look for Epilepsy, epileptic, epilepsia referring you to G40.909. The code for status of presence of a neurostimulator is not reported because Z46.2 already indicates the patient has a neurostimulator. Refer to ICD-10-CM coding guideline I.C.21.c.3. Verify code selections in the Tabular List.

"A new patient is seen in the pediatric office for ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (100.7°F). She has not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion, or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat, and neck. The patient is determined to have otitis media. Amoxicillin is prescribed. What is the correct E/M code reported for this visit?

" "99202 For a new patient visit, all three key components must be met: History - HPI (Extended), ROS (Extended), PFSH (none) = EPF Exam - Expanded problem focused (limited exam of ears, nose, throat, and neck) MDM - Moderate for the prescription drug management. The documentation supports 99202.

" An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped on water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service?

" "99213, S39.012A, W01.0XXA, Y92.030 The patient is an established patient. In the CPT® Index look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The provider documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, no additional work-up, 0 data points, and acute complicated injury, e.g., simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Lower Back Muscle Strain was the provider's diagnosis. In the ICD-10-CM Alphabetic Index look for Strain/low back. You are referred to S39.012-. Tabular List shows that a 7 th character is reported. A is reported for the initial encounter. Next go to the External Cause of Injuries Index. Look for Slipping (accidental) (on same level) (with fall)/on/surface (slippery) (wet) NEC. You are referred to W01.0-. In the Tabular List placeholders of X are needed for the 5th and 6th characters. The 7th character is reported with A to indicate initial encounter. Next look for Place of occurrence/residence/apartment/kitchen. You are referred to Y92.030. Review the code in Tabular List to verify accuracy.

" Using the CPT ® codebook to look up Strabismus in the index. Strabismus surgery would be performed to correct which of the following eye disorders?

" "Balancing the strength of extraocular muscles Strabismus in the CPT® index takes you to code range 67311-67345. In the text, find the subheading entitled Extraocular Muscles. All of these codes involve the muscles moving the eyeball, and most of these codes address adjusting one or more ocular muscles to correct an imbalance in the muscles causing the eye to be pulled too much in one direction, causing disorders like crossed or wandering eyes.

"CASE 8 PREOPERATIVE DIAGNOSES: 1. LOW BACK PAIN. 2. DEGENERATIVE LUMBAR DISC. POSTOPERATIVE DIAGNOSES: 1. LOW BACK PAIN. 2. DEGENERATIVE LUMBAR DISC. PERFORMED: Bilateral Paravertebral facet joint injection of steroid at the L3-L4 and L4-L5 with fluoroscopic guidance. DESCRIPTION OF PROCEDURE: The patient was transferred to the operative suite and placed in the prone position with a pillow under the abdomen. A smooth IV sedation was given with midazolam and fentanyl. The patient's back was prepped with Betadine in a sterile fashion, and we used lidocaine, 1% plain as a local anesthetic at the injection site. With the use of fluoroscopic assistance, first to the right and then to the left 20-degrees, the scotty-dog view was identified, and we were able to place the spinal 22-gauge needle, first to the right L3-L4, then to the right L4-L5, then to the left L3-L4, and then to the left L4-L5. We used a lateral x-ray to assess the proper placement of the needle. We proceeded to inject a mixture of 4 ml of 0.25% Marcaine plain plus 80 mg of methylprednisolone divided between the four joints. The needles were removed. The patient's back was cleaned, and a Band-Aid was applied. The patient was transferred to the recovery area with no apparent procedural complications. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c] ICD-10-CM code: [d]

" "Correct Answers for: a Evaluation Method Correct Answer Case Sensitivity CorrectExact Match 64493-50 CorrectExact Match 64493-RT, 64493-LT CorrectExact Match 64493-LT, 64493-RT Correct Answers for: b Evaluation Method Correct Answer Case Sensitivity CorrectExact Match 64494 CorrectExact Match 64494-RT CorrectExact Match 64494-LT Correct Answers for: c Evaluation Method Correct Answer Case Sensitivity CorrectExact Match 64494 CorrectExact Match 64494-RT CorrectExact Match 64494-LT Correct Answers for: d Evaluation Method Correct Answer Case Sensitivity CorrectExact Match M51.36 In the CPT® Index, look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance referring you to code range 64490-64495. In the numeric section, code selection is dependent on the location of the injection and how many levels are injected. Code range 64493-64495 is for the lumbar or sacral region. 64493 is reported for the first level (L3-L4). Code 64494 is reported for the second level (L4-L5). Modifier 50 is appended to 64493 to indicate it was performed bilaterally. 64494 is an add-on code; it is reported twice to indicate it was performed bilaterally. Depending on the payer, modifiers RT and LT may be appended. Fluoroscopy is included and not reported separately. ICD-10-CM code: The diagnoses listed are low back pain and degenerative lumbar disc. Low back pain is a symptom of degenerative lumbar disc and is not coded separately. Look in the ICD-10-CM Alphabetic Index for Degeneration, degenerative/disc disease referring you to see Degeneration, intervertebral disc NEC. Look in the Alphabetic Index for Degeneration, degenerative/intervertebral disc/lumbar region M51.36. Verify code selection in the Tabular List.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Chest mass

" R22.2 The main term is mass. In the ICD-10-CM Alphabetic Index, look for Mass/chest. You are referred to R22.2. Review the code in the Tabular List to verify the code accuracy.

"Using the ICD-10-CM codebook locate the diagnosis codes for the following condition: Fever

" R50.9

"The patient presents to the clinic today for an asthma exacerbation. She has been having a cough and difficulty breathing that has been getting worse for the last 2-3 days. She currently uses inhalers, but could not find any of her inhalers for this past week. She denies any fever or chills. Has a productive cough today. What is the level of history?

" "Detailed History HPI Location Severity Timing Modifying Factors Quality Duration Context Assoc Signs & Symptoms Brief (1-3) Brief (1-3) Extended (4 or more) Extended (4 or more) ROS Const GI Integ Hem/lymph Eyes GU Neuro All/Immuno Card/Vasc Musculo Psych All other negative Resp ENT, mouth Endo None Pertinent to problem (1 system) Extended (2-9 systems) Complete PFSH Past history (current meds, past illnesses, operations, injuries, treatments) Family history (a review of medical events in the patient's family) Social history (an age appropriate review of past and current activities) None None Pertinent (1 history area) Complete (2 (est) or 3 (new) history areas) Problem Focused Expanded Problem Focused Detailed Comprehensive CC: Asthma exacerbation HPI: Duration - Two to three days Associated signs and symptoms - Cough Quality - Productive cough Severity - Getting worse ROS: Constitutional - Denies fever or chills Respiratory - Difficulty breathing PFSH: Past History - Currently uses inhalers (current medication)

" A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?

" "Established patient office visit According to the E/M Guideline for New and Established Patient, when a provider is on call or covering for another provider, the patient's encounter will be classified as it would have been by the provider who is not available. In this instance, Dr. B would report an established patient office visit.

"Physical Exam: GENERAL: Alert, smiling child. HEENT: There is clear rhinorrhea. Pharynx is without inflammation. NECK: Supple. CHEST: Lungs are clear without wheeze or rhonchi. ABDOMEN: Soft, nontender. What is the level of exam?

" "Expanded problem focused Body Areas: Neck, Abdomen Organ Systems: Constitutional, ENMT, Respiratory There are 3 organ systems examined and 2 Body Areas. This is a limited exam of the affected body areas. The level of exam is Expanded Problem Focused.

"CASE 3 PROGRESS NOTE Chief complaint: Multiple ulcers. Subjective: The patient returns, accompanied by her caregiver who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better. Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin.(The ulcers are healing.) There is no cellulitis. The only uncomfortable area seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits which have distorted the bottom of her foot dramatically. To relieve the left foot pain,(Location of the foot pain. Patient had foot pain likely due to tophaceous deposits which are an indication of gout. This is not a definitive diagnosis documented by the provider. Code the symptom.) a sole nerve block posterior to the lateral malleolus is carried out with a 50:50 mixture of 1% lidocaine with epinephrine and .5% marcaine. Following this, she gets good relief from the pain of the lateral posterior part of the foot. The legs are cleansed with Hibiclens and multi-layer compression wraps are reapplied by the PA. Assessment: Ulcers are on the feet.(Location of the ulcers.) Edema is in the lower extremities. Foot pain is (Report the codes for the definitive diagnoses. Procedure performed for foot pain.) treated with a nerve block. Fantastic course to date, thanks to her caregiver Plan: Continue with wound care as before. Return to the office in six to eight weeks; at which time, assuming everything is going well, we could set up an OR time for panniculectomy. She appears to understand and is willing to proceed. What diagnosis code(s) are reported? [a] [b] [c] [d]

" "L97.511, L97.521, R60.0, M79.672

" A diabetic woman delivered her child and now returns to obstetrician's office for follow up. She has had type 1 diabetes controlled with insulin for most of her life. Her obstetrician will monitor her closely for several weeks to be sure her pregnancy does not cause her permanent problems. What diagnosis code is used for her visit 2 weeks after her delivery?

" "O24.03 Pregnancy codes will continue to be used during the postpartum (puerperal) period. In the ICD-10-CM Alphabetic Index look for Puerperal, puerperium (complicated by, complications)/ diabetes/pre-existing/type 1 directing you to O24.03. Verification in the Tabular List shows O24.03 indicates pre-existing type 1 diabetes mellitus in the puerperium (post-partum) period. Code P70.1 is reported on the newborn's record not the mother's record. Code O24.03 is a combination code in which Type 1 diabetes E10.9 is already noted in O24.03, so it is not reported. Only report E10 category when there are diabetic manifestations as indicated in the Tabular List, for example diabetic neuropathy or diabetic ketoacidosis.

"CASE 1 Pre-procedure Diagnosis: Asthma Post-procedure Diagnosis: Asthma (Post procedural diagnosis used for coding.) Procedure: Psychophysiological Therapy Biofeedback The patient returned to clinic with daily diary documenting home peak flow readings and asthma symptoms. Diary was assessed and discussed with patient. Patient reports reduced dosing with inhaled steroids and fewer asthmatic episodes. Lungs and respiratory resistance assessed. Lungs clear, no wheezes or rhonci noted. (Psychophysiological training.) HRV biofeedback was performed using a physiograph. (Biofeedback documentation.) ECG data were collected from the left arm and right leg, and were digitized at 510 Hz. EEG biofeedback equipment attached and baroreflex gain was assessed with beat-to-beat BP recordings and digitized at a rate of 252 samples per second. The sensor was placed on the participant's right middle finger, and the hand was elevated on a table to approximately the level of the heart. Respiratory system impedance (Zrs) (between 2 and 32 Hz with 2-Hz increments) was measured using a pseudorandom noise forced oscillation system. It was presented in 40 2-second bursts spaced equally throughout In order to minimize the effects of possible partial glottal closure during exhalation, each burst was triggered by the beginning of an inhalation. Post procedure, Inspirometer readings were recorded. Asthma symptoms were scored with the patient. Biofeedback procedure lasted approximately 28 minutes. (Biofeedback time.) The patient is to return to clinic in two weeks with daily diary. It is expected the patient will continue with reduced regiment and asthmatic episodes. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "Specified Answer for: a Correct90875 Specified Answer for: b CorrectJ45.909

" " CASE 2 Performed in the office Pre-procedure Diagnosis: Gastro-esophageal reflux disease (GERD), Heartburn Post-procedure Diagnosis: GERD (Post procedure diagnosis used for coding.) Procedure: Esophageal pH monitoring with Bravo pH Capsule (Acid reflux testing) Patient was placed in supine position on examining bed, IV moderate sedation was administered. Visualization of esophagus with anatomic markers located during endoscopy. Endoscopy was removed and the Bravo pH Capsule delivery system was passed into the esophagus using the oral passage until the attachment site was obtained at approximately 5cm proximal to the upper margin of the LES. The external vacuum pump was activated pulling the adjacent esophageal mucosa into the fastening well. Vacuum gauge at 600 mm Hg and held for 10 seconds. The plastic safety guard on handle was then removed and the activation button was depressed and turned attaching the pH capsule to the esophageal wall. (Placement of electrode placement.) The activation button on handle was then twisted 90 degrees and re-extended, releasing the pH capsule. Esophagoscopy was repeated to verify capsule attachment. Prior to procedure, the Bravo pH capsule was activated and calibrated by submersion in pH buffer solutions. The patient tolerated the procedure well and was transferred into the recovery room. The patient returned to the office two days later for download of the recording. The information was analyzed and interpreted. What are the CPT and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "Specified Answer for: a Correct91035 Specified Answer for: b CorrectK21.9

" "CASE 6 Pre-procedure Diagnosis: Aortic insufficiency; hypertension Post-procedure Diagnosis: Borderline Left Ventricular Hypertrophy, Mild Aortic Insufficiency, Left ventricular Ejection Fraction 80% Procedure: 2D with M-mode Echocardiogram with pulsed continuous wave with spectral display and Doppler color flow mapping Patient positioned in supine position on exam table. Echocardiogram proceeded without incidence. Findings: Borderline left ventricular hypertrophy. Mild aortic insufficiency. Left ventricular ejection fraction 80%. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" "Specified Answer for: a Correct93306 Specified Answer for: b CorrectI51.7 Specified Answer for: c CorrectI35.1

" "CASE 7 Pre-procedure Diagnosis: Persistent Right and Left Leg pains; Extensive varicose vein disease Post-procedure Diagnosis: Varicose vein disease with inflammation, venous insufficiency, leg pains due to varicose veins Procedure: Peripheral Vascular Duplex Ultrasound Evaluation of the Venous Anatomy of the Lower Extremities Patient's right and left leg venous anatomy was examined in the standing position utilizing a B-Mode Duplex ultrasound machine with a 12 MHz probe. The focus was to determine the location and flow characteristics of both the deep and superficial venous systems. The evaluations included dynamically focused gray-scale and color imaging supplemented by Doppler spectroanalysis. Valsalva maneuver as well as calf and thigh compressions were performed to determine the patency and direction of blood flow, the exact paths of venous reflux in the major venous trunks, tributaries, and perforator veins. Ultrasonic mapping included images of major deep veins of the leg, saphenofemoral junction, the great saphenous vein above and below the knee, and the short saphenous vein system below the knee. Measurements and flow characteristics were obtained and listed on venous map in chart. Bilaterally, the great saphenous veins were absent beginning at the saphenofemoral junction, due to previous surgery. Noted was venous reflux and enlargement of neovascular and tributary portions of the vein systems in the upper and lower legs. Abnormalities and associated perforator veins were documented on venous map in chart. The internal diameters of the leg varicosities varied to 5 and 3.8mm in diameter, bilaterally. No evidence of deep venous reflux or thrombosis noted within the femoral, popliteal, gastroncnemius, or posterior tibial vessels. Photocopies were taken of the venous abnormalities and are included in the medical record. Findings: Varicose vein disease with inflammation Venous insufficiency Leg pains due to varicose veins What are the CPT and ICD-10-CM codes? CPT Code: [a] ICD-10-CM codes: [b], [c], [d]

" "Specified Answer for: a Correct93970 Specified Answer for: b CorrectI83.11 Specified Answer for: c CorrectI83.12 Specified Answer for: d CorrectI83.813

" "CASE 9 Pre-procedure Diagnosis: Palpable Pulsating Abdominal Mass Post-procedure Diagnosis: AAA Procedure: Abdominal Aorta Duplex Ultrasound by ultrasound technician The patient was placed on the examining table in a supine position. Conductive gel was applied to the abdomen. The transducer was gently moved over the abdomen. An aortic mass was identified within the inferior aorta at approximately the 3.2 cm mark. Measurements were marked and recorded. Anterior-posterior measurement equaled 4.8 cm and transverse measurement equaled 5.7 cm. Report views and results were given to the ER physician caring for the patient by the radiologist who interpreted the ultrasound. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "Specified Answer for: a Correct93979-26 Specified Answer for: b CorrectI71.4

" " CASE 3 Pre-procedure Diagnosis: Sleep Apnea Post-procedure Diagnosis: Obstructive sleep apnea Procedure: Overnight Sleep Study 35-year-old patient in Hospital Sleep Lab for attended, overnight polysomnogram. (Polysomnogram performed.) Patient oriented to room and changed into overnight clothing and brought into lab by patient. Latency to sleep onset slightly prolonged at 32.3 minutes. During the first 82 minutes of sleep, 80 obstructive apneas were manifested (Respiratory Effort). The lowest SpO2 during the non-supplemented sleep period was 73% (Oxyhemoglobulin saturations (SPO2)). CPAP was then applied at 5 cm H2, and sequentially titrated to a final pressure of 18 cm H2O. The Apnea-hypopnea index (AHI) changed from 60 events/hr to 4 events/hr. SpO2 increased to 90%. The sleep study with and without CPAP shows severe obstructive sleep apnea with improvement with CPAP settings at 18 cm H20. Based on the improved SpO2 levels with CPAP, it is recommended this patient use a BIPAP machine during sleep hours due to obstructive sleep apnea events. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "Specified Answer for: a Correct95808 Specified Answer for: b CorrectG47.33

" " CASE 4 Pre-procedure Diagnosis: Excessive Daytime Sleepiness, Snoring, Epworth Score 18 Post-procedure Diagnosis: Sleep Study Procedure: Polysomnogram, attended 25-year-old patient underwent overnight polysomnogram with the recording of EEG(Parameter 1.), EOG(Parameter 2.), submental and anterior tibialis EMG(Parameter 3.), respiratory effort(Parameter 4.), nasal and oral airflow(Parameter 5.), EKG(Parameter 6.), continuous pulse oximetry(Parameter 7.). Total time in bed of 386 minutes and a total of sleep time of 221 minutes. The sleep latency was 24 minutes and the REM sleep latency was 18 minutes. Throughout the night, the patient had a total of 256 episodes of arousals and 6 awakenings. Sleep efficiency was 56%. No apparent parasomnia noted. The average oxygen saturation was reported to be 95% with the lowest saturation being 84%. There were no periodic leg movements for an index of 0.0 and cardiac arrhythmias were not present. Impression: Mild sleep apnea(Post-procedure diagnosis.) What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" "Specified Answer for: a Correct95810 Specified Answer for: b CorrectG47.30

" "CASE 8 Pre-procedure Diagnosis: Extensive keratosis lesions of left anterior neck Post-procedure Diagnosis: keratosis lesions left anterior neck Procedure: Blue Light Photodynamic Therapy with topical skin sensitizing agent Patient here for photodynamic therapy. Verbal instruction of procedure given to patient with patient verbalizing understanding. Patient positioned self in supine position on exam table. Safety goggles applied to eyes, noting patent seal and full coverage of ocular orbital areas. Application of topical Levulan® Kerastick® applied to left anterior neck keratosis lesions. Blue light lamp adjusted to reflect on left anterior neck. Phototherapy duration: 15 minutes. Post procedure skin was slightly reddened, no swelling noted. Post-procedure instructions were discussed with patient. Patient to return to office in eight weeks for assessment and possible repeat treatment. Procedure performed by the physician. What are the CPT® and ICD-10-CM codes reported? CPT codes: [a], [b] ICD-10-CM code: [c]

" "Specified Answer for: a Correct96573 Specified Answer for: b CorrectJ7308 Specified Answer for: c CorrectL57.0

" "CASE 10 Established patient Chief complaint: thoracic spine pain PROBLEM LIST: 1. Rheumatoid arthritis, right and left hands. 2. Compression fracture of the thoracic spine T11. 3. Alcoholism. 4. Depression/anxiety. REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every other week, Celexa 20mg a day, Klonopin .5mg as needed, aspirin 81mg a day, Ambien 10mg as needed, Hydrocodone as needed. PHYSICAL EXAM: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular. MUSCULOSKELETAL EXAM: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis. REVIEW OF DEXA(Dual Energy X-ray Absorptiometry) SCAN: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward's triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from 2005. ASSESSMENT: 1. Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated. 2. Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective. PLAN: 1. Continue current therapy. 2. Aspirate the synovial cyst in the left second finger. 3. Follow up in about 6-8 weeks. 4. Repeat labs prior to visit. PROCEDURE NOTE: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c], [d] ICD-10-CM codes: [e], [f], [g], [h]

" "Specified Answer for: a Correct99213-25 Specified Answer for: b Correct20612-F1 Specified Answer for: c Correct77080 Specified Answer for: d CorrectJ1020 Specified Answer for: e CorrectM06.041 Specified Answer for: f CorrectM06.042 Specified Answer for: g CorrectM71.342 Specified Answer for: h CorrectM80.08XD

" "CASE 9 Hospital Admission Chief complaint: Nausea and vomiting, weakness HPI: The patient is a 78-year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: MORPHINE Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. Family History: Mother deceased after childbirth. Father deceased from asphyxia. ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. Eyes: Negative for vision changes. Pulmonary: Negative for dyspnea. Cardiovascular: Negative for angina. Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. Neurologic: Negative for headaches. Negative for seizures. Psychiatric: Negative for anxiety. Negative for depression. Integumentary: Positive for rash for which she takes Benadryl. Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. Objective: Vital signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. Generally: No apparent distress, oriented x 3, pleasant Spanish speaking female. Head, ears, eyes, nose, throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus. Neck: Supple, full range of motion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy's sign. Back: Costovertebral angle tenderness Extremeties: No clubbing, cyanosis or edema. Laboratory Studies. Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. Assessment 1. Nausea, vomiting, diarrhea, likely gastroenteritis 2. Cystitis 3. Hypokalemia 4. Hyponatremia 5. Cholelithiasis 6. Diabetes mellitus type 2 7. Hypertension Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff-toxin and fecal stool culture and sensitivity. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h], [i], [j]

" "Specified Answer for: a Correct99222 Specified Answer for: b CorrectR11.2 Specified Answer for: c CorrectR19.7 Specified Answer for: d CorrectN30.90 Specified Answer for: e CorrectE87.6 Specified Answer for: f CorrectE87.1 Specified Answer for: g CorrectK80.20 Specified Answer for: h CorrectE11.9 Specified Answer for: i CorrectZ79.84 Specified Answer for: j CorrectI10

"CASE 7 Discharge summary Hospital course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that. Discharge Diagnoses: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Diabetes mellitus type 2 6. Hypertension Discharge Medications: 1. Levaquin 500 mg p.o. daily x2 days 2. Ciloxan ointment, apply b.i.d.to left eye x 4 days/ 3. Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20 4. Benadryl 25 mg p.o. daily p.r.n. rash 5. Diovan 320 p.o. daily 6. Calcium 600 mg p.o. daily 7. Vitamin C 500 mg p.o. daily. 9. Metformin 1000 mg p..o. daily 10. Lipitor 20 mg p.o. at bedtime 11. Coreg CR 20 mg p.o. daily. Discharge Diet: Cardiac Activities: ad lib Discharge Instructions: Patient to be NPO after midnight Sunday. Dismiss: Home Condition: Good Follow-up: Follow-up with me in 1 week. Follow-up on Monday morning for cholecystectomy. NPO after midnight on Sunday. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h]

" "Specified Answer for: a Correct99238 Specified Answer for: b CorrectK80.20 Specified Answer for: c CorrectN30.90 Specified Answer for: d CorrectH10.9 Specified Answer for: e CorrectE87.1 Specified Answer for: f CorrectE11.9 Specified Answer for: g CorrectZ79.84 Specified Answer for: h CorrectI10

" " CASE 8 XYZ Nursing Home Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious. Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts everywhere. Ancillary studies: A.M. labs - none new this morning. X-ray shows no evidence of fracture with definitive arthritis. Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias. Assessment & Plan: 1. Patient is an 84-year-old Caucasian male who presented after a fall with rib contusion, right shoulder pain and uncontrolled pain since. He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient's mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning. 2. Patient with elevated blood pressures upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently. 3. Very advanced dementia, will follow, continue on home medications. 4. Coronary artery disease and congestive heart failure. These appear stable at this time. 5. History of atrial fibrillation, sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control. 6. Type 2 diabetes mellitus. Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia. 7. We will follow the patient closely and adjust medications as necessary. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h], [i], [j]

" "Specified Answer for: a Correct99309 Specified Answer for: b CorrectS20.211A Specified Answer for: c CorrectM25.511 Specified Answer for: d CorrectR03.0 Specified Answer for: e CorrectF03.90 Specified Answer for: f CorrectI25.10 Specified Answer for: g CorrectI50.9 Specified Answer for: h CorrectI48.91 Specified Answer for: i CorrectE11.9 Specified Answer for: j CorrectZ79.84

" "CASE 10 10-Year-old established patient presents today for well child check with mother with complaints of frequent urination during the day. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. One dog, one rabbit. Denies dysuria, abdominal pain, or rashes, all other systems are reviewed and negative. Patient going into 4th grade with good grades. No parental concerns. Patient cooperates but does tend to back talk. Doing well on Concerta Exam General: Normal Head: Normal Eyes: Normal Ears: Normal Nose: Normal Mouth/throat: Normal Neck: Normal Abdomen: Normal Rectal: Not examined Genitals: Normal Skin: 3mm papule on dorsal R hand without disruption of creases Urinalysis: Ketones, nitrite, leukocytes normal; trace blood, low specific gravity. Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety. Assessment: Well Child Check, ADHD, Wart, Frequent Urination Refill Concerta 18mg PO q AM Wart cleansed with alcohol. Histofreeze x 25 seconds was performed to destroy the wart. Varicella Vaccine #2 administered without any complications. What are the CPT® and ICD-10-CM Codes? CPT® Codes: [a], [b], [c], [d], [e] ICD-10-CM Codes: [f], [g], [h], [i], [j]

" "Specified Answer for: a Correct99393-25 Specified Answer for: b Correct17110 Specified Answer for: c Correct90471 Specified Answer for: d Correct90716 Specified Answer for: e Correct81002 Specified Answer for: f CorrectZ00.121 Specified Answer for: g CorrectF90.9 Specified Answer for: h CorrectB07.9 Specified Answer for: i CorrectR35.0 Specified Answer for: j CorrectZ23

"CASE 3 Anesthesiologist personally performed case(Use modifier AA to indicate the Anesthesiologist personally performed the case.) Anesthesia Time: 13:04 to 13:41(Anesthesia time is 37 minutes.) Physical Status 3(Physical status 3 ‑ use P3 modifier.) PREOPERATIVE DIAGNOSIS: RLL Lung Cavity, possible CA of lung POSTOPERATIVE DIAGNOSIS: Right Lower Lobe Lung Carcinoma(Post-operative diagnosis confirms RLL CA.) PROCEDURE: Bronchoscopy(Procedure performed.) ANESTHESIA: Monitored Anesthesia Care(Use modifier QS to indicate monitored anesthesia care was used.) PROCEDURE DESCRIPTION: With the patient under satisfactory anesthesia, a flexible fiberoptic bronchoscope was introduced via oral cavity and advanced past the larynx for visualization of the bronchus. Cell washings were obtained and sent to pathology. The bronchoscope was then removed. Patient tolerated procedure well. Cell washings obtained from the right lower lobe were confirmed by pathology as malignant carcinoma. What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code(s): [a] ICD-10-CM code(s): [b] What is the time reported for this service? [c] minutes.

" 00520-AA-QS-P3, C34.31, 37

"CASE 10 CRNA directly supervised by anesthesiologist who is directing two other cases. CRNA inserted a separate CVP Swan-Ganz catheter, and an A-line Patient has a severe systemic disease that is a constant threat to life Anesthesia Time: 11:43 to 15:26 PREOPERATIVE DIAGNOSIS: Multivessel coronary artery disease. POSTOPERATIVE DIAGNOSIS: Coronary artery disease, native artery NAME OF PROCEDURE: Coronary artery bypass graft x 3, left internal mammary artery to the LAD, saphenous vein graft to the obtuse marginal, saphenous vein graft to the diagonal. ANESTHESIA: General BRIEF HISTORY: This 77-year-old patient who was found to have a huge aneurysm. Preoperative cardiac clearance revealed a markedly positive stress test and cardiac catheterization showed critical left-sided disease. Coronary revascularization was recommended. The patient has multiple medical illnesses including chronic obstructive pulmonary disease with emphysema and chronic renal insufficiency. I discussed with the patient and the family, the risks of operation including the risk of bleeding, infection, stroke, blood transfusion, renal failure, and death. At operation, we harvested a vein from the left leg using an endoscopic technique that turned out to be a very good conduit. Her obtuse marginal vessel was a 1.5-mm diffusely diseased vessel that was bypassed distally as it ran in the left ventricular muscle. The diagonal was a surprisingly good vessel at 1.5-mm in size. The LAD was bypassed in the mid aspect of the LAD and there was distal disease though a 1.5-mm probe passed quite easily. Good flow was measured in the graft. The patient came off bypass very nicely. Note should be made that her ascending aorta was calcified and we used a single clamp technique. DESCRIPTION OF OPERATIVE PROCEDURE: Following delivery of the patient to the operating room, the patient was placed under general anesthetic, was prepped and draped in the usual sterile manner. Arterial line through the skin. Right Pulmonary Artery Catheter and a Left Subclavian central lines were placed by the Anesthesia Department. A median sternotomy was made and the left internal mammary artery was harvested from the left chest wall, the saphenous vein was harvested from the left leg. The patient was heparinized and cannulated and placed on cardiopulmonary bypass with an aortic cannula on the undersurface of the aortic arch and a venous cannula through the right atrial sidewall. Note should be made that the upper aorta was very heavily calcified, but the area that we cannulated was felt to be disease free. The aorta was cross clamped and the heart was stopped with antegrade and retrograde cardioplegic solution. The heart was retracted out of the pericardial sac and then displaced into the right chest which afforded good access to the lone marginal vessel which was bypassed with a reversed saphenous vein graft using a running 7-0 Prolene suture. Cold cardioplegic solution was then instilled down this graft. Note should be made that during the mammary artery harvest, the left lung was completely adherent to the left chest wall, most likely from old episodes of pneumonia. Next, a second saphenous vein segment was placed to the diagonal vessel and then the left internal mammary artery was placed to the mid LAD. As noted, there was diffuse calcification distally in this artery just beyond the anastomosis, but the 1.5-mm probe passed very nicely and we felt that it was not necessary to double jump this LAD. With the cross clamp in place, two proximal aortotomies were made and the two proximal anastomoses were formed using 6-0 Prolene in a running fashion. Just prior to completion of the second anastomosis, appropriate d' airing maneuvers were performed and then the suture lines were tied as the cross clamp was removed. The patient was allowed to rewarm completely and was weaned from bypass. The cannulas were removed and the cannulation sites were secured with pursestring sutures. Once hemostasis was secured, chest tubes were placed and the wound was closed. Final needle, instrument, and sponge counts were reported as correct. The patient tolerated the procedure well and returned to the recovery room in stable condition. What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® codes: [a], [b] ICD-10-CM code: [c] What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® codes: [d], [e], [f], [g] ICD-10-CM code: [h] What is the time reported for this service? [i] minutes

" 00567-QK-P4, 99100, I25.10, 00567-QX-P4, 36556-59, 93503, 36620, I25.10, 223

"CASE 2 ANES Start: 14:07 ANES End: 17:33 (Total anesthesia time 3 hours 26 minutes, or 206 minutes.) Physical Status 3 Anesthesiologist: Michael D, MD (Physical status 3, use modifier P3. Personally performed by the anesthesiologist, use modifier AA.) Operative report Preoperative diagnosis: Lumbar spinal stenosis Postoperative diagnosis: L4-L5 spinal stenosis (Post-operative diagnosis of lumbar (L4-L5) stenosis.) Procedure: L4-5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative somatosensory evoked potentials, electromyographies and loupe magnification. (The following procedures were performed: L4-5 laminectomy, removal of synovial cyst, bilateral medial facetectomy and posterolateral fusion L4-L5 with vertebral autograft, bone morphogenic protein, chip allograft, all with intraoperative somatosensory evoked potentials, electromyographies and loupe magnification. The Laminectomy is more complex and carries a higher base value.) Anesthesia: General endotracheal (Type of anesthesia is general.) anesthesia. Description of Procedure: The patient was taken to the operating room and underwent intravenous anesthetic and orotracheal intubation. Her head was placed in the three-pin Mayfield headrest. She was turned into the prone position on a four-poster frame. All pressure points were carefully padded. The fluoroscope was brought in and sterilely draped to help localize the incision. A midline incision was made between L4 and L5 through skin and subcutaneous tissue and the paraspinal muscles were dissected free of the spinous process, lamina, facets and L4, L5 transverse processes. Self-retainers were placed more deeply. We proceeded to use the double-action rongeur to remove the L4-L5 spinous process lamina. 3 and 4 millimeter Kerrison punches were used to complete the laminectomy including removing the hypertrophied ligamentum flavum. We made sure that we decompressed from the top of the L4 pedicle to the bottom of the L5 pedicle, which was confirmed with intraoperative fluoroscopy. The medial facets were drilled and then we undercut over the nerve roots with a 3 millimeter Kerrison punch. Hemostasis was achieved with powdered gelfoam. We irrigated the wound. We decorticated the L4 and L5 transverse processes. We placed our vertebral autograft, bone morphogenic protein and chip allograft in the posterolateral gutters. Hemovac drain was placed. We closed the muscle with 0 Vicryl. Fascia was closed with 0 Vicryl. Subcutaneous tissue was closed with 2-0 Vicryl and the skin was closed with staples. What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What is the time reported for this service? [c] minutes.

" 00630-AA-P3, M48.061, 206

"CASE 4 Anesthesia services personally provided by Anesthesiologist(Use modifier AA to indicate the anesthesia was personally performed by the anesthesiologist.) Physical Status 2(Physical status 2, use modifier P2.) Anesthesia Start: 10:03 - Anesthesia Stop: 11:06 (Anesthesia time is 1 hour and 3 minutes, or 63 minutes.) PREOPERATIVE DIAGNOSIS: Sternal wound hematoma. POSTOPERATIVE DIAGNOSIS: Complicated upper abdominal wall wound.(Postoperative diagnosis used for coding if no other indication is found in the operative note.) NAME OF PROCEDURE: Sternal wound exploration and wound vac placement.(Procedure performed.) ANESTHESIA: Monitored Anesthesia Care(Use modifier QS to indicate MAC is used.) BRIEF HISTORY: He is a 52-year-old patient who is two weeks out from re-do sternotomy and aortic valve replacement for critical aortic stenosis in the setting of heart failure. He had a postoperative coagulopathy and required sternal re-exploration with open packing.(The wound is a post-operative complication.) He was closed the next day. He had serous discharge prior to going home but this was culture negative and the wound looked very good. He continued to have serous discharge in the clinic and it was felt he had a retained hematoma. He was scheduled for evaluation of the hematoma and wound vac placement. This was done without incident. He did not have any evidence of infection. There was no evidence of any sternal instability. DESCRIPTION OF OPERATIVE PROCEDURE: Following delivery of the patient to the operating room, the patient was placed on the operating table, prepared and draped in the usual sterile manner. His upper abdominal wound was explored. There was hematoma at the base of the wound which was very carefully evacuated(Confirms a postoperative hematoma.) and the wound was irrigated with antibacterial solution. A wound vac was then placed with the assistance of the wound care nurse.(Wound vac placed by a wound care nurse.) The patient was returned to the PCU in stable condition. What are the CPT ® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What is the time reported for this service? [c] minutes.

" 00700-AA-QS-P2, L76.32, 63

" CASE 5 ANES Start: 12:18 ANES End: 13:31 (Time reported is 1 hour 13 minutes, or 73 minutes.) CRNA: John Sleep, CRNA (Non-Medically Directed)(Modifier QZ used to indicate services are performed by a CRNA with no medical direction.) ASA Physical Status-III(Physical status 3—use modifier P3.) Operative Report Preoperative diagnosis: Stricture of the left ureter, postoperative Postoperative diagnosis: SAME(Postoperative diagnosis is the same as preoperative which is stricture of the left ureter, postoperative.) Procedure: 1. Cystoscopy of ileal conduit. 2. Exchange of left nephroureteral catheter. Anesthesia: Monitored anesthesia care.(Modifier QS is used to indicate MAC.) Description of Procedure: The patient is identified in the holding area, marked, taken to the operating room. Subsequently, she was given monitored anesthesia care. She was prepped and draped in the usual sterile fashion in the supine position. Next, using a flexible cystoscope, the ileal conduit was entered. Cystoscopy was performed, which showed the ureteroileal anastomosis on the left with a stent protruding from it. There were no calcifications seen on the stent. Thus, the cystoscope was removed from the ileal conduit and then a super stiff wire was advanced through the nephroureteral catheter, up into the kidney. Once it was up there, then the catheter was taken off of the wire and then a new 8-French x 28-centimeter, nephroureteral ureteral catheter was advanced fluoroscopically into the level of the kidney. Once this was done and its position was confirmed fluoroscopically, the wire was pulled. A good curl was there fluoroscopically in the kidney, as the wire was pulled. A good curl was seen in the bladder and then the distal end was protruding out from the ileal conduit. This was placed in the ostomy bag and the patient was taken in stable condition to the recovery room. What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® code: [a] ICD-10-CM code: [b] What is the time reported for this service? [c] minutes.

" 00860-QZ-QS-P3, N13.5, 73

" "CASE 7 CRNA performed anesthesia under medical direction of anesthesiologist Anesthesiologist medically directing one case CRNA placed arterial line Anesthesia Time: 10:43 to 12:50 Physical Status 3 PREOPERATIVE DIAGNOSIS: Left Renal Mass POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Left Partial Nephrectomy, Laparoscopic ANESTHESIA: General PROCEDURE DESCRIPTION: Abdominal wall insufflated. The laparoscope was placed through the umbilical port and additional trocars were placed into the abdominal cavity. Using the fiberoptic camera, the renal mass was identified and the diseased kidney tissue was removed using electrocautery. Minimal bleeding is noted. Instruments were removed and the abdominal incisions were closed by suture. Patient tolerated surgery well and was transferred to the Post Anesthesia Care Unit in satisfactory condition. What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code: [a] ICD-10-CM code: [b] What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® codes: [c], [d] ICD-10-CM code: [e] What is the time reported for this service? [f] minutes

" 00862-QY-P3, N28.89, 00862-QX-P3, 36620, N28.89, 127

"CASE 1 Anesthesiologist personally performed (Personally performed by anesthesiologist—use AA modifier.) Anesthesia Time: 7:12 to 10:08 (Time is 176 minutes.) Physical Status 2 (Physical status 2, use P2 modifier.) PREOPERATIVE DIAGNOSIS: Suspected Prostate Cancer POSTOPERATIVE DIAGNOSIS: Prostate Carcinoma (Post-operative diagnosis.) PROCEDURE: Radical Retropubic Prostatectomy (Procedure performed. Make note the procedure is "radical.") ANESTHESIA: General (General anesthesia.) What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® code(s): [a] ICD-10-CM code(s): [b] What is the time reported for this service? [c] minutes

" 00865-AA-P2, C61, 176

"CASE 8 CRNA performed anesthesia under medical direction of anesthesiologist Anesthesiologist medically directing three cases Anesthesia Time: 8:52 to 9:34 Physical Status 1 PREOPERATIVE DIAGNOSIS: Phimosis, congenital POSTOPERATIVE DIAGNOSIS: Phimosis, congenital PROCEDURE: Circumcision on six month old boy ANESTHESIA: Monitored Anesthesia Care What are the CPT® and ICD-10-CM Codes reported for the Anesthesiologist? CPT® codes: [a], [b] ICD-10-CM code: [c] What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® code: [d] ICD-10-CM code: [e] What is the time reported for this service? [f] Minutes

" 00920-QK-QS-P1, 99100, N47.1, 00920-QX-QS-P1, N47.1, 42

"CASE 9 Non-medically directed CRNA performed anesthesia care and documented intra-operative placement of continuous femoral nerve catheter for post operative pain. Anesthesia Time: 7:18 to 9:10 Physical Status 3 PREOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis POSTOPERATIVE DIAGNOSIS: Left Knee Osteoarthritis, localized primary, Acute post-operative pain PROCEDURE: Total Knee Arthroplasty ANESTHESIA: General anesthesia provided for surgery, Surgeon requested post-operative pain management via continuous femoral catheter What are the CPT® and ICD-10-CM Codes reported for the CRNA? CPT® code(s): [a], [b] ICD-10-CM code(s): [c], [d] What is the time reported for this service? [e] minutes

" 01402-QZ-P3, 64448-59-LT, M17.12, G89.18, 112 Look in the CPT® Index for Anesthesia/Arthroplasty/Knee referring you to 01402. P3 indicates a physical status level 3. Modifier QZ is used to indicate the services were performed by a CRNA without medical direction.The intra-operative placement of continuous femoral nerve catheter is separate from the general anesthesia used for the surgery; therefore, it is reported separately. The catheter is placed for management of the post-operative pain via continuous femoral catheter. To find the CPT® code to report this, look in the index under Femoral Nerve/Injection/Anesthetic, this directs you to 64447-64448. CPT® code 64448 is for the continuous infusion by catheter and includes the catheter placement, so a separate code for the placement would not be reported. Modifier 59 is appended to indicate it is a separate procedure from the general anesthesia used for the surgery. Modifier LT can be appended to indicate femoral nerve in the left leg. The CMS bilateral indicator for 64448 is one allowing modifier RT and LT to be appended.ICD-10-CM: The diagnosis for the general anesthesia is left knee osteoarthritis, localized, primary. Osteoarthrosis is osteoarthritis. Look in the ICD-10-CM Alphabetic Index for Osteoarthritis/primary/knee to find M17.1-. In the Tabular List, 5th character 2 is reported for the left knee. To report the acute postoperative pain, look in the Alphabetic Index for Pain(s)/postoperative NOS. You are referred to G89.18. Verify code selection in the Tabular List.Time: The start time is 7:18, the end time is 9:10. This calculates to 1 hour 52 minutes, or 112 minutes.

"CASE 3 Susan is a 67 years-old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year, but it has grown a lot this last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.) PAST MEDICAL HISTORY: Hypertension, arthritis. ALLERGIES: None. MEDICATIONS: Benicar and Vytorin. SOCIAL HISTORY: Cigarettes: None. PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery.) MEDICAL DECISION MAKING: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3-mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 11300, D49.2, Z85.828

"CASE 2 CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis. (The diagnosis to report, and location of the hidradenitis.) PROCEDURE NOTE: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. (The excision went to the subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) with a suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 11450-RT, L73.2

"Operative Report: INDICATIONS FOR SURGERY: The patient has a suspicious 1.5 cm lesion of the left upper medial thigh. Clinical diagnosis of this lesion is unknown, but due to the appearance, malignancy is a realistic concern. The area is marked for elliptical excision with gross normal margins of 3-4 mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars was drawn. The patient observed these marks in a mirror to understand the surgery and agreed on the location and we proceeded. PROCEDURE: The areas were infiltrated with local anesthetic. The area was prepped and draped in sterile fashion. The suspicious left upper most medial thigh lesion was excised as drawn, into the subcutaneous fat. This was sent for permanent pathology. The wound was closed in layers using 3.0 monocryl and 5.0 chromic. The repair measured 5.0 cm. Meticulous homeostasis was achieved using light pressure. The patient tolerated the procedure well. What CPT® code(s) should be reported for this example?

" 12032, 11403-51 The lesion is suspicious and not classified as malignant. A code from Excision-Benign Lesions is reported. Locate the code ranges by looking in the CPT Index for Excision/Skin/Lesion, Benign. Code selection is based on anatomic location and size in centimeters. The size is noted as 1.5 cm with margins of 3 mm on each side. 3 mm = 0.3 cm. 1.5cm + 0.3 cm + 0.3 cm = 2.1 cm. Code range 11400-11406 is used for excision of benign lesions on the trunk, arms, or legs. A size of 2.1 cm is reported with 11403. The note supports that an intermediate closure was performed. The repair measured 5.0 cm and is documented to be in layers, indicating an intermediate closure. Code range 12031-12037 is used to report intermediate repairs on the scalp, axillae, trunk and/or extremities. The repair measures 5 cm, making 12032 the correct code.

"CASE 6 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlarging suspicious lesion on the right side of his forehead. DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and was given no sedation. The area of his right forehead was draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient's mid forehead. This lesion had a maximum diameter of 1.1 cm with a 0.3 cm margin designed for total resection of 1.7 cm . The area for excision was infiltrated with 1% lidocaine with epinephrine. Careful dissection of the lesion was carried down through the dermis into the subcutaneous tissues. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was irrigated; several bleeders were cauterized. The defect was closed in multiple layers with 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this closure was 3 cm. This was covered with Steri-Strips, adaptic gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition. FINAL DIAGNOSIS: Skin, right forehead, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] (the second code has one modifier) ICD-10-CM code: [c]

" 12052, 11442-51, L85.8

"CASE 7 PREOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest. POSTOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest. PROCEDURES PERFORMED: Excision, dysplastic nevus, right chest with diameter of 1.2 cm and 0.5 cm margins on each side, and complex repair of 4.0 cm wound. ANESTHESIA: Local using 20 cc of 1% lidocaine with epinephrine. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Less than 2 cc. SPECIMENS: Dysplastic nevus, right chest with suture at superior tip, 12 o'clock for permanent pathology. INDICATIONS FOR SURGERY: The patient is a 49-year-old white woman with a dysplastic nevus of her right chest, which I marked for elliptical excision in the relaxed skin tension lines of her chest with gross normal margins of around 0.5 cm. I drew my best guess at the resultant scar, and she observed these markings well and we proceeded. DESCRIPTION OF PROCEDURE: We started with the patient supine. The area has been infiltrated with local anesthetic. The chest prepped and draped in sterile fashion. I excised the dysplastic nevus as drawn into the subcutaneous fat. Hemostasis was achieved using the Bovie cautery. To optimize the primary repair extensive undermining was done to pull wound edges together and retention sutures were used to keep it closed. This constituted a very a complex repair technique due to skin tension. The wound was closed in layers using 4-0 Monocryl and 5-0 Prolene. A loupe magnification was used. The patient tolerated the procedure well. ADDENDUM: Pathology report confirms it is benign. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 13101, 11403-51, D23.5

"Operative Report: INDICATIONS FOR SURGERY: The patient is a 72-year-old male with a biopsy-proven squamous cell carcinoma of his left forearm. With his permission, I marked my planned excision and my best guess at the resultant scar, which included a rhomboid flap repair. The patient observed these markings in a mirror, so he could understand the surgery, agree on the location and I proceeded. DESCRIPTION OF PROCEDURE: The patient was given 1 g of IV Ancef. The area was infiltrated with local anesthetic. The forearm was prepped and draped in a sterile fashion. I excised this lesion measuring 1.2 cm diameter as drawn into the subcutaneous fat. A suture was used to mark this specimen at its proximal tip and this was labeled at 12 o'clock. Negative margins were then given. Meticulous hemostasis was achieved using a Bovie cautery. I incised my planned rhomboid flap measuring 2cm x 2cm. I elevated the flap with a full-thickness of skin and subcutaneous fat. The total defect size was 5.44 sq cm. The flap was rotated into the defect and the donor site was closed and the flap was inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used throughout the procedure and the patient tolerated the procedure well. What CPT® code(s) should be reported for this example?

" 14020 elected based on anatomical location and defect size in square centimeters. Look in the CPT® Index for Skin/Adjacent Tissue Transfer and you are referred to code range 14000-14350. Code range 14020-14021 is used to report rhomboid flaps on the scalp/arms/and/or legs. The size of the lesion was measured as 1.2 cm; however, the total size of the defect that needed to be covered was 5.44 sq cm. Report the size of the defect being covered by the adjacent tissue transfer, which is 5.44 sq cm. Refer to the illustrations on adjacent tissue repairs in CPT® Professional Edition found in code range 14000-14061. Code 14020 is reported for an adjacent tissue transfer or rearrangement of arm with a defect of 10 sq cm or less. According to CPT® guidelines, excision of the lesion is included in the flap reconstruction and is not coded separately.

"Operative Report PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp. POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp. PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repair ANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Less than 5 cc. SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o'clock, anterior tip INDICATIONS FOR SURGERY: The patient is a 43 year-old male patient with a biopsy proven squamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for excision with gross normal margins of 4 mm and I drew my planned Yin-Yang flap closure. The patient observed these markings in two mirrors to understand the surgery and he agreed on the location. We proceeded with the procedure. DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The patient was placed prone, his scalp and face were prepped and draped in sterile fashion. I excised the lesion as drawn to include the galea. Hemostasis was achieved with the Bovie cautery. Pathologic analysis showed the margins to be clear. I incised the Yin-Yang flaps and elevated them with the underlying galea. Hemostasis was achieved in the donor site using Bovie cautery. The flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. The donor sites were closed and the flaps inset in layers using 4-0 Monocryl and the skin stapler. Loupe magnification was used. The patient tolerated the procedure well. What CPT® and ICD-10-CM codes are reported?

" 14020, C44.42 In the CPT® codebook, Yin-Yang flap repair falls under Adjacent Tissue Transfer codes. Look in the CPT® Index for Skin Graft and Flap/Tissue Transfer which directs you to code range 14000-14350. Based on the measurement calculating to 9.28 cm² (2.9 cm x 3.2 cm = 9.28 cm²) and the location of the scalp, the correct CPT® code is 14020. In the ICD-10-CM code book go to the Table of Neoplasms and look for skin NOS/scalp/squamous cell carcinoma/Malignant Primary column and you are referred to C44.42. Verify code selection in the Tabular List.

"A 45 year-old male with a previous biopsy positive for malignant melanoma presents for definitive excision of the lesion. After induction of general anesthesia, the patient is placed supine on the OR table, the left knee prepped and draped in the usual sterile fashion. IV antibiotics are given as the patient had previous MRSA infection. The previous excisional biopsy site on the left knee measured approximately 4 cm and was widely ellipsed with a 1.5 cm margin. The excision was taken down to the underlying patellar fascia. Hemostasis was achieved via electrocautery. The resulting defect was 11cm x 5cm. Wide advancement flaps were created inferiorly and superiorly using electrocautery. This allowed skin edges to come together without tension. The wound was closed using interrupted 2-0 Monocryl and 2 retention sutures were placed using #1 Prolene. Skin was closed with a stapler. What CPT® code(s) is/are reported?

" 14301 In the CPT® Index look for Advancement Flap and you are directed to See Skin, Adjacent Tissue Transfer, which leads to code range 14000-14350. Adjacent tissue transfer or rearrangement includes lesion excision and is selected based on size and location. The defect is 11 cm x 5 cm (55 cm 2) and located on the knee. Code 14301 is reported for adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.

"CASE 3 Preoperative Diagnosis 1. Loculated left pleural effusion, chronic Postoperative Diagnosis 1. Loculated left pleural effusion(Report this diagnosis for this procedure.), chronic Procedure Performed: Attempted, ultrasound guided thoracentesis Description of Procedure: The patient was prepped and draped in the sitting position. Using ultrasound guidance(Imaging guidance is performed.) and 1% lidocaine, the thoracic catheter was introduced into the pleural space where we encountered very thick fibrous type pleura.(The placement of the catheter in the pleural cavity to perform the thoracentesis.) The catheter was advanced, and we were unable to aspirate fluid. The catheter was removed. Sterile dressings were applied. Chest x-ray will be obtained for follow-up. Patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code: [a] ICD-10-CM code: [b]

" 32555-LT, J90

"CASE 9 PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis. POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis. PROCEDURE: Planned return to the OR to assess wound closure options. Wound excision and homograft placement with surgical preparation, exploration of distal extremity. FINDINGS AND INDICATIONS: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and overwhelming sepsis was found to have necrotizing fasciitis last week. At that time we excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof. There is an area on the lateral thigh that we may be able to be closed with a skin graft for a viable above-the-knee amputation. PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table. The above findings were noted. Sharp debridement with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area; however, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty. The homograft was meshed 1.5:1 and then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples. Upon completion of the homografting, photos were taken to demonstrate the rather desperate nature of this wound and the fact that it would require above the knee amputation for closure. The wound was dressed with a moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 15002-58, 15271-58-51, M72.6

"Operative Report Pre-Operative and Post-Operative Diagnosis: Squamous cell carcinoma, left leg Open wound, right leg Personal history of squamous cell carcinoma, right leg INDICATIONS FOR SURGERY: The patient is an 81 year-old white man with biopsy proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear. Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well. PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm². Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm². What CPT® codes are reported?

" 15100, 11603-51-LT, 15002-51-RT The first excision is for a malignant neoplasm of the left leg measuring 2.5 cm and repaired with a split thickness skin graft measuring 5.1 cm 2. In the CPT® Index look for Skin/Excision/Lesion/Malignant referring you to code range 11600-11646. The site is the leg, which narrows down the code range to 11600-11606. The size of the lesion is 2.5 cm making code 11603 correct. The second excision is a surgical wound preparation of an open wound of the right leg. Look in the CPT® Index for Skin Graft and Flap/Recipient Site Preparation directing you to codes 15002-15005. Report 15002 for the leg wound, which was repaired with a split thickness autograft measuring 3.2 cm 2. Split thickness autografts are added together (5.1 cm 2 + 3.2 cm 2) for a total graft size of 8.3 cm 2. In the CPT® Index look for Skin Graft and Flap/Split Graft referring you to codes 15100, 15101, 15120, 15121. Report 15100 for the split-thickness graft. Because the original surgery on the right leg was four months ago, this surgery is outside of any global period, so no additional modifier is needed. Modifier 51 is appended to indicate multiple procedures in the same session.

"CASE 10 PREOPERATIVE DIAGNOSES: 1. Basal cell carcinoma, right temple. 2. Squamous cell carcinoma, left hand. POSTOPERATIVE DIAGNOSES: Same PROCEDURES PERFORMED: 1. Excision of basal cell carcinoma right temple, with excised diameter of 2.2 cm and full thickness skin graft 4 cm2. 2. Excision squamous cell carcinoma, left hand, with rhomboid flap repair 2.5 cm2. ANESTHESIA: Local using 8 cc of 1% lidocaine with epinephrine to the right temple and 3 cc of 1% plain lidocaine to the left hand. INDICATIONS FOR SURGERY: The patient is a 77-year-old white woman with a biopsy-proven basal cell carcinoma of right temple that appeared to be recurrent and a biopsy-proven squamous cell carcinoma of her left hand. I marked the lesion of her temple for elliptical excision in the relaxed skin tension lines of her face with gross normal margins of around 2-3 mm. I also marked my planned rhomboidal excision of the squamous cell carcinoma of her left hand with gross normal margins of around 3 mm, and I drew my planned rhomboid flap. She observed all these markings with a mirror so she could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All areas were infiltrated with local anesthetic (the anesthetic with epinephrine). The face and left upper extremity were prepped and draped in normal sterile fashion. I excised the lesion of her right temple and left hand as drawn to the subcutaneous fat. Hemostasis was achieved with Bovie cautery. It took a few more passes to get the margins clear from the basal cell carcinoma on the right temple. The wound had become very large by that time, around quarter sized, and I attempted to close the wound. I began with a 3-0 Monocryl. It was simply too tight and was deforming her eyelid. I felt that we would have to close with a skin graft. I marked the area of her right clavicle for the donor site, and I prepped and draped this area in a sterile fashion. I infiltrated with a plain lidocaine. I harvested and defatted the full-thickness skin graft using scissors. I achieved meticulous hemostasis in the donor site using the Bovie cautery. The skin graft was inset into the temple wound using 5-0 plain gut suture. The skin graft was vented, and a xeroform bolster was placed using xeroform and nylon. The donor site was closed in layers using 4-0 Monocryl and 5-0 Prolene. I then turned my attention to the hand. The margins had been cleared from that region, even though it did take two passes. I incised the rhomboid flap and elevated it with a full-thickness subcutaneous fat. Hemostasis was achieved in the wound and donor site using Bovie cautery. The flap rotated into the defect. The donor site was closed with flap inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c] ICD-10-CM codes: [d], [e]

" 15240, 14040-51, 11643-59, C44.319, C44.629

"CASE 8 PREOPERATIVE DIAGNOSIS: Panniculus, Diastasis recti POSTOPERATIVE DIAGNOSIS: Panniculus, diastasis recti PROCEDURE PERFORMED: Abdominoplasty ANESTHESIA: General CLINICAL NOTE: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy. She has had long term problems with low back pain and constipation as a result of the diastasis recti to the point where child care and every day activities are limited. Since having her last child she has also developed a pannus causing significant chaffing and irritation, which at times results in bleeding and infection. She is here today for the above procedure. She understood the potential risks and complications including the risks of anesthesia, bleeding, infection, wound healing problems, unfavorable scaring, and potential need for secondary surgery. She wanted to proceed. She also understood the possibility of impaired circulation to the flaps and hematoma/seroma formation. PROCEDURE IN DETAIL: The patient was placed on the operating table in supine position. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The umbilicus was also marked, and the area was infiltrated with 100 cc of 0.5% Xylocaine with 1:200,000 epinephrine. After adrenaline effect, the incision was made. The flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity, and it appeared that an ellipse of skin could be removed through the superior margin of the umbilicus. The flap was incised at the midline for greater exposure. She had significant diastasis recti, which was closed with interrupted mattress sutures of 0 Ethibond, followed by a running suture of 0 Ethibond. She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. This gave an easy fit for the flap without undue tension. The #No. 15 drains were placed through the mons area and secured with 3-0 Prolene. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS, and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples, and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. Estimated blood loss was less than 30 cc. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a], [b] ICD-10-CM code: [c], [d]

" 15830, 15847, E65, M62.08

"CASE 4 PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used for coding) OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh, bilateral. (procedure performed) CLINICAL NOTE: This obese patient presents for the above procedure. She understood the potential risks and complications including the risk of anesthesia, bleeding, infection, wound healing problems, unfavorable scarring, and potential need for secondary surgery. She understood and desired to proceed. PROCEDURE: The patient was placed on the operating table in supine position. General anesthesia was induced.(General anesthesia.) Once she was asleep, she was turned and positioned prone. The buttocks and thigh regions were prepped and draped in the usual sterile fashion. She had been marked in the awake, standing position, outlining the incision area, along the gluteal crease that was in continuity with her medial thigh lift scar and extended to the posterior axillary line. The right posterior medial thigh(Location) region was infiltrated with tumescent solution utilizing 750 ml. The liposuction (Liposuction performed.) was then accomplished, removing a total of 200 ml. Then an incision was made along the gluteal crease at the desired site for the final incision. A posterior skin flap was elevated approximately 3 to 4 cm. Hemostasis was assured by electrocautery. There was no residual flap or dead space and the fascia was closed at the deep level with 0 PDS, and then in anatomical layers the closure was completed with 2-0, 3-0, and 4-0 PDS. Dermabond and Steri-Strips were then applied. The medial third was also closed with a running 4-0 plain gut. The same was then accomplished on the left side in similar fashion and steps, achieving a symmetric result, and closure was accomplished similarly (same procedure performed on both left and right sides requiring the use of modifier). A compression garment was applied. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] (use a modifier on this code) ICD-10-CM code: [b]

" 15879-50, E66.8

"Patient returns to the dermatologist after biopsies were done on several lesions. In discussing the pathology results with the patient the physician indicated she had a superficial basal cell carcinoma (BCC) on her right cheek and left hand. The physician discussed the different treatment options with the patient and she decided to try cryosurgery to destroy the skin cancers. Informed consent was obtained. The physician noted the measurements of the BCC of the face to be 0.7 cm and the BCC on the left hand to be 1.2 cm prior to destruction. What are the correct CPT® codes to report for this example?

" 17272, 17281-51 Basal Cell Carcinoma (BCC) is a malignant lesion. Destruction of malignant lesions are reported with code range 17260-17286. Code selection is based on anatomical location and lesion size in centimeters. A 0.7 cm lesion of the face is reported with 17281; Look in the CPT® Index for Destruction/Lesion/Facial. A 1.2 cm lesion of the hand is reported with 17272.17272 has a higher RVU and is listed first. 17281 is listed second with modifier 51 indicating multiple procedures performed at the same operative session by the same provider. Look in the CPT® Index for Destruction/Lesion/Skin/Malignant.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Acute myocardial infarction

" I21.9 The main term is infarction. In the ICD-10-CM Alphabetic Index, look for Infarct, infarction/myocardium, myocardial (acute) (with stated duration of 4 weeks or less) I21.9. Refer to the Tabular List. This is the correct code, even though there is no stated duration in the question, because code I21.9 lists Myocardial infarction (acute) NOS under the code. Note: There is a category note for I21 to use additional code, if applicable, to identify exposure to, use of, dependence of tobacco, or status post tPA in another facility. This is coded if known.

"A patient has a squamous cell carcinoma on the tip of the nose. After prepping the patient and site, the physician removes the tumor (first stage) and divides it into seven blocks for examination. Seeing positive margins, he removes a second stage, which he divides into five blocks. The physician again identifies positive margins. He performs a third stage and divides the specimen into three blocks proving to be clear of the skin cancer. What are the correct CPT® codes to report for this example?

" 17311, 17312, 17312, 17315, 17315 Codes are reported by the number of stages and tissue blocks. There were a total of three stages performed. CPT® 17311 is reported for the first stage and add-on code 17312 is listed twice for each additional stage. The first stage was divided into seven tissue blocks. Code 17315 is reported for each piece of tissue beyond five for any one stage. It isn't appropriate to add and average all blocks from all layers. CPT® +17315 is reported twice for the sixth and seventh blocks. Look in the CPT® Index for Mohs Micrographic Surgery.

"CASE 1 PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis) POSTOPERATIVE DIAGNOSIS: Same OPERATION Mohs micrographic surgery (Mohs surgery is performed) Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location) measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. Informed consent was obtained and the patient underwent fresh tissue Mohs surgery as follows. STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgical pen; the margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The wound was defined and infiltrated with 1% lidocaine with epinephrine 1:100,000 (Local anesthesia was used). The area of the tumor and margins were marked for excision. Additional soft tissue markings were created to keep the specimen oriented with the excision site.(Noting the tumor has been removed, which supports stage 1.) Hemostasis was obtained by electrocautery. A pressure dressing was placed. The tissue was divided into two tissue blocks (The tissue is divided into two tissue blocks.) which were mapped, color coded at their margins, and sent to the technician for frozen sectioning. The surgeon examined the tissue and no microscopic tumor was found persisting in the tumor margins on the tissue blocks. Following surgery, the defect measured 10 x 13 mm to the subcutaneous tissue.(Size and depth of the defect.) Closure will be done by the Dr. Hill from Plastics with a Burow's graft.(A Burow's graft is not reported because it was performed by a different provider.) CONDITION AT TERMINATION OF THERAPY: Carcinoma removed. Pathology report on file. What CPT® and ICD-10-CM codes are reported? CPT® codes: [a] ICD-10-CM code: [b]

" 17311, C44.311

"CASE 3 PREOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant. POSTOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.(Postoperative diagnosis is used for coding.) PROCEDURE: Right breast lumpectomy.(Procedure to be performed.) ANESTHESIA: A 1% lidocaine with epinephrine mixed 1:1 with 0.5% Marcaine along with IV sedation. INDICATIONS: The patient is a 23-year-old female who recently noted a right breast mass (lower outer quadrant). This has grown somewhat in size and we decided it should be excised. FINDINGS AT THE TIME OF OPERATION: This appeared to be a fibroadenoma.(""Appeared to be"" would not be considered a definitive diagnosis.) OPERATIVE PROCEDURE: The patient was first identified in the holding area and the surgical site was reconfirmed and marked. Informed consent was obtained. She was then brought back to the operating room where she was placed on the operating room table in supine position. Both arms were placed comfortably out at approximately 85 degrees. All pressure points were well padded. A time-out was performed. The right breast(The procedure was performed on the right breast.) was prepped and draped in the usual fashion. I anesthetized the area in question with the mixture noted above. This mass was at the areolar border at approximately the outer central to lower outer quadrant.(Specific location of the breast mass.) I made a circumareolar incision on the outer aspect of the areola. This was carried down through skin, subcutaneous tissue, and a small amount of breast tissue.(Depth of incision.) I was able to easily dissect down to the mass itself. Once I was there, I placed a figure-of-eight 2-0 silk suture for traction. I carefully dissected this mass out from the surrounding tissue along with a margin of healthy breast tissue. Once it was removed from the field, the traction suture was removed and the mass was sent in formalin to pathology. The wound was then inspected for hemostasis, which was achieved with electrocautery. I then re-approximated the deep breast tissue with interrupted 3-0 vicryl suture and another 3-0 vicryl suture in the superficial breast tissue. The skin was then closed in a layered fashion(Layered closure for intermediate repair.) using interrupted 4-0 Monocryl deep dermal sutures followed by a running 4-0 Monocryl subcuticular suture. Benzoin, Steri-Strips and dry sterile pressure were applied. The patient tolerated the procedure well and was taken back to the short stay area in good condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 19301-RT, N63.13

"PREOPERATIVE & POSTOPERATIVE DIAGNOSES: 1. Macromastia. 2. Back pain. 3. Neck pain. 4. Shoulder pain. 5. Shoulder grooving. 6. Intertrigo. NAME OF PROCEDURE: 1. Right breast reduction of 1950 g. 2. Right free-nipple graft. 3. Left breast reduction of 1915 g. 4. Left free-nipple graft. INDICATIONS FOR SURGERY: The patient is a 43 year-old female with macromastia and associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the extreme ptotic nature of her breasts, we felt she would need a free-nipple graft technique. In the preoperative holding area, we marked her for this free-nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location, and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah's Witness and refused blood products, but she did understand her risk of bleeding would significantly increase and we proceeded. DESCRIPTION OF PROCEDURE: The patient was given 40 mg of subcutaneous Lovenox in the preoperative holding area. She was then taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1 g was given. Anesthesia was induced. Both arms were secured on padded arm boards using Kerlix rolls. A similar body Bair Hugger was placed. The chest and abdomen were prepped and draped in sterile fashion. I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was de-epithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved using the Bovie cautery. Each of these wounds were temporarily closed using the skin stapler. The patient was then sat up. I felt we had achieved a very symmetrical result. The new positions for the nipple-areolar complexes were marked with a 42 mm areolar marker and methylene blue. The patient was then placed in the supine position and the new positions for the nipple-areolar complexes were de-epithelialized using the scalpel. Meticulous hemostasis was then achieved again using the Bovie cautery. The free-nipple grafts were then retrieved from the back table. They were each defatted using scissors and were placed in an on-lay fashion on the appropriate side, and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil-moistened sponge was affixed to each of the nipple-areolar complexes using 5-0 nylon suture. The vertical and transverse incisions were closed using 3-0 Monocryl, both interrupted and running suture, and 5-0 Prolene. The patient tolerated the procedure well. Again, meticulous hemostasis was achieved using the Bovie cautery. She was given another 1 g of Ancef at the 2-hour mark by our anesthesiologist, and was taken to the recovery room in good condition. What CPT® code is reported?

" 19318-50 With breast reduction surgery, either reduction mammaplasty or reduction mammoplasty is correct. In the CPT® Index look for Reduction/Mammaplasty and you are referred to 19318. Because this is a unilateral code per CPT® guideline, append modifier 50. Normally, with reduction mammoplasty the patient's nipple is repositioned with a pedicle of tissue after removal of the breast tissue and is considered part of the reduction mammoplasty.

"A patient presents for reduction of her left breast due to atrophy of the breast. After being prepped and draped, the surgeon makes a circular incision above the nipple to indicate where the nipple is to be relocated. Another incision is made around the nipple, and then two more incisions are made from the circular cut above the nipple to fold beneath the breast, which creates a keyhole shaped skin and breast incision. Skin wedges and tissue are removed until the surgeon is satisfied with the size. Electrocautery was performed on bleeding vessels and the nipple was elevated to its new position and the nipple pedicle was sutured with layered closure. The last incision was repaired with a layered closure as well. What is the correct CPT code to report for this example?

" 19318-LT The patient is having a reduction mammoplasty. To find the procedure in the CPT Code 19318 is found in Repair and or Reconstruction and is used to report a reduction mammoplasty. In the CPT Index, see Breast/Reduction.

"CASE 5 PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast. POSTOPERATIVE DIAGNOSIS: Hypoplasia of the breast.(Postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Bilateral augmentation mammoplasty.(Breast augmentation performed bilaterally.) ANESTHESIA: General.(General anesthesia.) OPERATIVE SUMMARY: The patient was brought to the operating room awake and placed in a supine position, where general anesthesia was induced without any complications. The patient's chest was prepped and draped in the usual sterile fashion. The patient had previous inframammary crease incisions on both the left and right sides. The extent of the dissection would be to the sternal border within two fingerbreadths of the clavicle and slightly beyond the anterior axillary line. The left breast(Left breast.) was operated upon first. An incision was made in the inframammary crease going through skin, subcutaneous tissue, down to the muscle fascia. Dissection at the subglandular level was then performed until an adequate pocket was made according to the previous limits. After irrigation with normal saline and careful hemostasis, a Mentor and Allergan silicone filled, high profile, textured implant was used and placed into the pocket.(Prosthetic implant used on the left breast filled to 300cc.) It was 300 cc. The skin was closed using 4-0 vicryl in an interrupted fashion for the deep subcutaneous tissue 4-0 Monocryl in an interrupted fashion was used for the superficial subcutancous tissue and the skin was closed using 4-0 Monocryl in a subcuticular fashion. Antibiotic ointment and Tegaderm were applied. The right breast(Right breast.) was operated on in a very similar fashion. The implant was a 340 cc silicone gel, high profile, textured implant from Allergan.(Prosthetic implant used on the right breast filled to 340cc.) Skin closure was the same. Both left and right breasts were very similar in size and shape. The patient had a bra applied. The patient tolerated this procedure well and left the operating room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM: [b]

" 19325-50, N64.82

"CASE 9 Procedure performed in office. PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain. POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain. OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles. PROCEDURE: The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed. I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding. We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 20553, J1030x4, M54.6, C78.01

"CASE 9 Procedure performed in office. PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain. POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain. OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles. PROCEDURE: The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed. I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding. We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 20553, J1030x4, M54.6, C78.01

"CASE 4 PREOPERATIVE DIAGNOSIS: Painful hardware, left foot. POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.(The postoperative diagnosis is used for coding.) PROCEDURE PERFORMED: Removal of hardware, left foot.(This is the working procedure until the report is read.) ANESTHESIA: Sedation and local DRAIN: None. ESTIMATED BLOOD LOSS: Minimal. INDICATIONS FOR PROCEDURE: The patient had his status post metatarsal fracture, treated with internal fiixation. Patient has suffered pain due to hardware for the past six months.(The diagnosis is confirmed in the body of the report.) Patient's pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed. DESCRIPTION OF PROCEDURE: With the patient supine on the operating table after the successful induction of anesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Small 0.5 cm incisions through the skin were made and blunt dissection was carried down to the screw heads. The screws were removed with the screwdrivers.(The removal of hardware is described.) The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition. MATERIAL SENT TO LABORATORY: None. COMPLICATIONS: None. CONDITION ON DISCHARGE: Satisfactory. DISCHARGE DIAGNOSIS: Painful hardware, left foot. DISCHARGE PLAN: Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable, when to call the physician, and follow-up care. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b], [c]

" 20680-LT, T84.84XA, G89.18

"CASE 6 PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy. ANESTHESIA: General endotracheal. DESCRIPTION OF THE PROCEDURE: After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We connected these two pins with clamps, and then under C-arm control, we reduced the fracture. All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] [b] ICD-10-CM code: [c]

" 20690-LT, 25605-51-LT, S52.532A

" A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured. What CPT® code is reported?

" 35820-78 This is a postoperative exploration and modifier 78 is necessary because this is an unplanned return to the OR by the same physician during the global period of another procedure. Modifier 78 is used for a return to the OR for complications. This was an exploration for postoperative hemorrhage of the chest. Look in the CPT® Index for Exploration/Blood Vessel/Chest which directs you to 35820.

"CASE 6 PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy. ANESTHESIA: General endotracheal. DESCRIPTION OF THE PROCEDURE: After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We connected these two pins with clamps, and then under C-arm control, we reduced the fracture. All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] [b] ICD-10-CM code: [c]

" 20690-LT, 25605-51-LT, S52.532A

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Increased procedural service Do not type the word "Modifier" for your answer.

" 22

"CASE 1 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body. PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. General anesthesia was used.) in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which, after inspection, there were none. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition. COMPLICATIONS: There were no complications. BLOOD LOSS: Minimal blood loss. COUNTS: Sponge and needle counts were correct. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 22514, M48.56XA

"CASE 2 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.) INDICATIONS: The patient is a 66-year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. A matrix is provided where new bone can grow and further stabilize the prosthesis. These are not reported separately.) The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 23616-LT, S42.202A

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Unrelated evaluation and management services by the same physician or other qualified health care professional during a postoperative period. Do not type the word "Modifier" for your answer.

" 24

"CASE 7 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Dislocation of right elbow. POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture. OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture. ANESTHESIA: General. INDICATIONS: This is a 12-year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture. The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed. The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position. It was elected to treat this non-surgically. A long arm splint was applied. The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 24565-RT, 24605-51-RT, S42.441A, S53.104A

"CASE 7 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Dislocation of right elbow. POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture. OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture. ANESTHESIA: General. INDICATIONS: This is a 12-year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture. The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed. The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position. It was elected to treat this non-surgically. A long arm splint was applied. The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 24565-RT, 24605-51-RT, S42.441A, S53.104A

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Do not type the word "Modifier" for your answer.

" 25

"CASE 8 PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. PROCEDURES: Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach. ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal. REPLACEMENT: Crystalloids. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. The patient tolerated the procedure well. Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 26055-F7, 20610-51-LT, M65.331, M75.52

"CASE 8 PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. PROCEDURES: Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach. ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal. REPLACEMENT: Crystalloids. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. The patient tolerated the procedure well. Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 26055-F7, 20610-51-LT, M65.331, M75.52

"CASE 10 PREOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. POSTOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. OPERATION PERFORMED: Open Left Achilles' tendon repair. ANESTHESIA: General anesthesia INDICATIONS: The patient is a 25-year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure. DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair. A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes. The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e]

" 27650-LT, S86.012A, W50.0XXA, Y93.67, Y99.8

What modifier is appended to report the technical component of a procedure?

"TC Some CPT® codes have a technical component and a professional component. Modifier 26 is appended when the professional component is provided, and modifier TC is appended when the technical component is provided. Professional services are those in which the physician performs supervision and interpretation with report. Technical services includes ownership of the equipment, space, and employment of the technicians or nurses who performed the study.

"CASE 10 PREOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. POSTOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. OPERATION PERFORMED: Open Left Achilles' tendon repair. ANESTHESIA: General anesthesia INDICATIONS: The patient is a 25-year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure. DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair. A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes. The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e]

" 27650-LT, S86.012A, W50.0XXA, Y93.67, Y99.8

"CASE 5 PREOPERATIVE DIAGNOSIS: Right ankle triplane fracture POSTOPERATIVE DIAGNOSIS: Right ankle triplane fracture(The postoperative diagnosis is used for coding.) PROCEDURE: Open reduction and internal fixation (ORIF), right ankle triplane fracture(This is the working procedure until the report is read.) ANESTHESIA: General endotracheal(The type of anesthesia utilized is provided. General anesthesia was used.) COMPLICATIONS: None SPECIMEN: None IMPLANT USED: Synthes 4.0 mm cannulated screws INDICATIONS FOR PROCEDURE: The patient is a pleasant 15-year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed. PROCEDURE IN DETAIL: The patient was brought back to the operating room and placed on an operating table, given a general anesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep. Under X-ray guidance(Radiologic guidance was used.), a pointed reduction clamp was placed from the anterolateral corner of the distal tibia(Documentation within the body of the report further specifies the fracture and treatment were of the distal tibia.) to the medial side, and I reduced the triplane fracture.(The fracture was reduced.) It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site.(Internal fixation was accomplished with screws.) The appropriate length screws were placed, confirmed by an X-ray to be in good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. Closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mold splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b], [c]

" 27827-RT, S82.391A, W19.XXXA

"CASE 3 OPERATIVE REPORT Preoperative Diagnosis: Plantar fasciitis, left Postoperative Diagnosis: Same as preoperative diagnosis.(The postoperative diagnosis is used for coding.) Procedures: Plantar fasciotomy, left heel.(This is the working procedure until the report is read.) For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications. This 61-year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus.(The description of the fasciotom is found within the body of the report.) The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted. Hemostasis: none Estimated Blood Loss: minimal Injectables: Agent used for local anesthesia was 5.0 cc Marcaine 0.5% with epinephrine. Pathology: No specimen sent. Dressings: Applied Bacitracin ointment. Site was dressed with a light compressive dressing. Condition: Patient tolerated the procedure and anesthesia well. Vital signs were stable. Vascular status was intact to all digits. Patient recovered in the operating room. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 28008-LT, M72.2

" What CPT® code(s) is/are reported for extensive excision of seven nasal polyps?

" 30115 In the CPT® Index look for Excision/Polyp/Nose directing you to 30110, 30115. The code descriptor for 30115 indicates polyp(s) and extensive. Thus, we would not report 30115 multiple times.

"CASE 2 PREOPERATIVE DIAGNOSIS: Left vocal cord tumor. PREOPERATIVE DIAGNOSIS: Left vocal cord tumor.(Report this diagnosis if no further positive findings are found in the operative note.) NAME OF PROCEDURE - Direct laryngoscopy with microscope, removal of tumor.(Indication of type of laryngoscopy being performed.) ANESTHESIA: General. COMPLICATIONS: None. SPECIMENS: Left vocal cord tumor to pathology.(Tumor was sent to pathology.) BLOODLOSS: Less than 10 ml. TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. The bed was turned 90 degrees clockwise. The alveolar guard was placed over the upper alveolus to protect the teeth. Appropriate drapes were placed. The anterior laryngoscope was inserted and direct laryngoscopy(Placement of the direct laryngoscope.) was performed with no abnormal findings other than the above-described tumor. The scope was suspended, and using the operating microscope(Operating microscope is used.) the anterior vocal cord tumor was removed. The mucous membrane posterior to the tumor was carefully incised and Reinke's space was entered. Careful dissection allowed mucous membrane elevation off of the anterior vocal cord up to the commissure, with what appeared to be complete excision of the tumor.(Removal of the tumor.) Minimal bleeding was noted. The area was sprayed with Cetacaine spray. The scope was gently removed. The teeth were evaluated and found to be free of injury. The drapes and instruments were removed. The patient was returned to anesthesia for care, allowed to awaken, extubated, and transported in stable condition to the recovery room. The patient tolerated the procedure well. FINDINGS: Patient is a pleasant 77-year-old white female with a history of the above-noted diagnoses. Operative findings included an otherwise normal larynx with the exception of the left anterior vocal cord tumor.(This is confirmation to report a tumor on the vocal cord.) It was fairly soft. What CPT® and ICD-10-CM codes should be used for this procedure? CPT® code: [a] ICD-10-CM codes: [b]

" 31541, D49.1

"CASE 4 Preoperative Diagnosis: 1. Mass, right upper lobe. Postoperative Diagnosis: 1. Carcinoma, right upper lobe.(Report this diagnosis if no further positive findings are found in the operative report.) Procedure Performed: VATS, right superior lobectomy. Description of Procedure: Under general anesthesia, after a double-lumen tube intubation, the right lung was collapsed and the right side up is oriented so the patient is in the left lateral decubitus position. We prepped and draped the patient in the usual manner and gave antibiotics. Then two 1 cm incisions were made along the posterior and mid axillary line at the ninth and seventh intercostal spaces. The lung was deflated and a camera was inserted.(VATS.) A longer (6 cm) incision was made along the fourth intercostal space anteriorly. We then freed up some adhesions at the top of the lung, both in the superior area away from the tumor and in the anterior mediastinal area. The tumor seemed to be in the right upper lobe.(Tumor is in the right lung.) The dissection began by ligating the superior pulmonary vein and its branches, and the upper lobe was freed up. The small fissure was incomplete, and I proceeded with the lobectomy. The pulmonary artery branches were then ligated. The bronchus was ligated, as well. The superior branches to the upper lobe were ligated with Endo GIA. The lobe was freed up and sent to pathology. The wound was then closed in layers. A chest tube was placed to suction, and the patient was sent to recovery in stable condition. Pathology confirmed carcinoma.(Indication to report the right lobe of the lung as cancerous.) What are the procedure and diagnosis codes for this procedure? CPT® code: [a] ICD-10-CM code: [b]

" 32663-RT, C34.11

" " A 27 year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C. What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?

" 32850, 32856, 32853 DOA means the individual is dead on arrival thus the lungs will be harvested from a cadaver donor. In the CPT® Index look for Donor Procedures/Lung Excision, the removal of the lungs by physician A will be reported with 32850 representing plural cadaver donor pneumonectomies (lung removals). In the CPT® Index look for Transplantation/Lung/Double, without Cardiopulmonary Bypass, the insertion of the lungs is reported with 32853 by physician C. In the CPT® Index look for Transplantation/Lung/Allograft Preparation directing you to 32855, 32856, 33933. The backbench preparation of both lungs (bilateral) by physician reported with 32856 by physician B. Because different physicians separately report each procedure, modifier 51 is not required.

"CASE 4 Preoperative diagnosis: Cardiac tamponade secondary to malignant effusion due to the pericardial metastasis from the lung.(This is the diagnosis as the pre and post-operative diagnoses are the same.) Postoperative diagnosis: Same Procedure: Pericardial Window via subxiphoid approach.(This is the working procedure description, but it must be verified in the report.) Details: The patient was positioned supine on the table and prepped and draped. A low midline incision approximately 5cm in length was made over the sternum and xiphoid.(This is the approach used to gain access to the pericardium.) This was carried down to the linea alba, which was opened. The xiphoid was divided. We then found the pericardium and opened the pericardium again with electrocautery. We enlarged the site so it was easily 1cm across.(The pericardium is cut open for drainage.) At this time, there was a gush of fluid under pressure. It was serosanguinous fluid. It was not turbid, nor was there any odor. We suctioned this fluid for approximately 500ml in the suction container. There was probably an additional 100ml of spill on the drapes. Approximately 100ml was also sent for cytology and culture.(A sample of body fluids retrieved during the procedure is sent to the lab for pathological workup.) After we felt we had fully drained the pericardium and had had a significant hemodynamic improvement, we then made a small transverse incision; to the right of her lower sternal incision and through this and across the fascia, we passed a #20-French Blake drain.(A tube is placed and left in the chest to allow for continued drainage.) This was placed on the diaphragmatic surface of the heart and was tied in place using 2-0 Ethibond sutures. We then closed the fascia with 0 Vicryl and the subctaneous tissue with 0 Vicryl. These were all interrupted, and the skin was stapled. At the end of the procedure the patient's condition remained stable. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 33025, C79.89, C34.90, I31.4

"PREOPERATIVE DIAGNOSIS: Heart Block POSTOPERATIVE DIAGNOSIS: Heart Block ANESTHESIA: Local anesthesia NAME OF PROCEDURE: Reimplantation of dual chamber pacemaker DESCRIPTION: The chest was prepped with Betadine and draped in the usual sterile fashion. Local anesthesia was obtained by infiltration of 1% Xylocaine. A subfascial incision was made about 2.5 cm below the clavicle, and the old pulse generator was removed. Using the Seldinger technique, the subclavian vein was cannulated and through this, the old atrial lead was removed, and a new atrial lead (serial # 6662458) was placed in the right atrium and to the atrial septum. Thresholds were obtained as follows: The P-wave was 1.4 millivolts, atrial threshold was 1.6 millivolts with a resultant current of 3.5 mA and resistance of 467 ohms. Using a second subclavian stick in the Seldinger technique, the old ventricular lead was removed and a new ventricular lead (serial # 52236984) was inserted and placed into the right ventricular apex. The thresholds were obtained and were as follows: R-wave was 23.5 millivolts. The patient was pacing at 100% at 0.5 volts, with resultant current of 0.8 mA and resistance of 480 ohms. When we were satisfied with the thresholds, the leads were connected to the pacemaker generator (serial # 22561587), which was inserted into the previously created pocket. The wound was thoroughly irrigated with antibiotic solution and hemostasis was obtained. The incision was closed in layered fashion with 2-0 Dexon. A compressive dressing was applied, and the patient tolerated the procedure very well. He was taken to the recovery room in satisfactory condition. What CPT® codes are reported?

" 33235, 33208-51, 33233-51 Look for Cardiac Assist Devices/Pacemaker System/Removal. Code 33235 reports removal of the electrodes of a dual pacemaker lead system. Next, look for Cardiac Assist Devices/Pacemaker System/Insertion/System. Code 33208 reports replacement of permanent pacemaker generator with transvenous electrodes to the right atrium and right ventricle. Code 33233 reports the removal of a pacemaker generator and is indexed - Cardiac Assist Devices/Pacemaker System/Removal. Modifier 51 reports multiple procedures performed during the same session.

" "CASE 9 Preoperative diagnoses: Critical aortic valve stenosis, coronary artery disease, hypertension, diabetes mellitus Postoperative diagnoses: Same Operation: Aortic valve replacement with a 19mm St. Jude bioprosthesis. Coronary artery bypass graft x 2 - reverse saphenous vein graft to left anterior descending artery and reverse saphenous vein graft to obtuse marginal artery. Anesthesia: General Indications: This is an 80-year-old female with a history of hypertension, diabetes mellitus, and coronary artery disease, who presented to the emergency department with a syncopal episode. An echo revealed severe to critical aortic valve stenosis. Cath confirmed this diagnosis as well as two-vessel coronary artery disease with a tight proximal left anterior descending artery lesion, a tight circumflex lesion, and a 40% right coronary artery lesion. Procedure: The patient was brought to the operating room and placed supine on the table. After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion. We to harvested the saphenous vein endoscopically from the left lower extremity. Once we were ready to divide the conduit, the patient was heparinized. The conduit was divided and prepared for bypass. A median sternotomy was performed; there was a pericardial cradle. We cannulated the ascending aorta. Antegrade and retrograde cardioplegia catheters were placed. The patient was placed on cardiopulmonary bypass with an ACT greater than 400. We examined the targets, and they were deemed to be graftable. At this point, the pulmonary artery was dissected off the aorta. We placed a vent through the right superior pulmonary vein, and then we cross-clamped the ascending aorta and gave cardioplegia in antegrade and retrograde fashion, as well as topical ice. We cooled the patient to 32 C. With an excellent arrest, we exposed the territory of the obtuse marginal. It was opened, found to be a graftable vessel. A reverse saphenous vein graft to the obtuse marginal was fashioned using 7-0 Prolene. The flow was measured at 90 ml/min. At this point, the territory of the LAD was exposed. It was opened, and a reverse saphenous vein graft to left anterior descending artery anastomosis was fashioned using 7-0 Prolene. Flow was measured at 110 ml/min. Cardioplegia was given down these grafts as well as in a retrograde fashion throughout the case, every 20 minutes. We performed a hockey-stick incision of the aorta approximately 1.5cm above the right coronary artery. We used silk sutures to expose the aortic valve. It was a severely calcified, trileaflet aortic valve. The leaflets were cut out. The annulus was debrided. We irrigated the ventricle, then we proceeded to size the valve to a 19mm valve. Sutures of 2-0 Ethibond were placed in ventriculo-aortic fashion circumferentially. They were then passed through the valve. The valve was seated and tied down without difficulty. The right and left coronary ostia appeared to be intact and free of obstruction. There appeared to be no evidence of weakness around the annulus. We rewarmed the patient. The aorta was closed using two layers of 4-0 Prolene with two felt strips. We proceeded to perform two proximal aortotomies once the veins were cut to length. The veins had bull-dogs on them. At this point, we removed the cross-clamp, and normal sinus rhythm was reinstituted. Ventricular pacing wires were placed, and after de-airing maneuvers, the vent was removed. We placed Blake drains into the mediastinum x 2. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c] ICD-10-CM codes: [d], [e], [f], [g]

" 33405, 33511-51, 33508, I35.0, I25.10, I10, E11.9

" A patient has a history of chronic venous embolism in the superior vena cava (SVC) and is having a radiographic study to visualize any abnormalities. In outpatient surgery center, the physician accesses the subclavian vein and the catheter is advanced to the SVC for injection and imaging. The supervision and interpretation of the images is performed by the physician. What codes are reported for this procedure?

" 36010, 75827-26 A radiographic study of the SVC is performed to visualize and evaluate any abnormalities. For the insertion of the catheter look in the CPT® Index for Catheterization/Vena Cava referring you to code 36010. For the radiology code look in the CPT® Index for Venography/Vena Cava guiding you to code range 75825-75827. Radiology code 75827 is correct for the SVC. Modifier 26 is appended to the radiology code because the physician is performing the procedure in an outpatient facility setting and does not own the radiology equipment.

" Preoperative Diagnosis: Aortic valve stenosis with coronary artery disease associated with congestive heart failure Postoperative Diagnosis: Same Anesthesia: General endotracheal Incision: Median sternotomy Description of Procedure: The patient was brought to the operating room and placed in supine position. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. She was cannulated after the aorta and atrium were exposed and after full heparinization. She went on cardiopulmonary bypass, and the aortic cross-clamp was applied. Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed, and the 23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed. Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The radial artery was anastomosed to the left anterior descending artery target in an end-to-side manner. The proximal anastomosis was then carried out to the root of the aorta. The patient came off cardiopulmonary bypass after aortic cross-clamp was released. She was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® codes are reported?

" 33405, 33533-51, 33517, 35600 A mechanical valve was placed (33405). Look in the CPT® Index for Replacement/Aortic Valve and you are directed to code 33405. A one artery, one venous CABG was performed (33533, 33517). Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass which directs you to codes 33517-33519, and also look for Arterial Bypass which directs you to codes 33533-33536. The left radial artery is an upper extremity artery and separately reportable (35600), as noted in the guidelines preceding categories Combined Arterial Venous Grafting for Coronary Artery Bypass and preceding Arterial Grafting for Coronary Artery Bypass. Modifier 51 is appended to 33533, because it is an additional procedure performed during the same session. The other codes are add-on codes; therefore, modifier 51 exempt.

"CASE 5 Preoperative diagnosis: Prosthetic valve endocarditis.(This is the working diagnosis, coming into the surgery.) Postoperative diagnosis: Same Operation: Re-replacement of a 10 year-old tricuspid valve using a 31 mm Carpentier-Edwards pericardial bioprosthesis.(This is the planned procedure statement, replacement of the tricuspid valve.) Procedure: The patient was brought to the operating room, and after having the appropriate monitoring devices placed, he was intubated and general endotracheal anesthesia was achieved. The patient was prepared and draped in the usual sterile fashion. The chest was entered via a median sternotomy incision.(This is the approach used.) Simultaneous to this, the right common femoral vein was dissected. The pericardium was opened, the patient was given systemic heparin, and the ascending aorta and superior vena cava were cannulated. Similarly, the right common femoral vein was cannulated. The patient was started on bypass.(This documents the use of cardiopulmonary bypass.) Caval snares were placed, and the right atrium was opened. An intra-atrial thrombus excised and cultured. The prosthetic valve was excised, the annulus was debrided and irrigated. The valve was sized and a 31mm valve was selected.(This was the removal of the old valve and the placement of the new one. Note just the leaflets were removed and the annulus stayed.) Pledgeted 2-0 Ethibond sutures were passed circumferentially around the annulus in a ventriculoatrial fashion. These sutures were tied and the valve was inspected. The valve was found to be well-seated,(This documents that the valve is in the correct place and fits well.) and the atrium was closed with running 4-0 Prolene sutures. The patient was rewarmed, deaired, and then weaned from bypass with low-dose inotropic support. Temporary drains were placed and the mediastinum was policed for hemostasis and the sternum re-approximated with stainless steel wire. The femoral vein and groin wounds were closed with layered Vicryl sutures. The patient was taken back to the Cardiac Surgical Unit in stable condition after tolerating the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 33465, 33530, T82.6XXA, I07.9

" Preoperative Diagnosis: Coronary artery disease associated with congestive heart failure. In addition, the patient has diabetes and massive obesity. Postoperative Diagnosis: Same Anesthesia: General endotracheal Incision: Median sternotomy Indications: The patient had presented with severe congestive heart failure associated with her severe diabetes. She had significant coronary artery disease, consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. She also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to her right system. The decision was therefore made to perform a coronary artery bypass grafting procedure particularly because she is so symptomatic. The patient was brought to the operating room. Description of Procedure: The patient was brought to the operating room and placed in supine position. Myself, the operating surgeon was scrubbed throughout the entire operation. After the patient was prepared, median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs almost three hundred pounds and with her obesity there was some concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit, she should have an arterial graft to the left anterior descending artery territory. She was cannulated after the aorta and atrium were exposed and after full heparinization. Attention was turned to the coronary arteries. The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target, and the radial artery was anastomosed to this target, and the proximal anastomosis was then carried out to the root of the aorta. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples. What CPT® coding is reported?

" 33533, 33517, 35600 One arterial graft and one vein graft was performed. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass for range 33517-33519. Next, look for Arterial Bypass which directs you to 33533-33536. This was a combination arterial-venous graft with one vein graft (33517) and one an arterial graft (33533). The upper extremity radial artery graft procurement (35600) is separately reportable. Codes 33517 and 35600 are add-on codes and are modifier 51 exempt.

"CASE 7 Preoperative diagnosis: Coronary artery disease. Hypercholesterolemia Postoperative diagnosis: Same Operation: Coronary artery bypass graft x 4. Left internal mammary artery to obtuse marginal artery, right internal mammary artery to the left anterior descending artery, reverse saphenous vein to the first diagonal artery and reverse saphenous vein graft to the right posterior descending artery. Indications: The patient is a 39 year-old gentleman with a history of hypercholesterolemia and hypertension, who presents with a positive stress test. Catheterization revealed left main, circumflex disease, as well as total right coronary artery disease. Procedure: The patient was brought to the operating room and placed supine on the operating table. After the induction of general endotracheal anesthesia, the patient was prepared and draped in the usual sterile fashion. We proceeded to harvest a saphenous vein endoscopically from the left lower extremity. At the same time, the LIMA and then RIMA were harvested by open technique. The pericardium was opened and tacked up to form a cradle. The patient was heparinized. The conduits were prepared for bypass. We opened the cardiac cradle, cannulated the ascending aorta and right atrium. Antegrade and retrograde cardioplegia catheters were placed. At this time, we placed the patient on cardiopulmonary bypass. The targets were examined, and they seemed to be graftable. At this point, we placed a cross-clamp on the ascending aorta and arrested the heart with antegrade and retrograde cardioplegia, topical ice, and the patient was cooled down to 32 C. At this point, we exposed the territory of the RPDA. It was found to be a modest target. A reverse saphenous vein graft to right posterior descending artery was fashioned using 7-0 Prolene. Flow was measured at 50 ml/min. Next, we directed our attention to the first diagonal artery. It was also a modest target. It was opened. The anastomosis was fashioned using the reverse saphenous vein graft with 7-0 Prolene. Flow was measured at 60 ml/min. At this point, we exposed the territory of the obtuse marginal. The left internal mammary was prepared. A LIMA to obtuse marginal graft was performed with 7-0 Prolene. There was excellent hemostasis. We tacked down the wings of the mammary. The bull-dog was placed on the mammary. At this point, we performed two proximal aortotomies with the4.0mm aortic punch. Two proximal anastomoses were fashioned after the veins were cut to length with 6-0 Prolene. Bull-dogs were placed on each of these veins. We rewarmed the patient. The territory of the left anterior descending artery was exposed. The RIMA was prepared. The RIMA to left anterior descending coronary artery (LAD) anastomoses was fashioned using the 7-0 Prolene. Once this was completed, the wings of the mammary were tacked. At this point, warm cardioplegia was given in retrograde fashion. The bull-dogs were removed from both the LIMA and the RIMA. We resumed perfusion of the heart. We de-aired the root of the aorta and removed the cross-clamp. The patient resumed a normal sinus rhythm. The sites were oversewn; the vein grafts were deaired in the usual fashion. We examined the proximal and distal anastomoses, and there was excellent hemostasis. Three Blake drains were placed, two into the mediastinum and one into the right pleura, as we did not enter the left pleural space. The patient was weaned off cardiopulmonary bypass without any difficulty. The sternum was reapproximated with heavy stainless steel wire in a mattress fashion. The pectoralis fascia and subcutaneous tissue were approximated with 1-Vicryl skin with 4-0 Vicryl as well as Dermabond. The lower extremities were closed in similar fashion. The instrument counts were correct. The patient was transferred to the SICU in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c] ICD-10-CM codes: [d], [e]

" 33534, 33518, 33508, I25.10, E78.00

"CASE 1 Preoperative diagnosis: Sinus of Valsalva aneurysm on the left coronary sinus.(This is the working diagnosis the unless report gives a different diagnosis or more defining information.) Postoperative diagnosis: Same Operation: Repair sinus of Valsalva aneurysm with pericardial patch.(This is the procedure performed, but coders must confirm the procedure was performed in the body of the notes.) Procedure: The patient was taken to the operating room and placed supine on the table. After general endotracheal anesthesia was induced, rectal temperature probe, a Foley catheter and TEE probe were placed. The extremities were padded in the appropriate fashion. Her neck, chest, abdomen, and legs were prepared and draped in standard surgical fashion. The chest was opened through a standard median sternotomy.(This describes the approach.) The patient was fully heparinized and placed on cardiopulmonary bypass.(The patient was placed on cardiopulmonary bypass.) At this point, we started to open the pericardium. We were met with a large amount of dense adhesions and some fluid that was blood-tinged, salmon colored, and it was cultured. Tonsil clamps were placed on the inferior portion of the pericardial sac and we used Bovie cautery and Metzenbaum scissors to take down all the adhesions laterally, exposing the right atrium first and then the aorta. There were some lighter adhesions over the left ventricle, which were broken with finger dissection. There was a moderate amount of fluid in different pockets that were suctioned free. There was no evidence of frank blood. After dissecting out the right atrium, we dissected out the aorta circumferentially using Bovie cautery and Metzenbaum scissors. We then freed up the entire LV and the apex, as well as the inferior and lateral borders of the heart. After this, we then checked the activated clotting time (ACT), which was greater than 550. The ascending aorta was cannulated without difficulty. A dual stage venous cannula was placed in the right atrium. Retrograde cardioplegia was placed in the right atrium through the coronary sinus, and antegrade cardioplegia was placed in the ascending aorta.(This is part of the dissection and findings. This describes how the bypass was performed, it is not important to the procedure itself. It's very important from a legal perspective.) After the patient was on bypass, we completed dissection. We looked through the superior pulmonary vein. It appeared to be densely adhesed, so we opted to vent through the apex of the LV. We proceeded to flush our lines, cooled to 32 degrees. Once we had a nice arrest we opened the aorta. An aortotomy was created in standard fashion, the area was tacked back, and we were able to identify the aneurysm in question.(This is the documentation of the aneurysm.) There was a large amount of thrombus and it was removed. There was also some mural thrombus which was laminar and stuck to the aneurysm, and I elected not to debride this area. This defect apparently took up the entire left of the sinus of Valsalva.(This tells you exactly where the aneurysm is located.) The coronary was probed and there was approximately 2-3mm rim of tissue beneath the coronary to sew to, and the valve was intact. The aortic valve was intact, and there was a rim of tissue just lateral to the annulus for us to sew to. After debriding and irrigating, we sized a bovine pericardial patch and sutured it in place with 4-0 Prolene suture.(This documentation describes the patch procedure.) This was done in a running fashion, working from the annulus up towards the coronary artery underneath the coronary, and then around laterally and superiorly, sewing through the aortic tissue. We now successfully excluded the aneurysm and packed the entire sinus.(This documents that the entire aneurysm was repaired.) We gave cardioplegia in a retrograde fashion, with nice flow back from the left main. We inspected the repair and it was competent. We irrigated one more time and closed the aorta, de-aired the heart with standard maneuvers, and removed the cross-clamp. We then weaned the patient off of bypass and re-warmed the patient. There was no aortic insufficiency, good function of the aortic valve, and no flow into the aneurysm anymore, with a nice patch repair. We closed the chest with stainless steel wires, the fascia was closed with Vicryl sutures, and subcutaneous tissue and skin were closed in similar fashion.(The rest of the note explains that the patient was removed from the bypass machinery and closure. Note there is no indication of chest tube placement. Any time you open the chest the negative pressure required for respiration is lost and a chest tube is placed to re-establish this negative pressure. This is never a separately coded item because it is an integral part of the surgery.) What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 33720, Q25.49

"CASE 3 Preoperative diagnosis: 6.7cm descending thoracic aortic aneurysm. Type B aortic dissection, chronic.(This is the working diagnosis, until report is reviewed.) Postoperative diagnosis: Same Operation: Left thoracotomy.(This is the surgical approach.) Repair of a descending thoracic aortic aneurysm with a 34 mm Gelweave graft.(This is the surgical procedure.) Bypass time: 1 hour, 15 minutes(Our first indication that cardiopulmonary bypass was used.) Procedure: The patient was brought to the operating room, placed on the table in the supine position. A blocker was placed on the left main stem bronchus, and we isolated the left lung. We proceeded to place the patient in the right lateral decubitus position. He was padded and secured with all pressure points relieved, and at this point, we prepared and draped the patient in the usual sterile fashion. We performed a left posterolateral thoracotomy;(This is our approach to this surgery.) dividing the muscles, the fourth intercostal space was entered. The lung was completely deflated. At the same time, we exposed the left common femoral vein as well as the left common femoral artery, and heparinized the patient. These vessels were isolated and prepared for cannulation. A venous line was placed into the right atrium through the common femoral vein, and this was secured. The patient was placed on partial bypass maintaining a blood pressure in the lower extremities of around 50 mmHg. We continued at this point with our dissection. The esophagus was plastered against the aorta. It was peeled off. Intercostals were controlled and divided. We placed an aortic cross-clamp proximally and distally, and we entered the aneurysm.(Here, we note the aneurysm.) We identified two lumens and these were resected, and proximally we identified the true lumen and resected the false lumen after obtaining control of the subclavian artery. Distally we fenestrated the wall between the true and false lumen to prevent any malperfusion. At this point, we sized the aorta to a 34mm aortic graft,(This is the description of the graft used for the repair.) and we fashioned the proximal anastomosis using 3-0 Prolene with a large needle in a running fashion. We nerve hooked this suture line and tied this down. The posterior suture line of the proximal anastomosis was reinforced with 4-0 Prolene pledgeted stitches. At this point, we removed the cross-clamp and pressurized the anastomoses. Areas of leak were controlled with 4-0 Prolene. The graft was cut to length and after examining our distal aorta and, making sure an appropriate fenestration had been performed, we fashioned an anastomosis again using 3-0 Prolene with a large needle. Before removing the proximal cross-clamp we de-aired the graft with a 25-gauge needle. We very slowly removed the proximal cross-clamp as well as the distal cross-clamp and flow was reinstituted down the aorta. We weaned the patient off bypass and examined our distal and proximal anastomoses. All incisions were closed and the patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b], [c]

" 33875, I71.2, I71.01

"CASE 10 Location: Regional Hospital TYPE OF PROCEDURE: 1. Abdominal aortic angiogram 2. Mesenteric artery angiogram HISTORY: Mesenteric ischemia. INFORMED CONSENT: The procedure was discussed with the patient and his wife. The risks, including bleeding, infection and vascular injuries such as dissection, perforation, thrombus, and embolus were outlined. Informed consent was obtained. CONTRAST: 123 ml Ultravist 370. DESCRIPTION OF PROCEDURE: The patient's right groin was sterilely prepped and draped. The skin and subcutaneous tissues were anesthetized with 2% lidocaine. The right common femoral artery was then percutaneously accessed and a wire advanced into the abdominal aorta under fluoroscopic visualization. A 5-French vascular sheath was placed into the right groin. An Omni Flush catheter was advanced to the upper abdominal aorta. Digital subtraction angiography of the abdominal aorta was performed. It demonstrates mild tortuosity of the aorta. The caliber is normal. A single renal artery is seen bilaterally without stenosis. The common iliac vessels are patent. The Omni Flush catheter was then exchanged for a Cobra 2 catheter. The superior mesenteric artery was then selectively catheterized. Digital subtraction angiography was performed in multiple obliquities. The origin is patent. No focal stenosis or branch occlusions are identified. Next, the celiac artery was selectively catheterized. Digital subtraction angiography was performed in 2 obliquities. The origin is normal. No focal stenosis or branch occlusions are present. Next, attempts were made to catheter the inferior mesenteric artery with the Cobra 2 catheter. This was unsuccessful. Selective catheterization of the inferior mesenteric artery was achieved with a Simmons 2 catheter. Digital subtraction angiography was then performed in 2 obliquities. The origin is patent. No stenosis or branch occlusions are present. The Simmons 2 catheter was removed as was the right groin sheath over a wire. Hemostasis in the right groin was then achieved using an Angio-Seal closure device. IMPRESSION: Normal abdominal aortic angiogram and mesenteric angiogram of selective catheterization of the celiac, superior mesenteric and inferior mesenteric arteries. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b], [c], [d], [e], [f] ICD-10-CM code: [g]

" 36245, 36245-59, 36245-59, 75726-26, 75726-26-59, 75726-26-59, K55.9

"CASE 2 Preoperative diagnosis: Acute renal failure.(This is the diagnosis.) Postoperative diagnosis: Same. Indication: Patient is a 23 year-old critically ill woman who went to the operating room for a lung transplant. A Vas-Catheter(Catheter.) was indicated to proceed with CVVHD upon arrival in the ICU. Procedure: Left subclavian Vas-Cath placement (insertion).(This is the working description of the procedure.) The left chest was draped and prepped in the usual sterile fashion and the patient was placed in the Trendelenburg position. The subclavian vein was readily located with a needle,(Entry directly into the subclavian vein indicates a non-tunneled catheter.) and the Seldinger technique was used to place a Vas-Cath for dialysis.(This is the description of the placement.) Excellent flow was returned through both lumens. The catheter was secured in place and a sterile dressing was applied. The patient is to be transported to the ICU where a post-procedural x-ray will be taken. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 36556, N17.9

"Procedure: Right femoral angiography, percutaneous transluminal tibioperoneal angioplasty and stenting. Description of Procedure: The patient was premedicated and brought to the cardiovascular laboratory. The right inguinal region is prepped and draped in the usual sterile fashion. Local cutaneous anesthesia was obtained with 1% Lidocaine. A 6 French sheath was inserted antegrade into the right femoral artery. It was kinked and was replaced with a 6 French Arrow sheath. Findings: Selective injections into the right femoral artery revealed diffuse irregularities of the superficial femoral artery with a 95 percent mid to distal stenosis and a 60 percent distal stenosis. The distal popliteal artery had an eccentric 60 percent stenosis. The tibial peroneal trunk was diffusely diseased with sequential 95 percent stenosis present. The anterior tibial and posterior tibial arteries are both occluded. We gave intravenous heparin 2,500 units. The distal vessel was wired with a V18 wire. We then dilated both superficial femoral artery lesions with a 5 x 4 Diamond balloon and achieved good angiographic result. We then elected to approach the tibial peroneal trunk that was a high-grade stenosis leading into the only remaining circulation. This was dilated with a 3 x 4 Diamond balloon. This had satisfactory results, but we elected to stent this for a better long term patency. We exchanged out the V18 wire for a coronary extra support wire and deployed a 3.5 x 40 mm GR2 coronary stent. This was then post-dilated to high pressures with a 3.5 x 40 mm NC Bandit balloon. We then performed inflations in the popliteal artery with a 4 x 2 Symmetry balloon, also achieving a satisfactory angiographic result. The balloon catheter was then withdrawn. The final angiographic result was excellent, with wide patency from the superficial femoral artery into the peroneal down to the ankle. Following the procedure, an ACT was obtained. The sheath was removed. A strong popliteal pulse was obtained. The patient was transported in stable condition to the recovery unit. Impression: 1. Successful percutaneous transluminal angioplasty of sequential 95 and 60 percent mid and distal superficial femoral artery lesions. 2. Successful percutaneous transluminal angioplasty of a 60 percent popliteal lesion. 3. Successful percutaneous transluminal angioplasty of diffuse 95 percent tibial peroneal trunk stenosis with stenting producing a residual stenosis to 0 percent. Which angioplasty codes are correct to report?

" 37230, 37224-51 Treatment of lesions in the femoral popliteal artery and stenosis in the tibial peroneal trunk to restore blood supply (revascularization) using angioplasty with placement of a stent in the tibial peroneal trunk is being performed. 37224 is coded for the angioplasty in the femoral-popliteal artery. Look in the CPT® Index for Revascularization/Artery/Femoral-Popliteal, 37224-37227. Angioplasty was performed in the femoral artery and in the popliteal artery; therefore, the correct code is 37224. Look in the CPT® Index for Revascularization/Artery/Tibial/Peroneal which directs the coder to 37228-37235. Angioplasty and stent placement were performed; therefore, the correct code is 37230. Modifier 51 denotes additional procedures performed during the same session.

"CASE 6 Preoperative Diagnosis: Multiple varicose veins with severe leg pain. Postoperative Diagnosis: Same. Procedure: Removal of multiple varicose veins, right lower leg, involving both the greater and lesser saphenous systems. Anesthesia: General. Procedure: With the patient prepped and draped in the usual sterile manner, multiple small incisions were made over the patient's varicose veins in the right leg. Through these incisions multiple clusters and branches from the greater saphenous vein and lesser saphenous veins were removed. Starting at the saphenofemoral junction, dilated tortuous segments of the greater saphenous vein and lesser saphenous vein were also removed. Most of the greater saphenous vein was removed to well below the knee. Meticulous hemostasis was achieved. All perforators associated with these clusters were ligated with 3-0 Vicryl suture. The patient's leg was wrapped in sterile Webril and Ace wrap. There were no complications. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 37722-RT, 37718-51-RT, I83.811

" An operative report lists excisional bilateral biopsies of deep cervical nodes and biopsy of right deep axillary nodes as the procedures performed. The pathology report comes back confirming lymphadenitis. What CPT® codes are reported?

" 38510-50, 38525-51-RT In the CPT® Index look for Lymph Nodes/Biopsy and you are directed to a series of codes. Turn to codes 38500 and 38510-38530. Code 38510 represents the deep cervical nodes and the 50 modifier indicates that they were excised bilaterally. Next, look to code 38525. This code is appropriate for reporting the deep axillary nodes excised. The RT modifier indicates these lymph nodes were taken only from the right side and modifier 51 indicates multiple procedures performed at the same session.

" " A 45 year-old patient with liver cancer is scheduled for a liver transplant. The patient's brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient. What CPT® codes are reported?

" 47140, 47146, 47147, 47135 In the CPT® Index, look for Hepatectomy/Partial/Donor referring you to 47140-47142. Code 47140 represents the portion of the liver taken from the donor. Next, look in the CPT® Index for Transplantation/Liver/Allograft Preparation referring you to 47143 - 47147. Segments II and III are to be allotransplanted. Codes 47146 and 47147 represent the backbench work with venous and arterial anastomosis. A vein and an artery are anastomosed so only report each of these codes one time. For the final code, look in the CPT® Index for Transplantation/Liver/Allotransplantation referring you to 47135; this represents the orthotopic allotransplantation into the patient.

"CASE 5 Preoperative Diagnoses 1. Sarcoid of lymph nodes(Diagnosis if no further positive findings are found in the operative note.) 2. New onset paratracheal adenopathy(Diagnosis if no further positive findings are found in the operative note.) Postoperative Diagnoses 1. Sarcoid of lymph nodes 2. New onset paratracheal adenopathy Procedure Performed: Mediastinotomy(Indication of what procedure is being performed.) Description of Procedure: The patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia was administered by the anesthesia department. The neck was prepped in standard fashion with betadine scrub, sterile towels and drapes. A standard linear incision was made over the trachea.(Procedure performed with the anterior cervical approach.) We were able to dissect down the pretracheal fascia into the mediastinum without difficulty. The extensive adenopathy was immediately apparent just below the innominate artery on the right paratracheal side. One exceedingly large lymph node was identified and biopsied extensively.(Biopsy performed.) The specimen was sent to pathology. Hemostasis was obtained without difficulty. The region was infused with a marcaine, lidocaine, and epinepherine mixture. The wound was closed in layers. The skin was closed with subcutaneous stitches and covered with Dermabond. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 39000, D86.1, R59.0

"CASE 2 Procedure: Uvulopalatopharyngoplasty. (The procedure is to repair the uvula and tonsils.) Indication: A 63-year-old with obstructive sleep apnea. He is intolerant of CPAP. Description of Procedure: I identified the patient and he was brought to the operating room. General endotracheal anesthesia was induced without complication. Tonsillar pillars and palate were injected with 0.25% Marcaine. The right tonsil was grasped with an Allis forceps and dissected from the tonsillar fossa(Right tonsillectomy. It's not billable because it's included in the primary procedure.) with a combination of blunt and cautery dissection. The posterior pillar remained intact as I proceeded to do similar mobilization of the left tonsil.(Left tonsillectomy. It's not billable because it's included in the primary procedure - cannot be unbundled.) I then made a mucosa incision across the base of the palate approximately 0.5 cm from the base of the uvula, connecting the anterior tonsillar incisions. The muscular portion of the uvula and edge of the soft palate was then opened. Posterior pillar was opened inferiorly on the right tonsil fossa, and extended through the palate to include the uvula, and then extended inferiorly on the left side. The uvula, edge of the soft palate, and both tonsils were removed in total. Hemostasis was achieved with electrocautery. The mucosal incision was then closed with interrupted Vicryl sutures. The oral cavity was irrigated with clindamycin solution. The patient was awakened, extubated, and brought safely to the recovery room. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM code: [b]

" 42145, G47.33

" " A 7 year-old female presents to the same day surgery unit for a tonsillectomy. During the surgery the physician notices the adenoids are very inflamed and must be taken out as well. The adenoids, although not planned for removal, are removed following the tonsillectomy. What CPT® code(s) is/are reported for the procedure?

" 42820 In the CPT® Index look for Tonsils/Excision/with Adenoids directing you to 42820-42821. Code 42820 represents the removal of both the tonsils and adenoids. These are age specific codes and 42820 represents anyone younger than age 12.

"CASE 9 PREOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. POSTOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. NAME OF PROCEDURE; Bilateral ventilation tube placement, Donaldson-Activent type, Adenoidectomy. ANESTHESIA: General ESTIMATED BLOOD LOSS: Less than 5 ml. FINDINGS: The patient is an 18 month old white male with a history of the above noted diagnosis. Operative findings included bilateral thickened drums. He had a right and left serous effusion. The left was aerated for the most part. He had an intact palate and a 3-4 + adenoid pad. TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General mask anesthesia was induced. Appropriate drapes were placed. Attention was turned to the right ear. The external canal was cleaned of cerumen and irrigated with alcohol. A radial incision was made in the right tympanic membrane. Middle ear was evacuated of effusion and Donaldson-Activent tube was followed by Ciprodex otic drops. The same procedure was performed on the contralateral side. The bed was turned 30° m clockwise fashion. The Crowe-Davis mouth gag was inserted and suspended. The palate was palpated and felt to be intact. The soft palate was elevated and under direct nasopharyngoscopy. The adenoid was removed with powered adenoidectomy blade taking care to avoid injury to the Eustachian tube orifice. The base was cauterized with Bovie suction cautery and a pack was placed. After several minutes, the packs were removed. The nasopharynx and oral cavity was irrigated and suctioned free of debris. The stomach was evacuated with orogastric tube. Re-evaluation showed no further active bleeding. Further drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken, extubated and transported in stable condition to the recovery room having tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b] ICD-10-CM codes: [c], [d]

" 42830, 69436-50-51, J35.2, H65.93

" A 12 year-old patient had an adenoidectomy in 2013 and a second adenoidectomy this year. What CPT® code(s) is/are reported for the second adenoidectomy performed this year?

" 42836 Sometimes adenoid tissue, even after it has been removed, will grow back when a few cells are left behind. For the removal of the secondary adenoid tissue, report code 42836 which represents the secondary adenoidectomy. Look in the CPT® Index for Adenoids/Excision with a code range of 42830-42836. In this case, the patient is over 12 years of age upon presentation for the secondary adenoidectomy, further supporting the criteria for 42836.

" " What is the CPT® code for removal of a foreign body from the esophagus via the thoracic area?

" 43045 In the CPT® Index, look for Esophagus/Removal/Foreign Bodies which directs you to 43020, 43045, 43194, 43215, 74235. There are two open approaches and two endoscopic approaches in the CPT® code book for the removal of a FB from the esophagus. 43020 is via a cervical approach and 43045 is via a thoracic approach, making code 43045 the correct choice.

" What CPT® coding is reported when a physician makes two separate incisions to perform a laparoscopic appendectomy and laparoscopic cholecystectomy?

" 47562, 44970-59 Code 47562 represents the laparoscopic cholecystectomy. In the CPT® Index look for Laparoscopy/Biliary Tract/Cholecystectomy or Cholecystectomy/Laparoscopic. You are directed to 47562-47564. Next, look in the CPT® Index for Laparoscopy/Appendix/Appendectomy. This directs you to 44970. Both codes can be reported because the physician made two separate laparoscopic site incisions to remove the gallbladder and appendix. We indicate this by appending modifier 59 to the 2 nd code.

"CASE 10 Preoperative diagnosis: Large right inguinal hernia. Bilateral undescended testes. Postoperative diagnosis: Bilateral inguinal hernias. Undescended testes. Procedure performed: Bilateral orchiopexy and bilateral inguinal hernia repairs as well as circumcision on a 10-year-old patient. Estimated blood loss: Less than 5 ml. Complications: None. Description of procedure: After informed consent had been obtained previously and reviewed again in the preoperative area, the patient was brought back to the OR, placed supine and general anesthesia was induced without problems. It was somewhat difficult to find an IV site, because of the patient's body habitus. However, there were no complications with anesthesia. The patient was then appropriately padded and prepped and draped in sterile fashion. 0.25% Marcaine plain was used for bilateral inguinal blocks as well as injected in the sub-q in the inguinal crease. I began on the right-hand side, where he had an intermittent right inguinal bulge for several months. A scalpel was used to make a skin incision following the creases and this was extended down through very generous subcutaneous fat and Scarpa's fascia to expose the external oblique aponeurosis. The external ring was identified as was the ilioinguinal ligament. The ring was opened for a short distance. The testis was high in the scrotum and was brought through. The gubernaculum was then divided. A very large hernia sac was carefully opened and very carefully dissected down to the level of the internal ring. There did not appear to be abdominal contents within the hernia sac., It was then twisted and suture ligated at the base. The hernia sac was then sent to pathology. The testis was pink and viable. A dartos pouch was created and the testis brought through it. The neck of the pouch was tightened with a few interrupted sutures of 3-0 Vicryl. Care was taken to make sure it did not twist the testicle that the testis lay in a normal anatomical position. The scrotal incision was then closed with 5-0 plain gut. The external ring was recreated by approximating the aponeurosis of the external oblique. The underlying ilioinguinal nerve was identified and spared. Scarpa's was approximated with 3-0 Vicryl and the skin closed with 5-0 Monocryl in a running subcuticular stitch. Steri-strips and dressing were placed over this. On the left-hand side initially, his testis was felt to be almost nonpalpable but on exam under anesthesia it again was within the high scrotum. With gentle pressure, I could make this essentially disappear into his abdomen suggesting a large communicating hydrocele. I made the decision to proceed with inguinal hernia repair and exploration. Again, he had a Marcaine inguinal block and the skin was also anesthetized with 0.25% Marcaine. A matching incision was made with a scalpel following the skin creases. This was extended down through subcutaneous tissues and Scarpas to expose the external oblique and the external ring. It was then twisted and suture ligated at the base with 3-0 Vicryl. The hernia sac was also sent to pathology. At this point, there was sufficient length to easily bring the testis into the scrotum. A dartos pouch was created and the testis was brought into it with care taken to make sure we did not twist the cord structures. The neck of the pouch was tightened with 3-0 Vicryl, and then the scrotal incision closed with 5-0 plain gut in an identical fashion. The external oblique was approximated with a few interrupted sutures of 3-0 Vicryl, to recreate the ring. Again, care was taken to preserve the underlying ilioinguinal nerve. Scarpa's was approximated 3-0 Vicryl, as well, and the skin was closed with Monocryl. Steri-Strips and dressing were placed over, this as well. 0.25% Marcaine plain was then used for a penile block. A circumcising incision was made approximately 3mm below the coronal margin and the penis partially degloved. Meticulous hemostasis was obtained with Bovie cautery. The excess prepuce was trimmed. It was then discarded. The skin edges were approximated with 5-0 plain gut in a running fashion x 2. Hemostasis was excellent. The glans head appeared normal. A dressing of conform and Vaseline gauze was applied. The patient was then extubated and sent to the recovery in stable condition. No complications. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code(s): [a], [b], [c] ICD-10-CM code(s): [d], [e], [f]

" 49505-50, 54640-50-51, 54161-51, K40.20, Q53.23, Z41.2

"CASE 3 Extent of Examination: Upper gastrointestinal endoscopy. Reason(s) for Examination: Gastroesophageal Reflux Disease (GERD).(This shows medical necessity for the procedure.) Description of Procedure: Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to upper GI endoscopy were explained. The patient agreed to proceed. No contraindications were noted on physical exam. Anesthesia was administered by the ICU staff. (See anesthesiologist report) Monitored anesthesia care (MAC) was administered by anesthesia team. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted through the mouth to the second part of the duodenum. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols. Findings: The esophagus was examined and no abnormalities were seen. The gastroesophageal junction (upper level of gastric folds) was located 40cm from the incisors. The stomach was examined and no abnormalities were seen. The small bowel was examined and no abnormalities were seen.(An upper gastrointestinal endoscopy to the duodenum was performed.) What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM code: [b]

" 43235, K21.9

" What CPT® code(s) is/are reported for an endoscopic direct placement of a percutaneous gastrostomy tube for a patient who previously underwent a partial esophagectomy?

" 43246 Code 43246 represents the direct percutaneous placement of a gastrostomy tube. We do not code for the partial esophagectomy (43116) because it was not performed at this time but was done prior to the tube placement. The code is indexed in CPT® under Endoscopy/Gastrointestinal/Upper/Tube Placement which refers you to code 43246. There are a couple of other ways to find this in the Index. It helps to remember anatomy and that each surgical section in CPT® has a diagram for you to review. The esophagus is part of the upper GI tract.

" A 66 year-old female is admitted to the hospital with a diagnosis of stomach cancer. The surgeon performs a total gastrectomy with formation of an intestinal pouch. Due to the spread of the disease, the physician also performs a total en bloc splenectomy. What CPT® codes are reported?

" 43622, 38102 In the CPT® Index, look for Gastrectomy/Total, you are directed to 43620-43622. A review of the code descriptors confirms CPT® code 43622 represents the complete gastrectomy with intestinal pouch formation. Code 38102 represents the en bloc total splenectomy and is an add-on code so it is modifier 51 exempt. In the CPT® Index, look for Splenectomy/Total/En bloc which directs you to 38102.

"CASE 10 Preoperative Diagnosis: Severe obesity. Hypertension. BMI 53. Postoperative Diagnosis: Severe obesity. Hypertension. BMI 53. Procedure Performed: Laparoscopic antecolic Roux-en-Y gastric bypass with 150 alimentary limb, and a 40 cm biliopancreatic limb. Anesthesia: General endotracheal anesthesia. Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. CO2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All of this was done under appropriate videoscopic observation. The procedure begins with identification of the gastroesophageal junction and dissection of the angle of His. On the lesser curvature of the stomach, a window is dissected into the lesser sac. A linear stapler is passed, and the stomach is transected. Reinforcement of the staple line was done with a continuous absorbable seromuscular suture, creating a pouch approximately 50 cc in diameter. An Ewald tube is used to calibrate the pouch. At this point, the ligament of Treitz is identified and 40 cm from the ligament of Treitz, the small bowel was transected. The distal limb of the small bowel is then brought to the upper abdomen, and a side-to-side gastrojejunostomy between the pouch and the alimentary limb is performed with a linear stapler. The gastrojejunostomy site is then closed with a double layer of running 2-0 Vicryl sutures. The anastomosis was observed for leakage with air and Methylene blue. There was no evidence of leakage. I then proceeded 150 cm distal from the gastrojejunostomy. A side-to-side jejunojejunostomy was created between the biliopancreatic limb and alimentary limb. This was performed using two applications of the linear stapler. The jejunojejunostomy site was closed with several applications of the linear stapler. Hemoclips were applied to the suture line for hemostasis. Good hemostasis was evident. A 19 French Blake drain was placed over the gastrojejunal anastomosis. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. The trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. She was extubated on the OR table and transferred to the recovery room in stable condition. There were no complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 43644, E66.01, I10, Z68.43

"CASE 6 Preoperative Diagnosis: Morbid obesity. Sleep apnea. BMI 40. Postoperative Diagnosis: Morbid obesity. BMI 40. Procedure Performed: Laparoscopic sleeve gastrectomy. Intraoperative esophagogastroduodenoscopy. Intraoperative endoscopy Anesthesia: General endotracheal anesthesia. Operative Procedure: The patient was brought to the operating room and placed on the OR table in supine position. Once general endotracheal anesthesia was achieved and pre-op antibiotics were given, the abdomen was prepped and draped in the standard surgical fashion. Access to the abdominal cavity was through a 1 cm supraumbilical incision with an Optiview trocar. Co2 was insufflated to achieve an intraabdominal pressure of approximately 15 mmHg. Accessory trocars were placed in the subxiphoid, right, mid, and left upper quadrants of the abdomen, as well as in the right and left lower quadrants of the abdomen. All this was done under appropriate videoscopic observation. The pyloric channel was then identified and approximately 4 cm proximal to it, the short gastric vessels of the greater curvature are taken down all the way up to the GE junction with the harmonic scalpel. A 38 french bougie is passed into the stomach into the pyloric channel and with the help of the linear cutter, the stomach is transected in a vertical fashion creating a gastric tube which is approximately 100 mm in diameter. The staple line is then over sewn with a running 2-0 Vicryl suture. Good hemostasis was achieved. Then I performed intraoperative esophagogastroduodenoscopy. The scope was advanced through the oropharynx, and under direct vision it was taken down through the esophagus and into the sleeve. There was no evidence of leak, bleeding, or any other abnormalities. A patent sleeve was seen all the way down to the pylorus. The scope was then retrieved carefully. A placement of a drain through the subhepatic space and extraction of the specimen through a right lower quadrant incision was done. All trocars were removed under appropriate videoscopic observation. There was no evidence of bleeding from any of the trocar sites. All the trocar sites were suture closed and injected with local anesthesia. The patient tolerated the procedure well. He was extubated on the table and transferred to the recovery room in stable condition. There were no complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code(s): [a] ICD-10-CM code(s): [b], [c]

" 43775, E66.01, Z68.41

"Look up the procedures in the CPT® codebook and list the CPT® code. No modifiers are necessary for this exercise. Pyloroplasty

" 43800

"CASE 1 Preoperative Diagnosis: Right-sided colonic polyps. Postoperative Diagnosis: Right-sided colonic polyps. Procedure: Laparoscopic right hemicolectomy with ileocolic anastomosis. Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine, modified-lithotomy position and Allen stirrups. Great care was taken to carefully pad and protect all areas of potential bodily injury. The abdomen was prepped and draped in the usual sterile manner.(Positioning and draping the patient is standard of care - not billable.) Using a supra-umbilical vertical incision, a Hasson technique(Type of laparoscopic approach. The Hasson technique employs an open type of port insertion site for laparoscopic procedures.) was employed to carefully place a 10 mm cannula. Carbon dioxide pneumoperitoneum of 15 mmHg was achieved, after which a 30-degree telescope was carefully introduced. Under direct vision, two left-sided ports were placed: one in the left lower quadrant, one in the left upper quadrant, each lateral to the epigastric vessels through horizontal stab wounds.(Placement of the trocars for visualization into the abdominal cavity.) With a combination of head up, head down, and right side up, the entire right colon was mobilized from the duodenum, pancreas, and right ureter, using 10 mm diameter Babcock grasping forceps and 5 mm diameter harmonic scalpel.(The colon is freed away from it's attachments to other structures. The Babcock grasper holds the colon in place while the harmonic scalpel cuts away the connections.) After complete mobilization and copious irrigation and verification of meticulous hemostasis, the supraumbilical port was lengthened to 4 cm, through which an Alexis wound protector was placed. The entire right colon was withdrawn.(Pulled to outside the cavity through the extended incision.) High ligation of the ileocolic arcade and the right branch of the middle colic(The division of the colon.) were undertaken using 10 mm diameter LigaSure Atlas.(Device used to seal or divide the circulation to that portion of the bowel slated for removal.) The Atlas was used for the remaining mesentery. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapler with a blue cartridge. The field was draped with blue towels, and the antimesenteric border of each staple line was excised along with the terminal ileum. A side-to-side, functional end-to-end anastomosis was fashioned between the remaining ileum and colon with a GIA 100 mm stapling device with a blue cartridge.(Reattachment of the two ends of the colon: ileocolostomy.) The staple line was verified for hemostasis, after which the afferent limb was secured to the efferent limb with 3-0 PDS II seromuscular Lembert-type sutures. After verification of anastomotic hemostasis, the apical enterotomy was also secured with a GIA 100 mm stapling device with a blue cartridge. The anastomosis was healthy, pink, widely patent, circumferentially intact, and easily returned into the peritoneal cavity.(The externalized colon is reinserted into the abdominal cavity after it is checked for hemostasis and perfusion.) After copious irrigation and verification of meticulous hemostasis, the fascia was closed with interrupted No. 1 Vicryl plus figure-of-eight sutures. The subcutaneous layers were irrigated and meticulous hemostasis was verified. Port sites were closed in a similar manner. The skin was closed and covered by dry dressings,(After the trocars are removed, the stab sites are sutured closed.) and the patient was discharged to the recovery room in stable condition, without having suffered any apparent operative complications. What are the CPT® and ICD-10-CM codes for this service? CPT® code(s): [a] ICD-10-CM code(s): [b]

" 44205, K63.5

" A 23 year-old woman presents with sudden LLQ (left lower quadrant) pain which does not resolve. The decision is made to perform exploratory laparoscopy revealing a cyst on the left ovary. The cyst is removed along with a partial oophorectomy. What is/are the CPT® code(s) reported for this procedure?

" 58661 Even though the patient started with a diagnostic (exploratory) laparoscopy it turned into a surgical laparoscopy. You cannot bill both procedures separately. Diagnostic laparoscopy is always included in a surgical laparoscopy. There was removal of the left ovary (partial oophorectomy) with the cyst. In the CPT® Index, look for Ovary/Laparoscopy directing you to codes 58660-58662, 58679. Reviewing the codes, 58661 is the correct code for the partial oophorectomy.

"CASE 5 Preoperative Diagnosis: History of rectal carcinoma. Postoperative Diagnosis: History of rectal carcinoma. Procedure Performed: Closure of loop ileostomy with small bowel resection and enteroenterostomy with intraoperative flexible sigmoidoscopy. Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine modified lithotomy position in Allen stirrups.(Lying on back with legs in stirrups.) Great care was taken to pad and protect all areas of potential bodily injury. Digital rectal examination revealed a widely patent circumferentially intact pouch anal anastomosis within 1 cm of the dentate line. Flexible sigmoidoscopy was performed revealing healthy pink mucosa. The abdomen was prepped and draped in the usual sterile manner, and a parastomal incision(Cutting around the ostomy opening to release it from the abdominal wall and surrounding area.) was made and carried down sharply into the peritoneal cavity. Meticulous hemostasis was obtained with electrocautery. A 360 degree subfascial mobilization was undertaken until approximately 40 cm of each the afferent and efferent limb reached above the skin in a tension-free manner. Betadine was insufflated down each limb to verify that no enterotomies or seromyotomies were made.(Verification that the colon is without injury or puncture from the dissection.) The mesentery was scored and vessels were divided with a 10 mm LigaSure Impact. The bowel was circumferentially cleared of fat proximally and distally, and each end was divided with a GIA 100 mm stapling device with blue cartridge. The field was protected with blue towels and the antimesenteric border of each staple line was excised. A side-to-side functional end- to-end anastomosis was fashioned with a GIA 100 mm stapling device.(Reattachment of the two ends of the colon in a side-by-side fashion.) The staple line was reinforced for hemostasis with 3-0 PDS 2 suture where necessary and the afferent limb was secured to the efferent limb with 3-0 PDS 2 seromuscular Lembert type sutures. After verification of the meticulous hemostasis, the apical enterotomy was secured with a GIA 100 mm stapling device. The anastomosis was healthy pink and widely patent and circumferentially intact and easily returned into the peritoneal cavity, after copious irrigation and verification of meticulous hemostasis. What are the CPT® and ICD-10-CM codes for this service? CPT®: [a] ICD-10-CM : [b], [c]

" 44625, Z43.2, Z85.048

"CASE 4 Extent of Examination: Proximal sigmoid colon. Reason(s) for Examination: Proctitis. Postoperative assessment: Proctitis. Description of Procedure: Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to sigmoidoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Patient was re-examined and no interval changes were noted from the preoperative history & physical. After being placed on the table, patient identification was verified prior to the procedure. Immediately prior to sedation for endoscopy the patient's ASA classification was Class 2: Mild systemic disease. Monitored anesthesia care (MAC) was administered by the anesthesia team.(This is important for the anesthesiologist.) The quality of the prep was adequate. Prior to the exam, a digital exam was performed and it was unremarkable. The procedure was performed with the patient in the left lateral decubitus position. The sigmoidscope was inserted to the proximal sigmoid colon.(This is pertinent as the correct code is selected by the level of exam in the colon.) In the rectum, a retroflex was performed. The withdrawal time from the proximal sigmoid colon was 8 minutes. The patient tolerated the procedure well. There were no complications. The heart rate was normal. The oxygen saturation and skin color were normal. IV moderate sedation was administered under direct supervision of the physician. Upon discharge from the endoscopy area, the patient will be recovered per established procedures and protocols. Findings: In the rectum, mild segmental inflammation with erythema(These are the symptoms of proctitis; only use symptoms in the absence of a definitive diagnosis.) was seen. There was no mucosal bleeding. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM code: [b]

" 45330, K62.89

"CASE 9 Extent of Examination: Terminal ileum. Reason(s) for Examination: Hx of rectal cancer s/p Low Anterior Resection (LAR) and colonic J pouch for closure of loop ileostomy. Description of Procedure: Informed consent was obtained with the benefits, risks, including the risk of perforation and alternatives to colonoscopy explained. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered. The bowel was prepared with Fleets enemas. The quality of the prep was fair. Prior to the endoscopic exam, a digital rectal exam was performed and it was unremarkable. The procedure was performed with the patient in the left lateral decubitus position. The cecum was identified by the ileocecal valve. The withdrawal time from the cecum was 7 minutes. The patient tolerated the procedure well. There were no complications. The exam was limited by poor preparation. Findings: At the splenic flexure, moderate inflammation with erythema, granularity, friability, and hypervascularity was seen. There was no mucosal bleeding. In the proximal descending colon, moderate segmental inflammation with erythema, granularity, friability, and hypervascularity. In the rectum an abnormality was noted. Anastomosis is patent and normal. No evidence of polyp. Just proximal prior to anastomosis - significant diffuse colitis was noted. What are the CPT® and ICD-10-CM codes for this service? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 45378, K52.9, 85.048

"CASE 8 Extent of Examination: Terminal ileum. Reason(s) for Examination: Anemia, Fe Deficiency Description of Procedure: Informed consent was obtained and I explained about the benefits, risks, including the risk of perforation and alternatives to colonoscopy. The patient agreed to proceed. No contraindications were noted on physical exam. Monitored anesthesia care (MAC) was administered by the anesthesia team. The bowel was prepared with GoLYTELY prep. The quality of the prep is based on the Ottawa bowel preparation quality scale. Total score: Right: 1 + Middle: 1 + Left: 1 + Fluid: 0 = 3/14. Prior to the exam, a digital exam was performed; hemorrhoids were noted. The procedure was performed with the patient in the left lateral decubitus position. The instrument was inserted in the anus and advanced to the terminal ileum. The cecum was identified by the following: the ileocecal valve and the appendiceal orifice. In the rectum, a retroflex was performed. The patient tolerated the procedure well. There were no complications. Findings: In the rectum, a few medium-size uncomplicated internal hemorrhoids were seen. The internal hemorrhoids were not bleeding. There was no evidence of inflammation, friability, granularity, or bleeding. Biopsy were taken. In the ascending colon and cecum there was mild granularity and red spots that were nonspecific and possibly due to air insufflation. No friability, ulcerations or bleeding. Biopsy taken. The remainder of the colon was normal. The terminal ileum was normal. What are the CPT® and ICD-10-CM codes for this service? CPT code: [a] ICD-10-CM codes: [b], [c]

" 45380, D50.9, K64.8

" A patient is seen in the gastroenterologist's clinic for a diagnostic colonoscopy. When performing the service, the physician notes suspicious looking polyps and removes three using a snare technique to send to pathology for further testing. What is/are the correct CPT® code(s) to report?

" 45385 A surgical endoscopy always includes a diagnostic endoscopy so only the surgical is reported. Reporting 45385 is the correct code for the colonoscopy with removal of polyps by snare technique. In the CPT® Index, look for Colonoscopy/Flexible/Removal/Polyp which directs you to 45384, 45385. Reviewing the descriptions of both codes directs you to 45385 which includes use of snare technique.

"CASE 5 Preoperative diagnosis: Left renal calculus. Postoperative diagnosis: Left renal calculus.(This is the diagnosis to report if there are no further positive findings are found in the operative note.) Procedure: ESWL 2300 shocks at 22kV. Description of Procedure: The KUB was reviewed, revealing a lower caliceal calculi on the left. The patient was anesthetized and positioned on the lithotripsy table. The stone was targeted and treated with 60 shocks for 2 minutes, and then a 2-minute pause was carried out. We then resumed at 60 slowly working up to 120, for a total of 1800 shocks on the lower pole, which completely disappeared.(Lithotripsy.) We then shocked the tip of the stent with 500 shocks as calcification was seen there on the prior KUB, but it was unclear on today's KUB with fluoro whether that was still present. The patient appeared to tolerate the procedure well, and he was brought to the recovery room in stable condition. He will follow up in 1 week for possible stent removal as KUB prior to the procedure. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code(s): [a] ICD-10-CM code(s): [b]

" 50590-LT, N20.0

"CASE 4 Preoperative Diagnosis: RT ureteral stones. Postoperative Diagnosis: RT ureteral stones. (This is the diagnosis to report as the pre and post-operative diagnoses match and the diagnosis is supported in the operative report.) Operation: Open right ureterolithotomy. Intraoperative Findings: The patient had marked inflammatory reaction around the proximal ureter, just below the renal pelvis. Multiple stone fragments were embedded in the edematous ureteral lining. Procedure: The patient was placed on the operating room table in the supine position. General anesthesia was induced. He was then placed in a right flank up position. An incision was made off the tip of the 12th rib, and dissection was carried down through skin, fat and fascia to open the lumbodorsal fascia entering the retroperitoneal space.(This indicates the surgery was performed by open approach.) The peritoneum was swept anteriorly. Careful dissection was then carried down in the retroperitoneal space to first identify the vena cava and then to identify the renal vein. Once these structures were localized, the ureter was identified. Careful dissection was done to mobilize the ureter and to identify the area of the stone impaction by palpation. The ureter was then opened longitudinally and the ureteral stent was identified. The multiple embedded stone fragments were then removed from the ureteral lumen. (Surgical removal of the stone from the ureter.) The ureteral lumen was then irrigated copiously, and no other stone fragments were identifiable. The ureterotomy was then re-approximated with interrupted sutures of 5-0 chromic. Inspection showed good hemostasis. Sponge and needle counts were correct, and closure was begun after placement of a Blake drain through separate inferior stab wound. Marcaine 0.5% with no epinephrine was used to infiltrate the intercostal nerves. The wound was then closed in layers with muscle and fascial approximation with #1 Vicryl. The skin was closed with staples. Sterile dressings were applied. The patient returned to the recovery area in satisfactory condition. What are the CPT® and ICD-10-CM codes reported for this procedure? CPT® code: [a] ICD-10-CM code: [b]

" 50610, N20.1

"CASE 7 Preoperative diagnosis: Intrinsic sphincter deficiency. Stress Incontinence. Postoperative diagnosis: Intrinsic sphincter deficiency. Stress Incontinence. Procedure: Cystoscopy with Durasphere injection. Estimated Blood Loss: Less than 5cc. Complications: None. Counts: Correct. Indications: This is a very pleasant female with intrinsic sphincter deficiency causing urinary incontinence. She understood the risks and benefits of the procedure, and she elected to proceed. Procedure Description: The patient was brought to the operating room and placed on the operating room table in the supine position. After adequate LMA anesthesia was accomplished, she was prepped and draped in the usual sterile fashion. A 21-French cystoscope was introduced in the patient's urethra. Her urethra was fairly pale, not well approximated, and was patulous. We injected 2 ½ syringes of Durasphere material into the urethra but were unable to get anymore than that amount into the tissue. There was moderate approximation of the urethral mucosa. The bladder was emptied and lidocaine jelly instilled. She was extubated and taken to the recovery room in good condition. Disposition: The patient was taken to the post anesthesia care unit and then discharged home. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code(s): [a] ICD-10-CM code(s): [b], [c]

" 51715, N36.42, N39.3

" The patient presents to the office for cystometrogram (CMG). Complex CMG with voiding pressure studies is done. Intraabdominal voiding pressure studies and complex uroflowmetry are also performed. What CPT® code(s) is/are reported for this service?

" 51728, 51797, 51741-51 In the CPT® Index look for Cystometrogram directing you to 51725-51729. Code 51728 describes a Complex cystometrogram with voiding pressure studies. In the CPT® Index look for Voiding Pressure Studies/Abdominal directing you to 51797. Add-on code 51797 is used for intra-abdominal voiding pressure studies. The parenthetical directs us to use 51797 in conjunction with 51728 or 51729. Code 51741 is used to report the complex uroflowmetry. The procedures were performed in the office setting, under the direct supervision of the provider and you would not use modifier 26 for the professional component. When multiple procedures are performed in the same investigative session modifier 51 is appended.

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Reduced services Do not type the word "Modifier" for your answer.

" 52

"CASE 6 Preoperative diagnosis: Ta grade 3 transitional cell carcinoma (TCC) bladder CA in January 2010 Postoperative diagnosis: Ta grade 3 transitional cell carcinoma (TCC) bladder CA in January 2010; now 2 new bladder lesions. Operation: Cystoscopy. Anesthesia: Local. Findings: There were 2 tiny papillary lesions in the posterior wall of the bladder; otherwise, the cystoscopy was negative. Procedure description: A flexible cystoscope was introduced into the patient's urethra. A thorough cystoscopic examination was done. Bilateral ureteral orifices were visualized effluxing clear yellow urine. All sides of the bladder were inspected, and retroflexion was performed. Cytology was sent. Plan: We will schedule the patient for a bladder biopsy at the next available date. What CPT® and ICD-10-CM codes are reported for this procedure? CPT® code(s): [a] ICD-10-CM code(s): [b], [c]

" 52000, N32.9, Z85.51

"CASE 1 Preoperative diagnosis: Desire for circumcision. Postoperative diagnosis: Desire for circumcision. (This is the diagnosis to report for this surgery if there are no further findings in the operative note.) Procedure: Circumcision. Anesthesia: General. Indications: The patient is a 19-year-old (The age of the patient.) white male, sexually active for two years. He requests circumcision. He understands the risks and benefits of circumcision. Procedure Description: The patient was brought to the operating room and placed on the operating room table in the supine position. After adequate LMA anesthesia was accomplished he was given a dorsal penile block and a modified ring block with 0.25% Marcaine plain. (This is the type of penile nerve block provided for the circumcision.) Two circumferential incisions (Surgical incision is made, as using a clamp or device is usually reserved for infants.) were made around the patient's penis to allow for the maximal aesthetic result. Adequate hemostasis was then achieved with the Bovie, and the skin edges were reapproximated using 4-0 chromic simple interrupted sutures with a U-stitch at the frenulum. The patient was extubated and taken to the recovery room in good condition. Disposition: The patient was taken to the post anesthesia care unit and then discharged home. What CPT® and ICD-10-CM codes should be reported? CPT® code(s): [a] ICD-10-CM code(s): [b]

" 54161, Z41.2

"CASE 9 Preoperative diagnosis: Transitional cell carcinoma in the bladder. Postoperative diagnosis: Transitional cell carcinoma in the bladder. Procedure: Cystoscopy; Excision bladder tumor -1 cm. Bilateral retrograde pyelogram. Cytology of bladder. Anesthesia: General. Estimated Blood Loss: 10 cc. Complications: None. Counts: Correct. Indications: The patient is a 58 year-old male status post partial cystectomy for transitional cell carcinoma of the bladder. He understood the risks and benefits of today's procedure, and elected to proceed. Procedure Description: The patient was brought to the operating room, placed on the operating room table, and placed in the supine position. After adequate LMA anesthesia was accomplished he was put in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. A 21-French rigid cystoscope was introduced through the urethra and a thorough cystourethroscopy was performed. A 1 cm tumor was noted on the posterior bladder wall. The tumor was resected without complications. We obtained bladder cytology and performed a retrograde pyelogram, which showed no filling defects or irregularities. The bladder was emptied, and lidocaine jelly was instilled in the urethra. He was extubated and taken to the recovery room in good condition. Disposition. The patient was taken to the post anesthesia care unit and then discharged home. Bilateral Retrograde Pyelogram Interpretation A bilateral retrograde pyelogram was performed, which showed no filling defects or irregularities. What are the CPT ® and ICD-10-CM for this procedure? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 52234, 74420-26, C67.4

"CASE 8 Preoperative diagnosis: Gross hematuria. Postoperative diagnosis: Bladder/Prostate tumor. Operation: Transurethral resection bladder tumor (TURBT) large (5.3 cm). Anesthesia: General. Findings: The patient had extensive involvement of the bladder with solid and edematous-appearing hemorrhagic tumor completely replacing the trigone and extending into the bladder neck and prostatic tissue. The ureteral orifices were not identifiable. Digital rectal examination revealed nodular, firm mass per rectum. Procedure description: The patient was placed on the operating room table in the supine position, and general anesthesia was induced. He was then placed in the lithotomy position and prepped and draped appropriately. Cystoscopy was done which showed evidence of the urethral trauma due to the traumatic removal of the Foley catheter (patient stepped on the tubing and the catheter was pulled out). The bladder itself showed extensive clot retention. There was papillary and necrotic-appearing nodular tissue mass extensively involving the trigone and the bladder neck and the prostate area. The ureteral orifices were not identified. After consulting with the patient's wife and obtaining an adjustment to the surgical consent, the tumor was resected from the trigone, bladder neck and prostate. Obvious edematous and hemorrhagic tissue was removed. Extensive electrocauterization was done for bleeding vessels. Several areas of necrotic-appearing tissue were evacuated. Care was taken to avoid extending resection into the area of the external sphincter. Digital rectal examination revealed the firm, nodular mass in the anterior rectum. No impacted stool was identified. At the end of the procedure, hemostasis appeared good. Tissue chips were evacuated from the bladder. Foley catheter was inserted. Patient was taken to the recovery room in satisfactory condition. Addendum: The patient had a previous partial prostatectomy and had been found to have T2b N0 MX prostate cancer. On the physical examination today and on the endoscopic exam, it was unclear as to whether the tumor mass was related to the bladder or recurrent prostate cancer. Pathology revealed bladder carcinoma in the trigone and bladder neck, and recurrent prostate cancer. What are the CPT® and ICD-10-CM codes for this procedure? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 52240, C67.0, C67.5, C61

" Benign prostatic hypertrophy with outlet obstruction and hematuria. Operation: TURP Anesthesia: Spinal Description of procedure: The patient was placed on the operating room table in a sitting position and spinal anesthesia induced. He was then placed in the lithotomy position, prepped and draped appropriately. Resection began at the posterior bladder neck and extended to the verumontanum (a crest near the wall of the urethra). Posterior tissue was resected first from the left lateral lobe, then right lateral lobe, then anterior. Depth of resection was carried to the level of the circular fibers. Bleeding vessels were electrocauterized as encountered. Care was taken to not resect distal to the verumontanum, thus protecting the external sphincter. At the end of the procedure, prostatic chips were evacuated from the bladder. Final inspection showed good hemostasis and intact verumontanum. The instruments were removed, Foley catheter inserted and the patient returned to the recovery area in satisfactory condition. What CPT® code is reported for this service?

" 52601 TURP is a Transurethral Resection of the Prostate and reported with 52601. In the CPT® Index, TURP directs you to See Prostatectomy, Transurethral. Prostatectomy/Transurethral directs you to 52601, 52630. A TURP is not a bilateral procedure and is not reported with modifier 50. Code 52630 is reported when it is done for residual or regrowth of the obstructive prostate tissue. Code 52640 describes postoperative procedures on the bladder neck.

" Preoperative diagnosis: Cytologic atypia and gross hematuria Postoperative diagnosis: Cytologic atypia and gross hematuria Procedure performed: Cystoscopy and random bladder biopsies and GreenLight laser ablation of the prostate. Description: Bladder biopsies were taken of the dome, posterior bladder wall and lateral side walls. Bugbee was used to fulgurate the biopsy sites to diminish bleeding. Cystoscope was replaced with the cystoscope designed for the GreenLight laser. We introduced this into the patient's urethra and performed GreenLight laser ablation of the prostate down to the level of verumontanum on, the prostatic crest near the wall of the urethra. There were some calcifications at the left apex of the prostate, causing damage to the laser but adequate vaporization was achieved. What CPT® code(s) is/are reported for this service?

" 52648, 52224-59 Laser vaporization is reported using CPT® code 52648. In the CPT® Index look for Prostate/Vaporization/Laser directing you to 52648. A biopsy is usually not reported at the same time of the laser procedure. In this case, the operative report clearly states that this procedure is a distinct procedure; it is a different procedure from the GreenLight laser ablation and is reported separately using modifier 59. CPT® code 52224 describes cystourethroscopy, with fulguration, with or without biopsy. In the CPT® Index look for Cystourethroscopy/Biopsy.

" A circumcision was performed on a newborn using a dorsal penile nerve block for anesthesia. The provider used a Plastibell for this circumcision. What CPT® code is reported?

" 54150 In the CPT® Index, look for Circumcision/Surgical Excision/Neonate 54150, 54160. A Plastibell is a type of device used in a circumcision. Code 54150 is correct. Modifier 52 is not required; because a dorsal penile nerve block was used. Code 54160 is specific to a surgical circumcision performed with "other than clamp or device" making this code incorrect. Code 54161 describes circumcision for a patient over the age of 28 days making this an incorrect code as well.

" What is the correct coding for a physician who performs an UGI radiological evaluation of the esophagus, stomach and first portion of the duodenum with barium and double-contrast in the hospital GI lab? (Physician is not employed by the hospital)

" 74246-26 A radiological evaluation is an X-ray. UGI stands for Upper Gastrointestinal (GI). Look in the CPT® Index for X ray/Gastrointestinal Tract follow the further pathway given. The first portion of duodenum was performed on making 74246 the most appropriate code. The UGI is performed in the hospital using hospital equipment. The physician is not indicated to be an employee of the hospital so we must report the professional services (component) only by appending modifier 26.

" Patient is a 67 year-old male with chronic orchialgia following a right inguinal hernia repair. He is admitted for scrotal exploration and simple orchiectomy. The patient is brought to the operating room and placed supine on the operating table. After adequate anesthesia was accomplished, he was prepped and draped in the usual sterile fashion; 0.25% Marcaine plain was infused in the skin along his median rhaphe and a 4 cm median rhaphe incision was made. We dissected into his right hemiscrotum and identified his right testis which was small and atrophic. The spermatic cord was identified and separated into 2 sections each section was double tied with #1 silk suture. The testis was then transected from the spermatic cord, distal to the sutures and no bleeding was noted from the stump of the spermatic cord. Scrotal skin was closed in two layers, the first layer with a running stitch of 3-0 Monocryl and the second was a 3-0 chromic in the horizontal mattress. Dermabond was applied over the incision. He was extubated and taken to the recovery room in good condition. What CPT® code(s) is/are reported for this service?

" 54520 The procedure is a simple orchiectomy with only the removal of the testis. The closure of a surgical incision in included in the procedure code and usually not reported separately. In the CPT® Index look for Orchiectomy/Simple. CPT® code 54530 describes a radical orchiectomy which is the removal of the testis and all associated structures. CPT® code 54522 describes the partial excision of one or both testis.

" A 58 year-old man with an enlarging right hydrocele is here for surgical repair. He is taken to the operating room where the hydrocele was enucleated from the skin in dartos fashion and delivered into the wound. It was skeletonized at the equator and then was opened and drained. Excess hydrocele sac tissue was excised with electrocautery. It was then wrapped backward around the spermatic cord and sewn there so it would not reform. There were a few pockets also opened up and skeletonized. The testicle was replaced in the scrotum. What CPT® code is reported for this service?

" 55040-RT A unilateral excision of a hydrocele is described with CPT® code 55040. In the CPT® Index look for Excision/Hydrocele/Tunica Vaginalis. HCPCS Level II modifier RT is used to indicate the right side. CPT® code 55000 describes puncture aspiration of hydrocele. CPT® code 55100 describes the drainage of a scrotal wall abscess.

"CASE 3 Preoperative diagnosis: Prostate cancer. Postoperative diagnosis: Prostate cancer.(This is the diagnosis to report. The pre and post-operative diagnoses are the same and are supported in the operative note.) Procedure: Ultrasound guidance placement of gold fiducial markers. Description of procedure: The patient is a 62-year-old male with prostate cancer. He is to undergo external beam radiation therapy, and radiation therapy, and radiation oncology asked me to place the fiducial gold markers. Informed consent was obtained. The patient was brought to the procedure room. He received oral sedation prior to the procedure. Ultrasound was performed, and utilizing 20ml of lidocaine, the prostate was numbed with lidocaine. Next, position markers were placed at the right and left bases, as well as the left apex of the prostate gland without difficulty.(This is the placement of markers for radiation therapy.) He had an excellent appearance and ultrasound. The patient did not suffer any pain or other problems during the procedure. The hospital ultrasound department assisted me in imaging.(Indication not to code for the radiology service.) What are the CPT® and ICD-10-CM that should be reported for this procedure? CPT® code(s): [a] ICD-10-CM code(s): [b]

" 55876, C61

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Decision for surgery Do not type the word "Modifier" for your answer.

" 57

"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 of her prolapse. She mentioned earlier in the appointment that she could not void when she came in today. She has not tried reducing it. I am hopeful that the pessary may help with that. The #6 was comfortable for her. I stood her up and put her through some maneuvers and it stayed nicely in place. Then she went walking with the pessary in place for 10 or 15 minutes and went up and down the stairs. She definitely was able to void more easily with it in. It was comfortable and she did not really notice it was in. On recheck it still seemed like she had a little more room in the pelvis. I removed the #6 and went up to a #7 size. This seemed to reduce the prolapse a bit better, but was a little uncomfortable for her. We went back to the #6 ring pessary with support. She was able to remove it and place it with instruction in our clinic today. DISPOSITION: We have ordered the #6 ring pessary (If the provider supplied the pessary, a HCPCS Level II code would be reported.) with support and it will be sent to her. After she gets the pessary, she will remove it once a week and leave it out overnight. She will continue to use the Premarin vaginal cream twice a week. She will return to clinic after she has used the pessary for 2 or 3 weeks, so we can check her tissues. She is to report if she has vaginal discharge or bleeding, as she is at risk for getting ulceration from the pessary. I answered all of her questions about her condition of pelvic organ prolapse and treatment with estrogen and pessary. She will call if she has any bleeding. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 57160, N81.3

"CASE 10 DIAGNOSES: 1. Complete procidentia 2. Recurrent urinary tract infections 3. Postmenopausal vaginal bleeding 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: Pt. with history of postmenopausal vaginal bleeding, anemia and recurrent urinary tract infections, although she denied any urinary incontinence. 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 was then placed on the right and left lateral cervix. A circumferential incision was made at the cervicovaginal junction using Bovie cautery. The vesicovaginal fascia was then dissected anteriorly using a combination of sharp dissection with Metzenbaum scissors and blunt dissection. Attention was then turned posteriorly. The posterior peritoneum was grasped with a half curve, identified a then incised using Mayo scissors. A weighted speculum was then placed in the posterior cul-de-sac. The uterosacral ligaments were identified and clamped bilaterally with Heaney clamps, and a transection suture using 0 Vicryl suture was placed at the tip of the clamp system in both the right and left side. The uterocervical ligaments were then tagged and held for use during the vaginal vault suspension. Attention was then turned to the anterior peritoneum. A finger was placed in the posterior cul-de-sac up around the uterine fundus distending the anterior vaginal epithelium and allowing the anterior peritoneum to be entered safely using Mayo scissors. The cardinal ligaments were clamped and cut bilaterally. The utero-ovarian ligaments were identified, cut, suture-ligated, and then free tied bilaterally. The uterus was then removed from the vagina and sent to pathology. All pedicles were then inspected and were found to be hemostatic. We could not visualize the ovaries but were palpated and felt to be atrophic. At this point, we began the vaginal vault suspension. There was some oozing from the patient's left side near the vaginal cuff area. This was controlled with a figure-of-eight suture of 0 Polysorb. Other small areas along the cuff were touched with the Bovie, and hemostasis was very good at this point. The uterosacral ligament remnant was put under pressure to palpate the ligament through its course to near the ischial spine. The bladder was drained with a Foley. A long Allis clamp was placed on the uterosacral near the ischial spine by tugging gently on the remnant that was stretched out and using the more inferior fibers. A suture of 0 Polysorb was placed through the ligament with care to drive the needle from superior to inferior, to avoid the ureter. A second suture was placed slightly more distal with 0 Maxon and then more distal again a 0 Polysorb. These were all held while a similar procedure was repeated on the left side with palpation of the ligament and the ischial spine and taking the inferior fibers. All of the sutures were held while the anterior and posterior repairs were made. The anterior vagina was then inspected and the cystocele identified. The vaginal wall was trimmed anteriorly. The posterior vagina was also inspected and excessive tissue was excised. At this point the vaginal cuff appeared hemostatic and was closed by first taking the 0 Polysorb, which is the distal uterosacral stitch and making an angle stitch to close the vagina. The anterior and posterior vaginal walls were closed as well as the pubocervical fascia anteriorly and the rectovaginal fascia posteriorly to get fascia to fascia closure. Once each of the angle stitches had been placed, they were held and not tied down yet. The 0 Maxon were then placed in a similar fashion through the anterior vaginal fascia and mucosa and the posterior fascia and mucosa. Lastly the 0 Prolene, which were the most superior stitches, were placed through the anterior posterior vaginal cuff, but these were taken slightly away from the cut edge so that the knots could be buried but again taking fascia and vaginal mucosa. Then a 0 Polysorb figure-of-eight suture was placed across the midline and vaginal mucosa so that we could completely bury the Prolene sutures at the end of the case. At this point, all of the sutures were tied except the Polysorb to close the mucosa in the midline. There appeared to be excellent vaginal support at this point. The Foley catheter was removed. The 17-French cystoscope sheath was placed through the urethra. The 70-degree lens was used with sterile water infusing to inspect the bladder. There was moderate trabeculation of the bladder. There were no mucosal lesions to explain her infections. There were no stones, stitches or other lesions. A quarter of an ampule of indigo carmine had been given about 10 minutes earlier IV. Strong ureteral jets were observed from both sides, although the right side concentrated the dye faster than the left side by about 5 minutes. The bladder was drained and the urethra was inspected with the 0-degree lens and there were no urethral lesions. The bladder was drained and the Foley catheter replaced. The last midline 0 Polysorb suture was closed over the midline to bury the Prolene. All the sutures were cut and the cuff was irrigated with the cystoscopy fluid. A rectal exam was done which did not yield any sutures. The vagina was then irrigated and was found to be hemostatic. A vaginal pack was then placed. The patient was awakened from general anesthesia and brought to the PACU in stable condition. What are the CPT and ICD-10-CM codes? CPT® code(s): [a], [b], [c], ICD-10-CM code(s): [d], [e], [f]

" 57260, 58260-51, 57283-59, N81.3, N95.0, N32.89

"CASE 6 Location: Regional Hospital Fluoro Hysterosalpingogram EXAMINATION: HYSTEROSALPINGOGRAM (PROCEDURE PERFORMED 8Y RADIOLOGIST) INDICATION: Infertility for 15 years. Patient had one child 15 years ago. Last menstrual period was 1/13/20XX. No history of pelvic infection or surgery COMPARISON: None PROCEDURE: The examination and anticipated discomfort was discussed with the patient. A plastic vaginal speculum was introduced with the patient's legs in the stirrups following preliminary vaginal examination and lubrication. The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. A 5F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Fluoroscopic and radiographic assessments were done. The patient tolerated the procedure well. FINDINGS: Contrast was administered through the catheter and multiple images were taken. There is a possible abnormal contour to the right cornua with patchy contrast opacification which may represent intramural contrast with intravasation. No definite spillage of contrast from either fallopian tube was identified IMPRESSION: 1. Possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation. 2. No contrast filling of either tubes and no spill into pelvic peritoneal space. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 58340, 74740-26, N97.9

"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, and there was no uptake at the 6- and 11 o'clock portions of the cervix. 4% topical lidocaine was placed without epinephrine, followed by 1 cc of 1% lidocaine also without epinephrine. A LEEP (Loop Electrocautery Excision Procedure biopsy.) biopsy was taken of the cervix without difficulty and this also cauterized the bleeding. Instructions given to the patient that she must refrain from intercourse for at least 1 week. She is aware to call if any severe pain, bleeding that does not stop, foul odor, or fever. She is aware the results will take approximately 1-2 weeks and she will receive direct notification. What are the CPT® and ICD-10-CM codes? CPT® code: [a] ICD-10-CM code: [b]

" 57460, R87.619

"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. PROCEDURE (continued): A #11 blade was then used to incise in a circumferential fashion. This incision was carried down to the cervix using a cone shape. The cervical biopsy was removed(The cervical biopsy is performed.) and marked at the 12 o'clock position using a silk suture. The cervical bed was cauterized using the Bovie cautery with good hemostasis noted. The FloSeal was placed into the cervical bed and the cervical stitches were tied together in the midline. Good hemostasis was noted. All instruments were removed from the patient's vagina. All sponge, needle and instrument counts were correct x 2. The patient was taken out of the dorsal lithotomy position and taken to the recovery room awake and in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT Code: [a] ICD-10-CM Code: [b]

" 57520, D06.9

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period. Do not type the word "Modifier" for your answer.

" 58

" 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?

" 58150 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 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?

" 58291 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.

"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 a Skyla 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]

" 58300, J7301, Z30.430

" 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 the CPT® and ICD-10-CM codes? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 58340, 74740-26, N97.9

"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 sheath were placed. Proper placement was confirmed and insufflation was performed. A suprapubic incision was then made and the suprapubic trocar and sheath were placed under direct visualization.(Indication the procedure is performed laparoscopically.) Findings were made as noted above and the right tube was ligated with the Falope-ring, and then the left.(The procedure is performed on the right and left side.) Pictures were taken to document proper placement. All instruments were removed and gas was allowed to escape. The sheaths were removed. Marcaine with epinephrine were placed again at the incision sites and they were closed with Monocryl in a subcuticular manner. The patient was allowed to emerge from the anesthetic and was transferred to the Postanesthesia Care Unit in stable condition. What are the CPT® and ICD-10-CM codes? CPT Code: [a] ICD-10-CM Code: [b]

" 58671, Z30.2

"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] ICD-10-CM codes: [c], [d]

" 59000, 76946, O36.0130, Z3A.36

"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-of-eight stitch. Good hemostatis was noted. Patient will return to clinic for follow-up in 6 weeks. What are the CPT® and ICD-10-CM codes? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e]

" 59400, O70.1, O77.0, Z37.0, Z3A.39

" 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?

" 59510, 59409-51 Only one baby is delivered vaginally making 59400, 59409-51 is 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.

"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 was attempted to be placed, but the fetus was already delivering into the vagina. The umbilical cord was severed at this time, and no fetal heart beat was noted on ultrasound. Ultrasound guidance was used for the entire procedure.(In order to bill for ultrasound guidance a permanent image must be retained in the medical record. There must also be a description of the images requiring the ultrasound guidance. Although this physician did keep an image there is no description of anything visualized through the ultrasound other than the fetal heartbeat. Without this description, the service is not separately billable.) Gentle traction was applied and the fetus delivered intact. There was no respiratory or cardiac effort noted. Bierer forceps were then used to remove the placenta intact. There was a small amount of bleeding noted from the lower uterine segment; 20 units of Pitocin was added to the patient's IV fluids and pressure was held against lower uterine segment for 5 minutes. At this time, hemostasis was noted to be excellent. The speculum was then removed, and the patient was taken out of the dorsal lithotomy position after her perineum was cleansed. The patient's anesthesia was discontinued and she was brought to the recovery room in stable condition. There were no complications during the procedure. The patient tolerated the procedure well. SPECIMEN(S): The products of conception were sent to pathology for cytogenetics and pathologic evaluation. PLAN: The patient will follow-up in the outpatient clinic. What are the CPT® and ICD-10-CM codes? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 59855, Z33.2, O35.9XX0

"CASE 1 Office note: RE: Injection, strapping of foot and ankle. Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat. Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.) Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR, vibration and temp normal. Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed diet, orthotic shoes. Return if need be in 61 days. What diagnosis code(s) are reported?

" M77.30

" A patient has a right thyroid lobectomy for a thyroid follicular lesion. An incision is made 2 cm above the sternal notch and carried through the platysma. The right thyroid was dissected free from the surrounding tissues. The isthmus was divided from the left thyroid lobe. The left thyroid lobe was explored revealing a single nodule. The right thyroid lobe was completely removed from the trachea and surrounding tissues. It was marked and sent off the table as a specimen. What CPT® code is reported?

" 60220 The patient had a unilateral thyroidectomy. Because only the right side is removed, it is a total unilateral (partial) thyroidectomy. In the CPT® Index look for Thyroidectomy/Partial directing you to code range 60210-60225. 60220 reports a unilateral total thyroid lobectomy with or without isthmusectomy.

"CASE 1 PREOPERATIVE DIAGNOSIS: Right thyroid follicular lesion. POSTOPERATIVE DIAGNOSIS: Right thyroid follicular lesion.(Diagnosis to report if no further detail is found in the note.) OPERATIVE PROCEDURE: Right thyroid lobectomy.(Planned procedure. Review the operative report to verify this is the procedure performed.) FINDINGS: A large thyroid mass in the inferior aspect of the right thyroid.(The findings confirm the diagnosis.) The right recurrent laryngeal nerve was identified intact and there were bilateral movements of vocal cords post procedure. DESCRIPTION OF OPERATIVE PROCEDURE: The patient was identified and taken to the operating room. She was placed in a supine reverse Trendelenburg position on the operating table. Once adequate sedation was given, the patient was intubated. The neck was prepped and draped in a standard surgical fashion. Using a #15 blade, a linear incision was made approximately 2.0 cm above the sternal notch. This incision was carried through subcutaneous tissues and through the platysma until the anterior jugular veins were identified. Superior and inferior flaps were then created using electrocautery. A midline incision was then made separating the strap muscles. Once the thyroid was encountered, the right thyroid lobe was dissected free from the surrounding tissues. Using the harmonic scalpel, the superior, medial and inferior vessels were divided. Using the harmonic scalpel, the isthmus was then divided free from the right thyroid lobe. The recurrent laryngeal nerve on the right side was identified and not touched during the case. The right thyroid lobe was explored revealing a single nodule. The right thyroid was then completely removed (This confirms the right thyroid lobectomy.) from the trachea and the surrounding tissues. It was marked and sent off the table as a specimen. The cavity was `then irrigated with saline and hemostasis was achieved using electrocautery. The fascia and the strap muscles were then approximated using 3-0 Vicryl suture and a drain was placed into the cavity, exiting the left aspect of the incision. The platysma was then reapproximated using 3-0 Vicryl suture. The skin was then reapproximated using 4-0 Monocryl suture in running subcuticular closure and covered with Dermabond. By the end of the procedure, the sponge, needle, and instrument counts were correct. The patient was extubated observing bilateral movement of the vocal cords. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 60220, E04.1

" CASE 2 PREOPERATIVE DIAGNOSIS: Papillary thyroid cancer. POSTOPERATIVE DIAGNOSIS: Papillary thyroid cancer.(Diagnosis to report if no further positive findings are found in the note.) OPERATIVE PROCEDURE: Near total thyroidectomy.(Procedure planned. Review the body of the operative report to verify this is the procedure performed.) ANESTHESIA: General endotracheal. FINDINGS: Nodular right thyroid with parathyroids visualized. ESTIMATED BLOOD LOSS: Approximately 100 cc. DESCRIPTION OF OPERATIVE PROCEDURE: The patient was identified and taken to the operating room. She was placed in the supine position on the operating table. Once adequate sedation was given, the patient was intubated. A towel was placed behind the patient's shoulder blades and the neck slightly extended. The neck was prepped and draped in the standard surgical fashion. Using a #15 blade, the patient's old incision was excised. The incision was carried down through subcutaneous tissue. The superior and inferior flaps were created and using electrocautery, a midline incision was made. Once the strap muscles were identified, using blunt dissection, a plane was developed in between the strap muscle, and the right thyroid. The right thyroid appeared nodular. Using blunt dissection and electrocautery, the right thyroid lobe was freed from surrounding tissues and removed.(The patient's right thyroid lobe was removed.) Using the harmonic scalpel, two-thirds of the left thyroid lobe and the isthmus were removed, sparing the parathyroids and staying clear of the recurrent laryngeal nerve.(Two-thirds of the patient's left thyroid lobe and isthmus were removed.) Once this was completed, hemostasis was achieved using electrocautery and Surgicel. Due to some bleeding around the parathyroid glands, Gelfoam and thrombin were placed over this area and the bleeding subsided. A round JP drain was then placed around the remaining thyroid tissue. The strap muscles were reapproximated using interrupted 3-0 Vicryl suture, the platysma was reapproximated using interrupted 3-0 Vicryl suture, and the skin was reapproximated using 4-0 Monocryl suture in an interrupted fashion and covered with Dermabond. By the end of the procedure, the sponge, needle, and instrument counts were correct. The patient was then transferred to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 60225, C73

"CASE 3 PREOPERATIVE DIAGNOSIS: Papillary carcinoma of the thyroid POSTOPERATIVE DIAGNOSIS: Papillary carcinoma of the left thyroid (Diagnosis to report if no further positive findings are found in the note.) Lymph nodes exhibiting metastasis (This is a working diagnosis. The lymph node exhibited signs of metastasis and was sent for pathologic testing. There is otherwise no confirmation of this status in the record.) PROCEDURE: Approximately 85% thyroidectomy (subtotal) (This is the procedure planned. Read the body of the operative report to verify this is the procedure performed.) INDICATIONS: The patient is a 43 year-old white female patient who was referred with a history of having been diagnosed in the fall of 20XX with a papillary carcinoma of the thyroid.(Confirmation of the diagnosis is reflected in the body of the report.) Thyroidectomy had been recommended to her; however, because she had no insurance, it became quite obvious that she was going to have a difficult time being cared for in another state where she was at the time. She returned to this area and came to the office. We completed her workup including PET scan, sestamibi scan for metastatic disease, etc. I recommended to her that we proceed with a subtotal thyroidectomy, and resect 85% of the thyroid. However, if we could isolate any parathyroids and preserve them, then we would do a total thyroidectomy. She appears to understand and is amenable to this and is willing to proceed. PROCEDURE: The patient was placed on the operating room table in the supine position, neck slightly hyperextended and the table tilted in reverse Trendelenburg. The neck and anterior chest were prepped and draped in the usual sterile fashion. The incision was to be made two fingerbreadths above the sternal notch. Actually there was a fold in her skin at this level and we simply followed this natural fold from the anterior border of the left sternocleidomastoid around to the anterior border on the right. This was deepened down through the subcutaneous tissue and the platysma muscle. Flaps were then created both superior and inferior to the incision, inferiorly to the sternal notch and superiorly well over and above the thyroid cartilage. At this point, it was quite apparent that the left lobe of the thyroid was rock hard, an entirely different feel from that of the right lobe. We began on the left side with mobilization of the inferior pole. Vessels were serially clamped, cut, and ligated on the left lobe side of the thyroid. Sutures were placed for traction at the point of clamping, staying inside these vessels. The vessels were closed with a suture ligature of 3-0 silk. As the thyroid was mobilized, the recurrent laryngeal nerve was identified and avoided throughout the course of the dissection. There was a small lymph node attached to the side of the gland (The lymph node attached to the gland was removed.) which appeared to be metastatic disease. This was obviously included with the specimen sent to pathology for confirmation. We also removed several enlarged lymph nodes. (Several large lymph nodes were removed.) The inferior pole was entirely mobilized, and then the middle thyroid vessels were dealt with as well, staying well away from the recurrent laryngeal nerve. Then the superior pole vessels were likewise clamped, cut, and ligated. This allowed us to divide the isthmus on the right lobe side of the midline and then remove the left lobe (The left lobe was removed.) without difficulty. There was one small bleeding vessel on or immediately adjacent to the recurrent laryngeal nerve; therefore, a Surgicel packing was applied to this area and bleeding was controlled. Then dissection began on the right side where we encountered a lesion toward the trachea which was half the size of a yellow pencil eraser and could have passed for a parathyroid. Biopsies of this were taken; however they returned simply fatty tissues.(Lesion biopsy was negative for cancer.) We mobilized the right lobe of the thyroid and left approximately 10% of the right lobe of the thyroid intact (Part of the right lobe was removed.) at the superior end of the right thyroid lobe. When the portion of the lobe was amputated, we controlled the bleeding from the raw edge of the thyroid with multiple suture ligatures of 3-0 silk. Once hemostasis was secure, the procedure was terminated. Hemostasis was secure throughout the wound. A 10mm Jackson-Pratt drain was placed through a separate stab wound and left to lay in the midline or slightly to the left of the midline in the thyroid cavity. Strap muscles were closed in the midline with multiple interrupted figure-of-eight sutures of 2-0 Vicryl. The platysma muscle was closed with 2-0 Vicryl and the skin closed with a continuous running subcuticular closure of 3-0 Monocryl. Dermabond was applied to the wound, and the drain secured with a 0 silk and a small gauze dressing. Prior to leaving the operating room, the patient was extubated and with the help of the anesthesia personnel, the glide scope was inserted into the hypopharynx and the larynx and vocal cords visualized, showing symmetric movement of the cords. This was confirmed by multiple observers. The procedure was terminated. The patient tolerated the procedure well and she was taken to the recovery area in stable condition. Estimated blood loss was 80 cc. Sponge and needle counts were correct times two. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 60252, C73

" A patient with primary hyperparathyroidism undergoes parathyroid sestamibi (nuclear medicine scan) and ultrasound and is found to have only one diseased parathyroid. A minimally invasive parathyroidectomy is performed. What CPT® and ICD-10-CM codes are reported for the surgery?

" 60500, E21.0 In the CPT® Index look for Parathyroidectomy or Parathyroid Gland/Excision directing you to code range 60500-60505. The parathyroidectomy is coded with 60500. Code 60502 is a re-exploration and code 60505 is used for a mediastinal exploration or transthoracic approach. In the ICD-10-CM Alphabetic Index look for Hyperparathyroidism/primary directing you to E21.0. Verification in the Tabular list confirms code selection.

" " A patient with a right side, benign adrenal adenoma has a laparoscopic adrenalectomy. What CPT® and ICD-10-CM codes are reported?

" 60650, D35.01 In the CPT® Index look under Adrenalectomy/Laparoscopic and you are directed to 50545. 50545 is for a Radical Nephrectomy which includes an adrenalectomy. If you look for Adrenal Gland/Excision/Laparoscopy you are directed to 60650 which is listed as transabdominal, lumbar or dorsal, so this is the correct code choice. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/adrenal and select from the Benign column and you are directed to D35.0-. In the Tabular List the 5 th character selection determines laterality, reporting 1 for the right side.

" A 35-year-old male has a left chronic subdural hematoma. He will undergo a left burr hole evacuation of the hematoma. What CPT® code is reported for this surgery?

" 61154 The keywords in this scenario are burr hole, evacuation, hematoma and subdural. All of those words are found in the code description of procedure code 61154. Look in the CPT Index for Burr Hole/for Drainage/Hematoma guiding you to codes 61154-61156. Look in the Nervous System section to select the correct code.

"CASE 7 PREOPERATIVE DIAGNOSIS: Acute epidural hematoma POSTOPERATIVE DIAGNOSIS: As above ANESTHETIC AGENT: General Endotracheal OPERATION: Left craniotomy for evacuation of epidural hematoma (emergent) INDICATIONS: The patient presented with a history of a motor vehicle accident. He presented to the emergency department neurologically intact. An urgent CT scan revealed a large epidural hematoma and the patient was taken emergently to the operating room for evacuation. PROCEDURE/TECHNIQUES/DESCRIPTION OF FINDINGS/CONDITION OF PATIENT: The patient was brought to the operating room and after induction of adequate general anesthesia, was prepped and draped in the usual sterile fashion for a left frontotemporal parietal craniotomy. A curvilinear incision was made beginning just anterior to the left ear, curving posteriorly, then upward and anteriorly, to and at the hair line just off the midline. The resulting musculocutaneous flap was then reflected anteriorly. Multiple burr holes were then placed and connected using the high-speed drill to create a large free bone flap. This was removed from the immediate operative field. Directly beneath the bone flap was a large well-formed clot which delivered itself from the epidural space. A bleeding point was found in the region of the middle meningeal artery. This was carefully and thoroughly coagulated using bipolar cauterization. A small opening was then made in the dura to ensure that there was not an underlying blood clot. There was not. This opening was primarily closed using 4-0 Nurolon. Additional meticulous hemostasis was then obtained. The bone flap was then replaced and held in place using multiple K LS fixation devices. Skin was then reapproximated using 2-0 Vicryl for the subcutaneous tissues and 5-0 Monocryl for the skin. The patient was then awakened from anesthesia at which time his vital signs were stable and he was neurologically improved from preoperatively. ESTIMATED BLOOD LOSS: 100 cc SPECIMENS: None LABS ORDERED: None DIAGNOSTIC PROCEDURES ORDERED: None COMPLICATIONS: None What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codec: [b], [c]

" 61312, S06.4X0A, V89.2XXA

" A 55 year-old man presents with uncontrolled tremors that have become quite severe and are now disabling. A trial of a deep brain stimulator electrode is recommended. The patient is placed in the head holder adapter for the frame. The scalp is incised exposing the skull using a perforator to make a single burr hole 2.5 cm from the midline at the level of the coronal suture exposing the dura and is punctured for access. Microelectrode recording (MER) and stimulation is done to target and reposition the electrodes to determine the best placement for the neurostimulator electrode. The neurostimulator electrode array is placed in the thalamus and fastened into position with radiographic image monitoring placement. The lead is coiled in a pocket under the galea, which is sutured closed, followed by skin closure. What CPT® code is reported?

" 61867 In the CPT® Index look for Neurostimulators/Implantation/Electrode Array/by Craniectomy directing you to 61863-61864, 61867-61868. Code 61867 is the correct code to report the neurostimulator electrode placed in the subcortical site (thalamus) by going through a burr hole using microelectrode recording.

"CASE 4 Code for the Primary Surgeon Only PREOPERATIVE DIAGNOSIS: Post-hemorrhagic hydrocephalus. POSTOPERATIVE DIAGNOSIS: Post-hemorrhagic hydrocephalus.(Diagnosis to report if no further positive findings are found in the note.) OPERATION: 1. Insertion of left frontal ventriculoperitoneal shunt. 2. Removal of right frontal external ventricular drain.(These are procedures planned; however, there is no documentation to support the removal.) Primary surgeon and assistant surgeon used. Anesthesia: General endotracheal. OPERATIVE INDICATION: Patient is an 8-year-old boy who suffered a significant head trauma with intraventricular hemorrhage. He previously had an external ventricular drain placed. He failed clamp trial.(What the initial surgery was and the reason for the procedure being performed.) Plan was made for permanent shunt implantation.(Even though this was a planned procedure following the patient's failed clamp trial, the initial procedure has no global days.) The risks and benefits of surgery were discussed in detail with the patient and family. Risks include bleeding, infection, stroke, paralysis, seizure, coma, and death. All questions were answered in detail. I believe the patient and family understand the risks and benefits of surgery and wish to proceed. OPERATIVE ACCOUNT: Patient was brought in the operating room and placed under general endotracheal anesthesia. His head was turned to the right, and a shoulder roll was placed. He was then clipped, prepped, and draped in the usual sterile fashion. Using the micropoint electrocautery, a half-moon incision was carried out over the patient's left coronal suture at the mid-pupillary line. The galea was divided and the scalp flap retracted. A second incision was created above and behind the pinna of the ear. Attention was turned to the abdomen where a 2-cm incision was carried out just to the left and superior to the umbilicus. Using the micropoint electrocautery, subcutaneous dissection was carried down to the superficial rectus fascia. The fascia was secured with hemostats, elevated, and opened sharply in a vertical fashion. This allowed dissection of the underlying muscular fibers. We then secured the deep rectus fascia with hemostats, elevated this, and opened this sharply. The underlying peritoneum was visible. This was secured and opened, allowing easy passage of a #4 Penfield into the peritoneal cavity.(Peritoneal access for the ventriculo-peritoneal shunt.) A subcutaneous tunneler was then used to bring a Medtronic BioGlide catheter from the abdominal to the retroauricular incisions. This was then brought to the anterior incision. It was secured to the distal end of the Medtronic Delta valve, performance level 1, with 3-0 silk tie. The Midas perforator was then used to create a burr hole.(A burr hole was created, but it is included in placement of the shunt.) The brain needle was then placed to the dura and electrocautery applied, creating a small durotomy, through which the brain needle was advanced. This was advanced into the ventricle (Ventricular access for the ventriculo-peritoneal shunt.) with excellent return of cerebrospinal fluid under elevated pressure. We observed slightly stiff ependymal walls at the time of passage. The brain needles were removed and a new Medtronic BioGlide ventricular catheter was advanced down this track with excellent return of cerebrospinal fluid. This catheter was trimmed and secured to the proximal end of the valve with 3-0 silk suture. (Insertion of the ventricular portion of the ventriculoperitoneal shunt.) Spontaneous flow of cerebrospinal fluid was observed at the distal end of the peritoneal catheter prior to placement within the peritoneum. All wounds were then thoroughly irrigated with vancomycin-containing saline, and 1 ml of vancomycin-containing saline was injected into the bulb of the shunt. At the two cranial incisions, the galea was reapproximated with inverted 3-0 Vicryl suture. Skin edges were approximated with a running 5-0 Monocryl stitch. At the abdominal incision, the peritoneum and deep rectus fascia were closed with a 3-0 Vicryl pursestring. Superficial rectus fascia was closed with interrupted 3-0 Vicryl suture. Subcutaneous tissue was reapproximated with interrupted and inverted 3-0 Vicryl suture. Skin edges were reapproximated with a running 5-0 Monocryl stitch. That wound was washed and dried, and a sterile dressing was applied. At the cranial wound, the patient's hair was shampooed and bacitracin ointment applied to the wounds. The patient was awakened, extubated, and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported for the primary surgeon? CPT® code: [a] ICD-10-CM code: [b]

" 62223, G91.3

" A 6-week-old baby had a cerebrospinal fluid shunt placed two days ago. The shunt is not draining the excess CSF and the baby is returning to the OR for shunt removal and replacement by the same surgeon who placed the original shunt. What CPT® code is reported for this surgery?

" 62258-78 A complete removal of the cerebrospinal fluid shunt system with a replacement is performed. Look in the CPT® Index for Shunt/Brain/Removal directing you to codes 62256-62258. Modifier 78 is the appropriate modifier to append for two reasons: (1) the patient returned to the operating room following the initial procedure during the postoperative period; (2) The same surgeon performed the initial procedure and the removal and replacement of the shunt.

" A patient recently experienced muscle atrophy and noticed she did not have pain when she cut herself on a piece of glass. The provider decides to obtain a needle biopsy of the spinal cord under ultrasound guidance in the outpatient setting. The biopsy results come back as syringomyelia. What CPT® and ICD-10-CM codes are reported for the biopsy procedure?

" 62269, 76942-26, G95.0 In the CPT® Index look for Biopsy/Spinal Cord/Percutaneous and you are directed to code 62269. Instructional note under code 62269 indicates for radiological supervision and interpretation, see 76942, 77002, and 77012. Ultrasound guidance for needle placement, 76942, can be separately billed. Modifier 26 is appended for the professional services. In the ICD-10-CM Alphabetic Index look for Syringomyelia directing you to code G95.0. Verification in the Tabular List confirms code selection.

" A patient with a malignant neoplasm of the spinal meninges is receiving a programmable pump implantation for chemotherapy. The patient is placed in the prone position where the provider made a midline incision overlying the area of the spinal cord. The reservoir was placed in the subcutaneous tissues and attached to the previously placed catheter. Layered sutures were used to close the incision. The patient tolerated the procedure well and was released in good condition. What CPT® and ICD-10-CM codes are reported for this procedure?

" 62362, C70.1 The procedure performed is implanting a programmable pump which allows the infusion of a medication (for example, chemotherapy) for treatment. For insertion or implantation of the pump, in the CPT® Index look for Infusion Pump/Spinal Cord directing you to codes 62361-62362. This is a programmable pump making 62362 the correct code selection. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/spine, spinal (column)/meninges and select from the Malignant Primary column directing you to C70.1. Verification in the Tabular List confirms code selection.

" A patient has severe spinal stenosis between L3-L5 inferior to disc space. A laminectomy is performed on L4 along with a decompression of L3-L4 and L4-L5. What CPT® code is reported for this surgery?

" 63005 Only a laminectomy with decompression is performed. There is no documentation to indicate a facetectomy, foraminotomy, or discectomy was performed. Look in the CPT Index for Laminectomy/for Decompression/Lumbar or Decompression/Spinal Cord. Verify code selection in the Nervous System section.

" "ASE 9 PREOPERATIVE DIAGNOSIS: Spinal stenosis at L4-L5 POSTOPERATIVE DIAGNOSIS: Spinal stenosis at L4-L5 OPERATION PERFORMED: Right L4-5 lamino OPERATION PERFORMED: L4-L5 laminotomy, right foraminotomy, bilateral decompression of the lateral recess OPERATIVE ANESTHESIA: General endotracheal tube anesthesia. ESTIMATED BLOOD LOSS: Minimal. OPERATIVE COMPLICATIONS: None apparent. OPERATIVE FINDINGS: Tight stenosis at L4-5 from ligament hypertrophy and facet arthropathy. OPERATIVE INDICATIONS: The patient is a 51‑year‑old gentleman. He has had ongoing lower extremity pain with numbness and tingling on the right side more so than the left side. He has had paresthesias. He has had progressive loss of strength. He has had very little back pain, however. The patient is brought to the operating room for operative decompression following an MRI scan that showed tight spinal stenosis at L4-5, having failed conservative measures to date. DESCRIPTION OF PROCEDURE: The patient was given 1 gm of Kefzol preoperatively. He was taken to the operating room where he underwent general endotracheal tube anesthesia without complications. All appropriate anesthetic monitors and lines were placed. He was placed prone onto a Wilson frame which was padded in the usual fashion. All pressure points were checked and padded appropriately. The patient's back was then outlined with a marking pen through the L4-5 level in a vertical direction. He was then prepped using Prevail solution and allowed to dry. He was draped using sterile technique. Marcaine 0.25% with 1:200,000 units of epinephrine was instilled in the proposed incision for a total of 10 cc of injection. Using a #10 blade scalpel, a vertical midline incision was made. The soft tissues were dissected down to the thoracolumbar fascia using Bovie coagulation. The fascia was incised on the right hand side and the paraspinal muscles were stripped off the lamina and spinous processes of L4 and L5 on the right. A self-retaining Taylor retractor was placed into the wound and intraoperative fluoroscopy revealed the L4-5 level. The soft tissue in the interlaminar space was then resected with a rongeur. The ligamentum flavum was resected with Kerrison punches and cervical curets. The laminotomy was performed on the superior aspect of L5 and the undersurface of L4. The laminotomy was taken out to the medial edge of the right pedicle. A foraminotomy was performed with a #3 Kerrison punch for the exiting right L5 nerve root. The lateral recess was now decompressed. The disc was inspected and found not to be ruptured. We then decompressed the patient's left side by slightly depressing the thecal sac with cottonoids and under-cutting the interspinous ligament with Kerrison punches so that the right lateral recess was also decompressed from overgrowth of the ligamentum flavum. The wound was copiously irrigated using warm bacitracin solution. Depo-Medrol 40 mg in 1 cc was placed epidurally. A piece of Gelfoam was placed over the laminotomy defect to try to preserve the epidural space, and the wound was ready for closure. During all areas of closure, bacitracin irrigation was used in copious amounts. The fascia was closed with #0 Vicryl in an interrupted fashion. The subcutaneous tissue was closed with #3‑0 Vicryl in an interrupted fashion. The skin was closed with #4‑0 Vicryl in an interrupted fashion to the subcuticular space. Steri-Strips were placed on the wound. A sterile dressing was placed. The patient was taken to the recovery room in stable condition with sponge and needle counts correct times three. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 63030-50, M48.061

"CASE 10 PREOPERATIVE DIAGNOSIS: Left L5 radiculopathy; left L5-S1 neural foraminal stenosis. POSTOPERATIVE DIAGNOSIS: Left L5 radiculopathy; left L5-S1 neural foraminal stenosis. PROCEDURE PERFORMED: L5-S1 hemilaminectomy with left foraminotomy; microsurgical technique. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 25 ml. SPECIMENS: None. DRAINS: None. COMPLICATIONS: None. INDICATIONS: This woman has a history of left lower extremity L5 radicular pain. She has had previous surgery in the lumbar region for a herniated disc. Her preoperative exam was remarkable for subjective complaints in an L5 pattern on the left. Her MRI scan showed high-grade neural foraminal narrowing on the left due to facet arthropathy. Based on these findings, treatment options were discussed including ongoing conservative therapy and surgical intervention. After contemplating alternatives, the patient elected to proceed with surgery. DESCRIPTION OF PROCEDURE: After extensive preoperative counseling, informed consent was obtained. The patient was brought to the operating room, intubated, placed under general anesthesia, and positioned in the prone position. A wide area of the lumbar region was prepped and draped in standard fashion. A midline incision was marked overlying the L5-S1 spinous processes and infiltrated with 0.5% Marcaine with 1:200,000 epinephrine. A standard surgical timeout was performed wherein the patient was identified and the surgical site and procedure were confirmed. Preoperative dose of antibiotics was administered IV. The skin was incised and subcutaneous bleeding points were controlled. The subcutaneous fat was transgressed to the lumbodorsal fascia, which was incised in the midline from the top of the spinous process of L5 through the bottom of the spinous process of S1. Paraspinous musculature was elevated subperiosteally and reflected laterally towards the patient's left. A high speed osteotome was used to create a trailing edge laminotomy of L5 and a leading edge laminotomy of S1, encompassing the medial third of the facet complex. Microscope was then employed for magnification and i1iumination. A variety of curettes and rongeurs were then used to complete the laminotomy. The bone resection was carried laterally until the medial edge of the pedicle was encountered. As the bone resection and ligamentous resection was conducted, a large fragment of synovium type material with admixed scar tissue was extracted, resulting in marked decompression of the thecal sac and root sleeve. A probe could then be admitted through the neural foramen. For this aspect of the procedure, the microscope was utilized for magnification and illumination. A confirmatory x-ray was obtained with the probe inserted through the L5-S1 foramen, both the L5 and S1 root sleeves were directly visualized and were completely without impingement. Hemostasis was achieved with bipolar coagulation. A bulging of the disc was appreciated, but the decision was made to forego a discectomy. A pledget of fat was harvested from the subcutaneous tissue and tucked in the laminotomy defect. A layered closure was then conducted using interrupted 0 Vicryl sutures. The lumbodorsal fascia was closed using interrupted 0 Vicryl sutures in watertight fashion. The skin was closed using interrupted buried subcuticular 3-0 Vicryl sutures followed by Mastisol and Steri-Strips. Sterile dressing was applied. The patient was aroused from anesthesia and extubated without difficulty. All final needle and sponge counts were correct. There were no perioperative complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 63042-LT, M54.16, M48.07

" " CASE 6 PREOPERATIVE DIAGNOSIS: Dorsal column stimulator generator malfunction. POSTOPERATIVE DIAGNOSIS: Dorsal column stimulator generator malfunction. PROCEDURE PERFORMED: Replacement of dorsal column stimulator generator. ATTENDING: John Smith, MD ANESTHESIA: Monitored anesthetic coverage with local. ESTIMATED BLOOD LOSS: Less than 5 ml SPECIMENS: None. DRAINS: None. COMPLICATIONS: None. IMPLANTS: Medtronics prime advanced nonreconstructable generator. INDICATIONS: This woman has a dorsal column stimulator in place and has benefited from the therapy. Her current device has a complication in which it began malfunctioning approximately a month prior to this procedure and she has gradually noticed declining effectiveness. The device was interrogated approximately a week prior to this procedure and no telemetry was obtained, indicating a breakdown of the battery. On this basis, revision of the device was offered and accepted. PROCEDURE IN BRIEF: After extensive preoperative counseling, informed consent was obtained. The patient was brought to the operating room and positioned on the table in the left lateral decubitus position. Sedation was induced and a dose of IV antibiotics was administered. A wide area of the right lateral flank region surrounding her existing scar was prepped and draped in standard fashion and infiltrated with 0.5% Marcaine with 1:200,000 epinephrine. The skin was incised. The pouch housing the existing generator was entered. This was explanted and a new prime advanced generator was prepared. The leads were disconnected from the old generator and connected to the new generator in the same orientation. An impedance test was performed, which yielded acceptable results. The generator was implanted and secured to the fascia using 0 Ethibond suture. The wound was irrigated copiously and closed in layers using interrupted 0 and 3-0 Vicryl sutures followed by Mastisol and Steri-Strips to reapproximate the skin. Sterile dressing was applied. The patient was aroused from sedation and taken to the recovery area in good condition. All final needle arid sponge counts were correct. There were no apparent complications. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 63685, T85.113A

" " A patient with hydronephrosis has a left nephrostomy and he has agreed to a pyelography (IVP) to rule out a right renal obstruction. The patient was placed prone on the X-ray table one hour after IV infusion of contrast. Contrast flowed from the left and right renal pelvis, down the ureters into the bladder where a Foley catheter was positioned. The IVP showed no obstruction or abnormalities in the urinary tract aside from the left hydronephrosis of the pelvis. The right kidney and ureter showed no obstruction. Bladder appeared within normal limits. What CPT® code is reported for the radiological services?

" 74400-26 A radiographic exam of the urinary tract is performed with IV injection of contrast medium and radiographs are taken. This is performed to assess the anatomy and function of the kidneys, bladder, and ureters. In the CPT® Index look for X-ray/with Contrast/Urinary Tract or Urography/Intravenous. Reviewing the codes in the numeric section leads you to report 74400 for an intravenous pyelography. Modifier 26 is appended to indicate the professional service.

" " Operative Report PROCEDURE: Left L3-L4 peri-articular paravertebral facet joint injection. PATIENT HISTORY: The patient is a 67 year-old woman referred by Dr. X for repeat diagnostic/therapeutic spinal injection procedure. She is about 1 1/2 years status post lumbar decompression for stenosis. Two weeks ago she underwent an interarticular left L4-L5 paravertebral facet joint injection. She had no relief of symptoms from that injection. TECHNIQUE: The patient was positioned prone and the skin was prepped and draped in the usual sterile fashion. The skin and underlying soft tissues were anesthetized with 3 cc of 1% lidocaine. Due to the advanced degenerative changes, the left L3-L4 paravertebral facet joint could not be distinctly visualized fluoroscopically, despite trying numerous angles. This was explained to the patient who wished to proceed with the injection. A 22-gauge 6-inch spinal needle was advanced toward the region of the left L3-L4 paravertebral facet joint under fluoroscopic guidance. Injection of 0.5 cc of Isovue 200 contrast showed the needle was not in an intravascular location. Intra-articular placement could not be confirmed and the injection was presumed to be peri-articular. 2 cc containing equal parts preservative free 2% Lidocaine plus Depo-Medrol (80 mg per ml) was injected. The patient reported injection of medication produced discomfort in the region of her usual left low back pain. Immediately following the procedure, upon standing up from the procedure table, she reported her pain was a little bit better. What CPT® code(s) is/are reported for this procedure?

" 64493 Nerve block injections are selected based on location and number of levels. Code 64493 is described as a paravertebral facet joint of lumbar spine, single level. This code descriptor includes imaging guidance, and it is not reported separately. In the CPT® Index look for Injection/Paravertebral Facet Joint/Nerve/with image guidance.

"PROCEDURES PERFORMED: 1. Bilateral facet joint injections, L4-L5 2. Bilateral facet joint injections, L5-S1. 3. Fluoroscopy. TECHNIQUE: The AP view was aligned with the proper tilt so that the end plates for the desired levels were perpendicular. The AP image showed the sacrum and the L5 spinous process. Manual palpation located the sacral hiatus. The 6 inch, 20 gauge needle with a slight volar bend was inserted using fluoroscopy into each facet joint under AP image. The bilateral L4-L5, and L5-S1 facet joints were injected in a systematic fashion from caudal to cranial. A sterile dressing was applied. The patient tolerated the procedure well with no complications and was transferred to recovery in good condition.

" 64493-50, 64494 x 2 In the CPT® Index, look for Injection/Paravertebral Facet Joint/Nerve/with Image Guidance directing you to 64490-64495. Code selection is based on the location and the number of levels. The initial and one additional separate level lumbar facet joint injections performed bilaterally, at two levels, so use modifier 50 on facet injection codes 64493. Modifier 51 is not reported on add-on code 64494 because add-on codes are exempt from modifier 51. Add-on codes are also exempt from modifier 50. Report 64494 twice to indicate this was performed bilaterally. Depending on the payer, modifiers RT and LT may be appended. Fluoroscopy was utilized for all services and is bundles in codes 64490-64495 and not reported separately.

" A 45-year-old female has carpal tunnel syndrome. A neuroplasty is performed on her left wrist. During the surgery the patient's blood pressure starts dropping and the surgeon decides to stop the operation. How should the procedure be reported?

" 64721-53 Modifier 53 is the appropriate modifier to append when the surgeon elects to terminate a surgical procedure due to the patient's blood pressure dropping which threatens the well-being of the patient.

"The patient is complaining of severe corneal pain and believes a wood chip entered his eye. He was working in his woodworking shop without goggles this morning. After placing two drops of proparacaine 0.5% in the right eye, I administered fluorescein and examined the cornea under ultraviolet light using a slit lamp. Seidel sign negative for penetrating injury. A small piece of wood was identified under a flap of lamellar cornea, and I was able to dislodge the wood and flush it from the eye. A single suture was placed to secure the flap. What CPT® code is appropriate for this procedure?

" 65275 The presence of the foreign body has no bearing on code selection. In the CPT® Index , see Cornea/Repair/Wound/Nonperforating 65275. Note the code reads with or without removal of foreign body. The key to code choice is the site of the injury, which is the cornea and it was a nonperforating injury (lamellar means partial thickness of the cornea). The topical anesthetic is bundled into the procedure, although the physician could bill separately for any IV sedation used or if a therapeutic contact lens was applied.

"CASE 5 PREOPERATIVE DIAGNOSIS: 1. Cataract, right eye. POSTOPERATIVE DIAGNOSIS: 1. Cataract, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: 1. Complex phacoemulsification with manual stretch of the iris, right eye. 2. Peripheral iridectomy, right eye. ANESTHESIA: Topical.(Topical anesthesia is used.) INDICATIONS: The patient was seen in the Ophthalmology office with a complaint of decreased vision in the right eye and was diagnosed with a cataract in the right eye. The patient was symptomatic and therefore, given the option of cataract surgery for improved vision or observation. The details of the procedure were discussed at length as well as the potential risks, which include, but are not limited to, permanent decrease of vision from infection, inflammation, bleeding, retinal detachment and need for reoperation. The patient understood the above and desired to proceed with cataract surgery. DESCRIPTION OF PROCEDURE: The patient received dilating drops and anesthesia in the preoperative area and was later brought into the operating room. The patient was sedated by the anesthesia staff. The patient was then prepped and draped in the usual sterile manner. The microscope was focused onto the right eye and the speculum was inserted to separate the eyelids.(The procedure begins in the right eye.) The tip of the 2.8 mm keratome blade was used at the 6:00 o'clock position to create the paracentesis that after which Amvisc plus was injected into the anterior chamber to create a deep anterior chamber. The same blade was used at 1:00 o'clock to create the main clear corneal wound into the anterior chamber.(This describes the approach.) A two hand technique using iris expansion devices was used to expand the size of the pupil.(Manual iris expansion.) The instruments were used at the sites directly opposite of one another to stretch the iris. They were then rotated 180 degrees to stretch the iris in that new meridian. The cystotome needle on the balanced salt solution syringe was used to initially create the capsulorrhexis flap and the capsulorrhexis forceps were used to create the continuous capsulorrhexis tear.(A capsulorrhexis tear is created.) A flat tip hydrodissection cannula on the balanced salt solution syringe was used to hydrodissect and hydrodelineate the lens. The phacoemulsification unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex.(Phacoemulsification is used to break up the lens so it can be removed.) The bag was inflated with Amvisc plus and a lens of 27.5 diopter model SI40MB was injected into the bag(An intraocular lens is inserted.) and then dialed into place. The Amvisc plus was removed with irrigation and aspiration mode. The anterior chamber was then inflated to the appropriate firmness using balanced salt solution. After the globe was inflated to the appropriate firmness, 0.1 cc of Vancomycin was injected into the anterior chamber. The wounds were checked for leakage and none was found. The globe was checked for appropriate firmness and found to be desirable. The speculum was disinserted and the patient was brought into the postoperative area where postoperative instructions for surgical eye care were given, including the use of topical eye drops and the need for subsequent follow-up. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 66982-RT, H26.9

"CASE 6 IV SEDATION AND LOCAL PREOPERATIVE DIAGNOSIS: Cataract of the left eye POSTOPERATIVE DIAGNOSIS: Cataract of the left eye Cataract extraction, foldable posterior chamber intraocular lens of the left eye PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. An intravenous line was started in the patient's left arm. After appropriate sedation, a left O'Brien and left retrobulbar block were administered, which consisted of a 50/60 mixture of 0.75% Bupivacaine and 2% lidocaine. The Honan balloon was then placed over the operative eye. While the surgeon scrubbed for 5 minutes the patient was prepped and draped in the usual sterile fashion including instillation of 5% Betadine solution to the left cornea and cul-de-sac, which was irrigated with balanced salt solution and the use an eyelid drape. A limbal incision was performed with the super sharp blade. Provisc was injected into the anterior chamber. A capsulotomy was performed with a cystitome and Utrata forceps such that it was 6 mm and oval in shape. Hydrodissection was performed with balanced salt solution. The nucleus was removed using the phacoemulsification mode of the Alcon 20,000 Legacy Series System by divide and conquer technique under Viscoat control. The cortex was removed using the irrigation aspiration mode. The anterior chamber was then filled with Proviso and the AcrySof foldable posterior chamber intraocular lens was then inserted into the capsular bag and rotated into position such that the optic was well centered. The Proviso was removed using the irrigation and aspiration mode. Miochol was injected to constrict the pupil. The wound was checked and deemed to be watertight. A collagen shield soaked in Ciloxan and Pred Forte was applied. The standard postoperative patch and shield were placed and the patient was transferred to the Recovery Room in stable condition. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 66984-LT, H26.9

"CASE 5 Location: Regional hospital. (Provided at the hospital, the radiologist will report the professional component.) Study: Ultrasound Urinary Tract Indications: Status ureteral reimplantation (The surgical procedure has been performed. The ultrasound is being performed after a surgical procedure for evaluation of continued reflux.) to evaluate for continued vesicoureteral reflux. Left Kidney:(Kidney evaluated.) Length: 7.0 cm Prior length: 7.4 cm Parenchyma: Cortical scarring. Pelvic dilatation: Normal Calyceal dilatation: Normal Hydronephrosis grade: Normal Interval hydronephrosis change: None Right Kidney: Length: 6.6 cm Prior length: 6.4 cm Parenchyma: Cortical scarring. Pelvic dilatation: Normal Calyceal dilatation: Normal Hydronephrosis grade: Normal Interval hydronephrosis change: None Ureters: (Ureters evaluated.) Normal Bladder: (Bladder evaluated.) Almost empty and difficult to evaluate. Impression: 1, Interval right renal enlargement without hydronephrosis. (Diagnosis—right renal growth.) 2. Stable asymmetric small left renal size (Additional diagnosis—small left renal size.) likely to represent diffuse cortical scarring. What are the CPT® and ICD-10-CM codes reported for this service? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e]

" 76770-26, Z48.816, N13.70, N28.81, N27.0

"CASE 1 ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of the intramuscular quadrants was dissected using Aebli scissors. The muscles were isolated using a Gass muscle hook with an 0 silk suture attached to it. The patient had an inspection of the intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin sclera. The patient had an examination of the retina using an indirect ophthalmoscope and he was noted to have 3 tears in the temporal and inferotemporal quadrant and 2 tears in the superior temporal quadrant. (Exam reveals the location of the tears.) These were treated with cryoretinopexy.(Cryoretinopexy is the use of intense cold to close the tear in the retina.) Most posterior edge of each of the tears was marked with a scleral marker followed by a surgical marking pen. The patient had 5-0 nylon sutures placed in each of the 4 intramuscular quadrants. The 2 temporal sutures were placed with the anterior bite at about the muscle insertion, the posterior bite 9 mm posterior to this. In the nasal quadrants, the anterior bite was 3 mm posterior to the muscle insertion and the posterior bite was 3 mm posterior to this. A 240 band was placed 360 degrees around the eye and a 277 element from approximately the 5-1 o'clock position. The patient had another examination of the retina and was noted to have a moderate amount of subretinal fluid, so a drainage sclerotomy site was created at approximately the 9:30 o'clock position incising the sclera until the choroid was visible.(A sclerotomy is performed to drain subretinal fluid.) The choroid was then punctured with a #30-gauge needle. A moderate amount of subretinal fluid was drained from the subretinal space. The eye became relatively soft and 0.35 ml of C3FS gas was injected into the vitreous cavity 3.5 mm posterior to the limbus. The superior temporal and inferior temporal and superior nasal sutures were tied down over the scleral buckle. The 240 band was tightened up and excessive scleral buckling material was removed from the eye.(Sclera buckling is performed.) The inferior nasal suture was tied down over the scleral buckle and all knots were rotated posteriorly. The eye was reexamined. The optic nerve was noted to be nicely perfused. The tears were supported on the scleral buckle. There was a small amount of residual subretinal fluid. The patient received posterior sub-Tenon Marcaine for postoperative pain control. The 0 silk sutures were removed from the eye. The conjunctiva was closed with #6-0 plain gut suture. The patient received subconjunctival Ancef and dexamethasone. The patient was patched with atropine and Maxitrol ointment. The patient tolerated the procedure well and returned to the postoperative recovery room. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 67107, H33.021

" What CPT® code is used to report surgery to remove an aqueous shunt from the patient's extraocular posterior segment of the eye?

" 67120 An aqueous shunt is implanted material in the extraocular posterior segment of the eye. In the CPT® Index, look for Eye/Removal/Implant/Posterior Segment referring you to 67120-67121. It can also be found by looking for Removal/Implant/Eye.

" The patient has hypertropia in her right eye with prior eye operations in this eye and today we are performing a recession of the superior oblique muscle to balance this muscle and eliminate strabismus. Adjustable sutures are applied. She is pseudophakic. What CPT® codes are reported for this procedure?

" 67318, 67331, 67335 In the CPT® Index, look for Strabismus/Repair/Superior Oblique Muscle 67318. Code 67318 is the only code listed describing a procedure on the superior oblique muscle. In addition to 67318, report add-on codes for adjustable sutures. In the index, see Strabismus/Repair/Adjustable Sutures 67335. This patient has a history of ophthalmic surgery . The medical history of ocular surgery makes the procedure riskier and more difficult. Look in the index for Strabismus/Repair/Previous Surgery, Not Involving Extraocular Muscles 673331. Modifier 51 never is applied to add-on codes.

"CASE 2 PREOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes. POSTOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes. PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes. ANESTHESIA: General. CONDITION: To recovery, satisfactory. COUNTS: Needle count correct. ESTIMATED BLOOD LOSS: Less than 1 ml. INFORMED CONSENT: The procedure, risks, benefits, and alternatives were thoroughly explained to the patient's parent who understands and wants the procedure done. PROCEDURE: The patient was prepped and draped in the usual sterile manner under general anesthesia.(General anesthesia is used for this procedure.) Starting on the right eye (This indicates the procedure is performed on the right eye.) the upper punctum was dilated with double-ended punctal dilator, and starting with a 4-0 probe, increasing up to a 2-0 probe, the nasolacrimal duct was dilated until probed patent.(This indicates the nasolacrimal duct is probed.) Then, using a curved 23-gauge punctal irrigator, 0.125 ml of sterile fluorescein stained saline was easily irrigated down the nasolacrimal duct into the nostril where it was carefully collected with a clear #8 catheter. The instruments were removed and an identical procedure was done on the opposite eye nasolacrimal duct.(The same procedure is performed on the left eye.) TobraDex eye drops were placed in each lower cul-de-sac. The eyelids were closed. The patient left the operating room for recovery in satisfactory condition, accompanied by myself and Dr. Smith. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 68811-50, H04.553

"CASE 4 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Foreign body, right external ear canal. ANESTHETIC: General. Time began: 10:15 a.m. Time ended: 10:35 a.m. POSTOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.(The postoperative diagnosis is used for coding.) PATHOLOGY SPECIMEN: None. OPERATION: Removal of foreign body using the microscope. DATE OF PROCEDURE: 05/12/XX Time began: 10:21 a.m. Time ended: 10:22 a.m. DESCRIPTION OF OPERATION: Under general anesthesia(General anesthesia is used.) with the microscope in place, a pearly white plastic ball was seen virtually obstructing the entire ear canal. Gently with a curette, this was teased out of the ear canal atraumatically.(The foreign body is removed.) The ear canal and eardrum were perfectly intact. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 69205-RT, T16.1XXA

"CASE 3 PREOPERATIVE DIAGNOSIS: Bilateral protruding ears. POSTOPERATIVE DIAGNOSIS: Bilateral protruding ears. PROCEDURE: Bilateral otoplasty. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. PROCEDURE IS AS FOLLOWS: The patient was placed supine then prepped and draped in the usual sterile fashion. Measurements were taken from the helix to the mastoid at the superior, mid, and inferior portions and they were within 1 to 2 mm of the same bilaterally and were approximately 17 mm superior, 24 mm middle, and 25 mm inferior. The right ear was begun first.(Procedure is performed on the right ear.) A curved incision was made just anterior to the sulcus (An incision is made.) of the posterior ear. This was done with a 15-blade scalpel. Electrocautery was used for hemostasis and further dissection. An iris scissors was used to dissect the soft tissues off of the mastoid region and the posterior ear. The concha was shut back and sutured in place with clear 4-0 nylon suture and in a horizontal mattress pattern.(The concha, which is the external part of the ear, is sutured in place.) Three tacking sutures were used. This brought the ear back approximately 2 to 3 mm. However, greater correction was needed and Mustarde' sutures were placed. (This is a suturing technique used to perform otoplasty.) The mid and superior portions of the antihelical fold were placed.(There are a total of three portions of the external ear that are repaired during this otoplasty.) These were spaced widely on either side of the helical fold. They were then sutured in place, tacking the fold more acutely to a point that was deemed acceptable and held in that position. Next, a margin of skin was excised along the posterior ear and closure of the wound was performed with 5-0 chromic suture. Prior to closure, full hemostasis had been obtained with electrocautery. Both ears were done in the exact same fashion; therefore only one is dictated in detail. (This indicates that a bilateral procedure is performed.) The patient was then checked very carefully for symmetry. Postoperative measurements were approximately 14 mm superior, 15 mm mid, and 16 mm lower. What are the CPT ® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM code: [b]

" 69300-50, Q17.5

"Diagnosis: Calcification left basal ganglia. Where are the basal ganglia located?

" Cerebral Cortex

"CASE 7 PREOPERATIVE DIAGNOSIS: Tympanic membrane perforation, conductive hearing loss in the right ear. POSTOPERATIVE DIAGNOSIS: Tympanic membrane perforation, conductive hearing loss in the right ear. NAME OF PROCEDURE: Right tympanoplasty via the postauricular approach. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Less than 20 ml. COMPLICATIONS: None. SPECIMENS: None. INDICATIONS: This is a 9-year-old white female with the above diagnoses and now presents for surgical intervention. INTRAOPERATIVE FINDINGS: Intraoperative findings revealed tympanosclerosis posteriorly with a central eardrum perforation of approximately 30% of the surface of the eardrum. There was no cholesteatoma. The ossicular chain is intact. DESCRIPTION OF OPERATTVE PROCEDURE: Under satisfactory general anesthesia the patient was given preoperative intravenous antibiotic. The right ear was prepared and draped in the usual sterile fashion. A postauricular incision was made and the temporalis fascia graft was harvested. The posterior ear canal skin was elevated and tympanomeatal flap was developed. The Rosen needle was used to freshen the edge of the perforation. Gelfoam was placed in the middle ear space. The graft was cut into the appropriate size and laid medial to the remnant of the tympanic membrane anteriorly, posteriorly, inferiorly and superiorly. Antibiotic ointment and Gelfoam were placed in the ear canal. Closure of the wound was done in layers with 4-0 Vicryl for the subcutaneous tissue and 4-0 Prolene for skin. Pressure dressing was placed around the right ear. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 69620-RT, H72.01, H90.11, H74.01

"CASE 4 Location: Independent Diagnostic Testing Facility, radiologist employed by the facility. (Radiologist is employed by the facility, the IDTF will bill for global component.) CT BRAIN/HEAD W/WO CONTRAST EXAM: CT Head, without and with Contrast August 5, 20XX. COMPARISON: None available. HISTORY: Non-small-cell lung cancer. (Patient has non-small cell lung cancer, not specified to location in lung.) TECHNIQUE: Axial images of the calvarium without and with (CT performed without and with contrast.) 125 cc Omnipaque-300 intravenous contrast. (Contrast was intravenous.) FINDINGS: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal mucosal thickening. The sphenoid ethmoid and frontal sinuses are clear bilaterally. No hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection or mass. Calcification left basal ganglia without mass effect, nonspecific, likely benign. Abnormal but nonspecific decreased density in the periventricular and subcortical white matter of the cerebral hemispheres bilaterally without mass effect or enhancement, most consistent with remote microvascular ischemic change present to mild degree. Bilateral intracavernous carotid and vertebral arteriosclerotic calcification. Probable anterior communicating artery aneurysm 6 x 5 mm. Recommend intracranial CT angiography to further characterize. CONCLUSION: 1. No finding suggestive of metastatic disease. 2. Probable (Aneurysm is probable and would not be coded.) 6 x 5 mm anterior communicating artery aneurysm. Recommend intracranial CT angiography to further characterize. 3. Cerebrovascular arteriosclerosis. (Additional diagnosis of cerebrovascular arteriosclerosis.) 4. Nonspecific cerebral white matter lesions (Additional diagnosis of cerebral lesions.) most consistent with remote microvascular ischemic change. 5. Calcification left basal ganglia,(Additional diagnosis of calcification left basal ganglia.) likely benign; however, recommend continued imaging follow-up. What are the CPT® and ICD-10-CM codes reported for this service? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e]

" 70470, C34.90, I67.2, G93.9, G23.8

" A patient reports to the hospital radiology department for a functional MRI of the brain. The technologist asks the patient to perform small tasks. He takes the images of the patient at rest and while performing the tasks. What CPT® code is reported?

" 70554 The test performed is a functional MRI of the brain. From the CPT® Index look for Magnetic Resonance Imaging (MRI)/Diagnostic/Brain. You are referred to 70551-70555. Refer to the code descriptions. There are two codes describing functional MRI, which are 70554 and 70555. Because the test is performed by the technician, not a physician, the service is reported with 70554.

" A patient is positioned on the scanning table headfirst with arms at the side for an MRI of the thoracic spine and spinal canal. A contrast agent is used to improve the quality of the images. The scan confirms the size and depth of a previously biopsied leiomyosarcoma metastasized to the thoracic spinal cord. What CPT® and ICD-10-CM codes are reported?

" 72147, C79.49 In the CPT® Index look for Magnetic Resonance Imaging (MRI)/Diagnostic/Spine/Thoracic. Code 72147 describes an MRI of the thoracic spine with contrast. The diagnosis is a secondary (metastasized) cancer to the thoracic spinal cord. Look in the ICD-10-CM Alphabetic Index for Leiomyosarcoma which states see also Neoplasm, connective tissue, malignant. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/connective tissue NEC/cord (true) (vocal)/spinal (thoracic) and select from the Malignant Secondary (column) you are guided to code C79.49.

"CASE 2 Location: Regional Hospital(The hospital will report the technical component. Only the professional component should be reported.) MRI OF THE LUMBAR SPINE History: Low back pain.(Reason for the MRI, also known as Lumbago.) Technique: On a 1.5 Tesla magnet multiple sagittal and axial(Sagittal and axial images were taken.) images were performed through the lumbar spine(Location—lumbar spine.) using variable pulse sequences. Findings: There is normal lumbar alignment. The conus is in normal position at the thoracolumbar junction. No suspect bone marrow lesions are present. There is mild anterior wedging of the L3 vertebral body. I am uncertain whether this is an acute or chronic finding. At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis. At the L1-2 level, there is no disc bulge or protrusion. There is no central canal or neural foraminal stenosis. At the L2-3 level, there is moderate loss of disc height. There is 106s of T2 signal. There is a focal area of increased T1 signal involving the L2-3 disc. This could be related to disc calcification or possibly blood product. There is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis. At the L3-4 level, there is a minimal posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis. At the L4-S level, there is mild loss of disc height and loss of T2 disc signal. There is a moderate size right paracentral disc protrusion impinging the anterior aspect of the thecal sac. There is no central canal stenosis. There is no neural foraminal stenosis. At the L5-S1 level, there is no disc bulge or disc protrusion. There is no central or neural foraminal stenosis. IMPRESSION: Mild anterior wedging of the L3 vertebral body.(Wedging of vertebrae is considered Osteoporosis.) It is uncertain whether this is acute or chronic finding. There is increased T1 signal involving the L2-3 disc which could be related to calcification or possible hemorrhage although this is felt to be less likely. Moderate size right paracentral disc protrusion at L4-5.(Disc protrusion is coded as intervertebral disc displacement and is in the lumbar region.) Multilevel degenerative disc disease.(Degenerative Disc Disease covers more than one level in the lumbar spine.) What are the CPT® and ICD-10-CM codes reported for this service? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 72148-26, M48.56XA, M51.26, M51.36

"CASE 1 Location: Imaging center, radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.) STUDY: FEMUR AP AND LATERAL(2 views taken.) REASON: LEFT LEG PAIN LEFT FEMUR: COMPARISON: There are no prior studies for comparison. FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is concentrically seated within the acetabulum without deformity of the femoral head. IMPRESSION: Normal (Findings are normal, the reason for the study is used for the diagnosis.) views of the left femur. What are the CPT® and ICD-10-CM codes reported for this service? CPT® code: [a] ICD-10-CM code: [b]

" 73552-LT, M79.605

" A patient arrives at the urgent care facility with a swollen ankle. Anteroposterior and lateral view X-rays of the ankle are taken to determine whether the patient has a fractured ankle. What CPT® code(s) is/are reported?

" 73600 In the CPT® Index look for X-ray/Ankle and you are guided to range 73600-73610. There were two views taken (anteroposterior and lateral views), so CPT® code 73600 is correct.

"CASE 9 Location: Regional Hospital EXAMINATION: 1. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT ABDOMEN - NEUTRAL ENTERAL WITH IV CONTRAST- 2D REFORMATS) 2. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT PELVIS - NEUTRAL ENTERAL WITH IV CONTRAST - 20 REFORMATS) Clinical Indication: Unexplained abdominal pain and diarrhea, as well as weight loss. Normal colonoscopy. Comparison: None. PROCEDURE: In accordance with policy and procedure standard medication reconciliation was performed by the radiologic technologist prior to IV contrast administration. No contraindication was identified. The examination was performed in accordance with the standard protocol on a 43-year-old male. Following preprocedure assessment, informed consent was obtained. Conscious sedation Independent observation performed by Amy Smith, RN. Total Time of Sedation: 60 minutes. Vital signs, pre-procedure and post-procedure monitoring were done by nurse in attendance with me performing the conscious sedation. A transnasal intubation was done following a nasal drop of a local anesthetic. Under fluoroscopic guidance, using guidewire and positional maneuvers, the enteroclysis catheter was advanced and the tip anchored at the distal horizontal duodenum. Neutral enteral contrast was infused and monitored to a total of approximately 3.5 L. 0.6 mg Glucagon was administered IV prior to IV contrast administration. CT acquisition was done during continued infusion of enteral contrast following a 45 to 50 seconds delay. Intravenous administration of 100 ml lsovue 370 at 4 ml/second infusion rate. CT parameters used were 40 x 0.625 mm collimation reconstructed at 2 mm section thickness reconstructed at 1 mm intervals. The source images were transferred to an independent workstation (EBW) and cross referenced multiplanar interactive 2D interpretation was done by the radiologist. Images were reviewed using soft tissue window settings. Following completion of the infusion, the catheter was withdrawn into the stomach and refluxed contrast removed prior to catheter removal. No acute adverse events occurred. FINDINGS: There is no evidence of transmural inflammatory disease changes involving the small bowel or the colorectum. There is, however, mild prominence of the vasa recta in the right lower abdomen, mild increased attenuation of the cecum and ascending colon and adjacent distal small bowel. Suggest biopsy at the ascending colon to exclude microscopic colitis. If the patient has a history of blood in the stools, air double-contrast enteroclysis would be of value to exclude aphthous ileitis. CT enteroclysis may not be able to assess for early Crohn's until transmural involvement is seen. The rest of the colon also appears normal. There are no fold changes to suggest adult celiac disease. There is no evidence of a small bowel mass. The mesentery appears normal. Solid abdominal organs are grossly unremarkable. IMPRESSION: 1. No evidence of transmural inflammatory disease changes involving the small bowel or colorectum. No fold abnormalities to suggest sprue. 2. Prominence of vasa recta of cecum and ascending colon and distal ileum with question of mild increased attenuation. Consider microscopic colitis. See discussion and recommendation above. If there is strong clinical suspicion of Crohn's disease, consider air DC barium enteroclysis to exclude or confirm early aphthoid changes. 3. Reproduction of abdominal pain during contrast infusion, thus, correlated for visceral hypersensitivity. 4. Solid abdominal organs grossly unremarkable. What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b], [c], [d], [e] ICD-10-CM codes: [f], [g], [h]

" 74177-26, 74340-26, 44500, 99152, 99153X3, R10.9, R19.7, R63.4

" A 55 year-old female is having a diagnostic mammogram performed on her left breast because a screening mammogram detected density in the breast. What CPT® and ICD-10-CM codes are reported?

" 77065-LT, R92.2 Diagnostic mammograms differ from screening mammograms. The examination focuses specifically on an area of breast tissue appearing abnormal in a screening mammogram. In the CPT® Index look for Mammography; or look for Breast/Diagnostic Imaging/Mammography, Diagnostic. The mammogram was performed only on the left breast (unilateral) reporting code 77065 and appending the LT modifier. Because this is not a screening mammogram, the Z codes for screening would be inappropriate to report. In the ICD-10-CM Alphabetic Index look for Findings/mammogram NEC/inconclusive result (due to dense breasts) or look for Dense breasts which refers you to code R92.2. Verify code selection in the Tabular List

" A 40 year-old female is scheduled for a routine screening baseline bilateral mammogram with computer-aided detection (CAD). What are the CPT® and ICD-10-CM codes reported?

" 77067, Z12.31 In the CPT® Index look for Mammography/Screening Mammography or Mammography/ with Computer-Aided Detection (CAD). Code 77067 is for the screening bilateral mammography with computer aided detection. Look in the ICD-10-CM Alphabetic Index for Screening/neoplasm (malignant) (of)/breast/routine mammogram and you are guided to Z12.31.

"CASE 3 Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.) STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS, PRODUCING DIRECT DIGITAL IMAGE REASON: SCREEN BILATERAL DIGITAL MAMMOGRAPHY WITH COMPUTER-AIDED DETECTION (CAD) (Use of CAD.) No previous mammograms are available for comparison. CLINICAL HISTORY: The patient has a positive family history of breast cancer.(Family history of breast CA.) Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system. FINDINGS: Residual fibroglandular breast parenchymal tissue is identified bilaterally. No dominant spiculated mass or suspicious area of clustered pleomorphic microcalcifications are apparent. Skin and nipples are seen to be normal. The axilla is unremarkable. IMPRESSION: BIRADS 1 - NEGATIVE(Negative screening.) What are the CPT® and ICD-10-CM codes reported for this service? CPT® code(s): [a], ICD-10-CM code(s): [b], [c]

" 77067, Z12.31, Z80.3

Anesthesia start time is reported as 7:14 am, and the surgery began at 7:26 am. The surgery finished at 8:18 am and the patient was turned over to PACU at 8:29 am, which was reported as the ending anesthesia time. What is the anesthesia time reported?

" 7:14 am to 8:29 am (75 minutes) Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. Anesthesia start time (7:14) and anesthesia end time (8:29) calculates as 1 hour and 15 minutes or 75 minutes of total anesthesia time.

"CASE 10 Clinical Indications: Inpatient day 32 in ICU with fever, hematuria, generalized edema, pneumonia URINE FUNGAL CULTURE - Urine Special Requests: None Culture: No fungus isolated in 30 days LOWER RESP FUNGAL W/DIR. EXAM - Sputum Special Requests: None Stain for Fungus: No fungi seen Culture: One colony Candida albicans BLOOD FUNGAL CULTURE - Blood Arm, Right Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks BLOOD FUNGAL CULTURE - Blood Right IJ Catheter SWAN Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks What are the CPT® and ICD-10-CM codes? CPT® Codes: [a], [b], [c], [d], ICD-10-CM Codes: [e], [f], [g] 87102, 87102-59, 87103, 87103-59, J18.9, R60.1,

" 87102, 87102-59, 87103, 87103-59, J18.9, R60.1, R31.9

" "CASE 9 Requested by D Freeman, MD SURGICAL PATHOLOGY REPORT Collected: 4/20/20XX Received: 4/20/20XX. The pathologist providing the service is an employee of the lab. CLINICAL DATA: Post-heart transplant, rule out rejection. GROSS DESCRIPTION: A) Received in a scant amount of formalin labeled ""right ventricle endomyocardium"" are seven tan-brown, irregular soft tissues averaging 0.1 cm in greatest dimension. The specimen is submitted in toto in cassette A1. B) Received in a vial of immunofluorescence fixative labeled ""right ventricle endomyocardium"" are two tan, irregular soft tissues averaging 0.1 cm in greatest dimension. Specimen is entirely submitted for immunofluorescence. MICROSCOPIC DESCRIPTION: A) Sections of the paraffin-embedded material show six fragments of myocardium which are adequate to evaluate. There are few mononuclear cells present within the tissue, but these are beneath the threshold required to diagnose biologically meaningful rejection. No cell injury is seen and no inclusion bodies are noted. B) Sections of the frozen myocardium demonstrate two fragments of myocardium and one fresh blood clot. There is no inflammatory cell infiltrate. IMMUNOFLUORESCENCE REPORT: Tissue, received in transport media, is washed in buffer and snap frozen in liquid nitrogen-cooled isopentane. Acetone-fixed frozen sections of the snap-frozen tissue are incubated with fluorescein-conjugated polyclonal antibodies to IgG, IgM, IgA, C3, C1q, fibrinogen, and albumin. Localization is thus via direct immunofluorescence. Indirect immunofluorescence staining of peritubular capillaries for C4d. Results are as indicated below: Block (Original Label): B Population: Microvascular endothelium Label Marker For Results Special Pattern or Comments C4d C4d (Quidel Clone A213), immunofluorescence 2+ Venule staining with high interstitial background .Block (Original Label): B1 Population: Microvascular endothelium Label Marker For Results Special Pattern or Comments IgG IF IgG, immunofluorescence Negative Interstitial staining IgA IF IgA, immunofluorescence Negative IgM IF IgM, immunofluorescence 2+ Capillary and venule staining C3 IF C3, immunofluorescence 2+ Venule staining C1q IF C1q, immunofluorescence 2+ Venule staining FIB IF Fibrinogen, immunofluorescence Negative Diffuse interstitial staining ALB IF Albumin, immunofluorescence Negative Diffuse interstitial staining FINAL DIAGNOSIS: A, B) Right ventricular endomyocardial biopsy: 1. No significant cellular rejection. 2. Immunofluorescence studies positive for humoral/vascular rejection (IgM and complement present). Please see comment. COMMENT: A, B) This is the 4th biopsy since transplant. Compared to his most recent biopsy, the current specimen shows no change in the degree of cellular rejection. What are the CPT® and ICD-10-CM codes? CPT® Codes: [a], [b], [c] ICD-10 Code: [d]

" 88307x2, 88346, 88350x7, T86.21

" "CASE 8 Location: Regional Hospital EXAM: Renal and bladder ultrasound dated 10/01/20XX Renal artery Doppler evaluation dated 10/01/20XX COMPARISON: Renal MRA dated 04/01/20XX HISTORY: 80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study. FINDINGS: Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for interpretation. The right kidney measures 10.1 cm without evidence of pelvic caliectasis. There is a small 8mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and appears within normal limits. The aorta demonstrates peak systolic velocity of 1.07 m/sec. The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70. The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77. The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67. The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63. The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69. IMPRESSION: RENAL ARTERY DOPPLER STUDY: 1. Moderate stenosis of the right renal artery origin. 2. Mild to moderate left renal artery origin stenosis. RENAL AND BLADDER ULTRASOUND: 1. Bilateral probable renal cysts. 2. Normal appearing bladder What are the CPT® and ICD-10-CM codes reported for this service? CPT® codes: [a], [b] ICD-10-CM code: [c]

" 93976-26, 76770-26-59, I70.1

"CASE 5 Mark is a 45-years-old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. PAST SURGICAL HISTORY: Nasal surgery, knee surgery. (Past medical history) SOCIAL HISTORY: Cigarettes: None. (Social history) FAMILY HISTORY: He does have a family history of melanoma in his paternal grandfather who died from it. (Family history) PHYSICAL EXAMINATION: On examination, he has subcutaneous masses of his left forearm and two spots of his left posterior arm. That is the biggest of those three. It is about 1.3 cm. He has four on his right upper extremity, two on his lower forearm and two on his posterior arm. He has some of his belly. (Organ: Skin) MEDICAL DECISION MAKING: The patient has multiple lipomas (Diagnosis) which are tender. He would like them removed. With his permission, I have drawn how we would incise the skin over these and about how long the scar would be. There is really no alternative to treatment other than surgery. Some plastic surgeons will do this with liposuction, but I have found that personally the recurrence rate is quite high when I have tried to do it with liposuction, so I generally just excise them. Risks would include infection and bleeding. (Elective major surgery (removal of subcutaneous lipoma has a 90-day global); although provider documents risk of infection and bleeding, this is not above the normal risk associated with a surgery.) We do not know why people get these, so this is something that Mark will have to deal with forever. We will do that here in the office. We will do about three at a time. We are going to start with his left upper extremity. It will be a privilege to take care of Mark. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 99201, D17.21, D17.22, D17.1

" A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritis and a history of cardiac disease. The provider performs a detailed history, comprehensive exam and a medical decision making of moderate complexity. What CPT® code is reported?

" 99203 In the CPT® Index look for Office and/or Other Outpatient Services/Office Visit/New Patient and you are directed to codes 99201-99205. For New Patient visits, all three key components must be met. This service supports a level 3 new patient visit, 99203.

"CASE 2 The patient is a 32-year-old male here for the first time. (New patient.) Chief Complaint: Left knee area is bothersome,(Chief complaint.) painful moderate severity.(HPI: Severity) The patient also notes swelling (HPI: Associated Signs & Symptoms) in the knee area,(HPI: Location) limited ambulation,(HPI: Severity again (not counted twice)) and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. (HPI: Duration) Problem occurred spontaneously. Problem is sporadic.(HPI: Timing) Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems, so patient has avoided using it. (HPI: Modifying factors and their affects.) Past Medical History: Patient denies any past medical problems. Surgeries: Patient has undergone surgery on the appendix. Hospitalizations: Patient denies any past hospitalizations that are noteworthy. Medications: Hydrocodone Allergies: Patient denies having allergies. (PFSH: Past Medical History) Family History: Mother: No serious medical problems; Father: No serious medical problems.(PFSH: Family History) Social History: Patient is married. Occupation: Patient is a chef. (PFSH: Social History) Review of Systems: Constitutional: Denies fevers. Denies chills. Denies rapid weight loss. Eyes: Denies vision problems. Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems. Cardiovascular: Denies chest pains. Denies an irregular heartbeat. Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath. Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool. Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination. Integumentary: Denies any rashes. Denies having any insect bites. Neurological: Denies numbness. Denies tremors. Denies loss of consciousness. Hematologic/Lymphatic: Denies easy bruising. Denies blood clots. Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite. (ROS: Complete) Review of Previous Studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. (Previous studies reviewed used in MDM.) Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. (Exam: Eyes) Gait is normal. (Exam: Musculoskeletal) Skin is intact. No rashes, abrasions, contusions, or lacerations. (Exam: Skin)No venous stasis. No varicosities. (Exam: Cardiovascular) Reflexes are normal patellar. No clonus.(Exam: Neuro) Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. (Exam: Musculoskeletal) Neck: Neck is supple. No JVD. (Exam: Neck) Impression: 1. Infective synovitis of the left knee 2. Contracture of the left knee 3. Possible medial meniscal tear of right knee (Uncertain diagnosis) Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day (Over the counter medication), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy.(Physical therapy prescribed) We will obtain an MRI (Additional test ordered) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Uncertain prognosis on the tear. The patient is sent for additional work-up to determine if there is a tear present.) What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 99203, M65.162, M24.562

" "CASE 1 IDENTIFICATION: The patient is a 37-year-old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37-year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist. PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

" 99212, M79.89, I27.20

"CASE 6 Hospital progress note Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain. The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date. Objective: Vital Signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98. General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). Laboratory Data: Shows C Diff-toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. Assessment: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Hypokalemia 6. Diabetes mellitus type 2 7. Hypertension If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest-x-ray PA and lateral this morning to evaluate that. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h]

" 99232, K80.20, N30.90, H10.9, E87.1, E87.6,E11.9, I10

" " A 33 year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?

" 99238 The patient is being discharged from the hospital. Hospital discharge codes are determined based on the time documented the provider spent providing services to discharge the patient. The provider documented 20 minutes which is reported with 99238.

" 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?

" G0101 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.

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Waiver of liability statement on file (goes with ABN) Do not type the word "Modifier" for your answer. [a] [b]

" GA, GU

" " Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk, but her mother has returned to work and is using a breast pump but has not seemed to produce enough milk. PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week. ASSESSMENT Four month-old well check Cold Mild thrush Diaper rash PLAN: Okay to advance to baby foods Okay to supplement with Similac Nystatin suspension for the thrush and creams for the diaper rash if it recurs Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio What E/M code(s) is/are reported?

" 99391 Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 25.

" CASE 4 AGE: 33-year-old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.) HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. (Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.) PAST MEDICAL HISTORY: Depression. FAMILY HISTORY: no cancer or heart disease, mother has hypertension. SOCIAL HISTORY: TOBACCO USE: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. REVIEW OF SYSTEMS: Patient denies any symptoms in all systems except for HPI. PHYSICAL EXAM: (Comprehensive physical exam.) CONSTITUTIONAL: Well developed, well-nourished individual in no acute distress. EYES: Conjunctivae appear normal. PERLA ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx. NECK: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted. RESPIRATORY: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. CARDIOVASCULAR: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema. CHEST/BREAST: Breasts normal to inspection with no deformity, no breast tenderness or masses.(Breast exam.) GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all 4 quadrants. GU: EXTERNAL/VAGINAL: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.(Thin prep Pap smear collection.) CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.(Pelvic exam.) ADNEXA/PARAMETRIA: No masses or tenderness noted. LYMPHATICS: No lymphadenopathy in the neck, axillae, or groin. MUSCULOSKELETAL EXAM: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability. EXTREMITIES: BILATERAL LOWER: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone. SKIN: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers. NEUROLOGIC: CNs II-XII grossly intact. PSYCHIATRIC: Mood and affect appropriate. LABS/RADIOLOGY/TESTS: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, PAP smear. ASSESSMENT/PLAN: UNSPECIFIED ACQUIRED HYPOTHYROIDISM What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

" 99395, Z00.00, Z01.419, E03.9

" A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?

" 99475 This visit meets the criteria for Inpatient Neonatal and Pediatric Critical Care. Codes 99471-99476 are used to report the direction of the inpatient care of a critically ill infant or young child from 29 days through less than 6 years. Codes are further divided by initial and subsequent care. This is the initial care of a critically ill 3 year-old. Services provided in the ER by the admitting provider may not be coded. When a neonate, infant or child requires initial critical care services on the same day the patient has already received hospital care or intensive care services by the same provider, only the initial critical care service code (99468, 99471, 99475) is reported. Code 99475 is the correct code for this service.

"A 22-year-old female is admitted to ICU for acute renal (kidney) failure due to sepsis (causal organism unknown). Applying the coding concept from ICD-10-CM guideline I.C.1.d.1.b, what ICD-10-CM codes are reported (in the correct sequencing)?

" A41.9, R65.20, N17.9 ICD-10-CM guideline I.C.1.d.1.b indicates: The coding of severe sepsis requires a minimum of two codes. First, a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional codes(s) for the associated acute organ dysfunction are also required (if present). The first code to report is sepsis; look for the main term Sepsis in the ICD 10-CM Alphabetic Index referring you to code A41.9. Next, look for Sepsis/with organ dysfunction (acute) (multiple) referring you to code R65.20. For the last code, look for Failure/renal/acute referring you to code N17.9. In the Tabular List you will find an instructional note under subcategory R65.2 indicating what codes should be reported first and what codes should be reported as additional codes.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Chlamydial inflammation of the testes

" A56.19 Inflammation and chlamydia are both main terms. In the ICD-10-CM Alphabetic Index, look for Inflammation, inflamed, inflammatory/testes, which directs you to see Orchitis. Orchitis is the inflammation of the testes. Look for Orchitis/chlamydial or Chlamydia, chlamydial/orchitis. You are referred to A56.19. Review the code in the Tabular List to verify the code accuracy. Under code A56.19 chlamydial orchitis is listed.

"CASE 9 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. OPERATIVE PROCEDURE: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen, as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room. OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times. We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken. What diagnosis code(s) are reported? [a] [b] [c] [d]

" B20, D73.3, K65.1, B19.20

" Which of the following are also known as the greater vestibular glands?

" Bartholin's glands 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.

"CASE 10 Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer. He's having some increasing pain in his breast which is due to the cancer. He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He's had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we'll obtain a bone scan to ascertain the extent of his disease. Sincerely, John Smith, M.D. What diagnosis code(s) are reported? [a] [b] [c] [d] [e]

" C50.922, G89.3, M54.2, Z17.0, Z79.810

" A 42-year-old male with thyroid cancer is admitted to the hospital for hypersecretion of calcitonin (functional activity) caused by the cancer. Choose the ICD-10-CM code(s) to report.

" C73, E07.0 When a patient has functional activity (thyrotoxicosis or disorders of thyrocalcitonin secretion) associated with a neoplasm, the neoplasm should be reported first, and the functional activity caused by the neoplasm is reported as a secondary code. There is no documentation of the patient having a history of other cancers so a Z code is not appropriate. In the ICD-10-CM Alphabetic Index look for Carcinoma/thyroid; there is no listing in the Alphabetic Index. Use the instruction - see also Neoplasm, by site, malignant which is next to Carcinoma. In the Table of Neoplasms, locate Neoplasm, neoplastic/thyroid (gland)/Malignant Primary (column) directing you to code C73. In the Tabular List, C73 states to "Use additional code to identify any functional activity." The second diagnosis code is in the Alphabetic Index under Hypersecretion/calcitonin directing you to code E07.0. Verify code selection in the Tabular List.

" "Physical Exam: CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90% GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is supple and the trachea is midline. Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft and nondistended. There is no tenderness, rebound or guarding noted. There are no masses. No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic. NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla. MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or edema to the digits. What is the level of exam?

" Comprehensive Organ Systems: Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Integumentary, Neurologic, Lymphatic, Musculoskeletal. Ten organ systems were examined. The level of exam is Comprehensive.

"A 50 year-old patient has a mass removed from his chest. The surgeon sends it to pathology. The pathology report indicates the mass is a benign tumor. What ICD-10-CM code is reported?

" D36.7 In the ICD-10-CM Alphabetic Index, in the Table of Neoplasms, look for Chest (wall) NEC and report the code from the benign column, D36.7. Verify code selection in the Tabular List.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Sickle-cell anemia

" D57.1 The main term is anemia. In the ICD-10-CM Alphabetic Index, look for Anemia/sickle-cell - see Disease, sickle-cell. Disease, diseased/sickle cell directs you to D57.1. Review the code in the Tabular List to verify the code accuracy. Sickle-cell anemia NOS is listed as an inclusion term under D57.1. Note: There is a category note under D57 to use an additional code for any associated fever. This is coded if known.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Ruptured spleen (not due to an injury)

" D73.5 The main term is ruptured. From the ICD-10-CM Alphabetic Index look for Rupture, ruptured/spleen/nontraumatic. You are referred to D73.5. Review the code in the Tabular List to verify the code accuracy. The diagnosis documents the rupture of the spleen was not due an injury, also called nontraumatic. Splenic rupture, nontraumatic is listed as an inclusion term under D73.5.

" According to CPT® guidelines what is the first step in selecting an evaluation and management code?

" Determine the category or subcategory According to the CPT® guidelines the first step to determining a level of evaluation and management visit is to determine the category or subcategory of service.

" What is the term for uncontrolled muscle movements?

" Dyskinesia Dyskinesia is the term for uncontrolled muscle movements.

"CASE 4 SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall she feels quite well. Unfortunately, she has put on 20 pounds since our last visit. OBJECTIVE: HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage. Neck: No significant adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated. ASSESSMENT 1. Diabetes mellitus, type 1. 2. Diabetic neuropathy. 3. Acute sinusitis. (The definitive diagnoses are reported.) PLAN: At this time, I have recommended the addition of some Keflex for her acute sinusitis.(Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required. What diagnosis code(s) are reported? [a] [b]

" E10.40, J01.90

" What ICD-10-CM code is reported for a type 2 diabetic cataract on the left eye?

" E11.36 Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/type 2/with/cataract which directs you to code E11.36. Verify code selection in the Tabular List. Note that this is a combination code that define the disease and complication with one code.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Uncontrolled diabetes with diabetic cataracts

" E11.36 The main term is diabetes. In the ICD-10-CM Alphabetic Index, look for Diabetes, diabetic/with/cataract. You are referred to E11.36. Review the code in the Tabular List to verify the code accuracy. The term uncontrolled is not a factor in code selection for diabetes under ICD-10-CM. Note: There is a note to use an additional code under the category E11 to identify if the diabetes is controlled with insulin, oral antidiabetic drugs, or oral hypoglycemic drugs if known.

"Surgical procedure: Myringotomy What anatomic location is being operated on?

" Ear

"Documentation: Recession of left inferior rectus muscle, 5 mm. What anatomic location is being operated on?

" Eye

"CASE 7 Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability. Exam: Pleasant 85-year-old woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort. Impression: 1. Dementia 2. Right shoulder pain. 3. Benign hypertensive cardiovascular disease, a complication of diabetes. 4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115. Plans: 1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from cerebral small vessel disease or Alzheimer's is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test. 2. For the shoulder we decided on right deltoid bursa steroid injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection. 3. Follow up in 3 months. Procedure: Injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the posterolateral edge of the acromion and into the subacromial space and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time. What diagnosis code(s) are reported? [a] [b] [c] [d]

" F03.90, I11.9, M25.511, E11.59 The patient has multiple diagnoses. It's important to report the diagnoses that the provider treated during the encounter and any chronic conditions that affect the care of the patient. The provider documents that the patient has dementia. The provider is not sure of the cause. Look in the ICD-10-CM Alphabetic Index for Dementia which directs you to F03.90 . The provider performs a joint injection to treat the patient's right shoulder pain. In the Alphabetic Index, look for Pain(s)/joint/shoulder which directs you to M25.51-. Turn to the Tabular List for the 6th character to indicate the right shoulder, M25.511. The patient is also diagnosed with benign hypertensive cardiovascular disease. The provider reviewed the labs (cholesterol and LDL) to monitor this condition. In the Alphabetic Index, look for Hypertension, hypertensive (benign)/cardiovascular/ disease (arteriosclerotic) (sclerotic) - see Hypertension, heart. Look for Hypertension, hypertensive (benign)/heart which directs you to I11.9. The last diagnosis listed is controlled type 2 diabetes. In the ICD-10-CM Alphabetic Index, look for Diabetes, diabetic/type 2/with circulatory complication NEC which directs you to code E11.59. Verify codes in the Tabular List. E11.59 is reported, because the physician documents the hypertension and heart disease are complications of diabetes.

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Right hand, thumb Do not type the word "Modifier" for your answer.

" F5

"CASE 5 PREOPERATIVE DIAGNOSIS: Cataract, left eye POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia(Report the postoperative diagnosis.) PROCEDURE: 1. Cataract extraction with IOL implant 2. Correction of presbyopia(Patient is also diagnosed with presbyopia.) with lens implantation PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with a Supersharp blade. Non-preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition. What diagnosis code(s) are reported? [a] [b]

" H26.9, H52.4

" A child is exhibiting leukocoria in the left eye, and an MRI of the skull is ordered to rule out retinoblastoma. What diagnosis code is reported?

" H44.532 Look in the ICD-10-CM Alphabetic Index for Leukocoria and you are directed to see Disorder, globe, degenerated condition, leucocoria. Disorder/globe/degenerated condition/leucocoria directs you to H44.53-. In the Tabular List, 6th character 2 is reported to indicate the left eye. Leucocoria reports a symptom rather than an actual diagnosis. In leucocoria, an abnormal white reflection from the retina is visible through the pupil upon examination of the eye. It can be indicative of retinoblastoma, a congenital retinal cancer, but until this diagnosis is confirmed, the symptom of leucocoria is the appropriate diagnosis to report.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Otitis media left ear

" H66.92 The main term is otitis. In the ICD-10-CM Alphabetic Index, look for Otitis/media. There is no additional information provided. You are referred to H66.9-. The dash indicates an additional character is required for a complete code. Review the code in the Tabular List for the 5th character. Under subcategory H66.9 you will see Otitis Media NOS listed. The 5th character is 2 indicating the infection is in the left ear. This is an infection of the middle ear (media).

"CASE 2 PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.) PROCEDURES PERFORMED: 1. Placement of left Nucleus cochlear implant. 2. Facial nerve monitoring for an hour. 3. Microscope use. ANESTHESIA: General. INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for the surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed. PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4-0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition. What diagnosis code(s) are reported?

" H90.3

"ED Visit: Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the chest x-ray, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD which is stable and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ED, to go directly to the unit. What is the level of medical decision making?

" High New problem to examiner, additional workup; dialysis (four points); Labs, EKG, and X-ray reviewed (three points); risk is High (chronic illness posing a threat to life). The medical decision making is High.

" "Subsequent Hospital Visit LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12. IMPRESSION: 1. Severe exacerbation of CHF 2. Poorly controlled HTN 3. Worsening ARF due to cardio-renal syndrome PLAN: 1. Increase BUMEX to 2 mg IV Q6. 2. Give 500 mg IV DIURIL times one. 3. Re-check usual labs in a.m. Total time: 20minutes. What is the level of medical decision making?

" High Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.

"CASE 3 CC: HTN INTERVAL HISTORY: No new complaints. EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema. IMPRESSION: Stable HTN(Patient is diagnosed with hypertension.) on current meds. PLAN: No changes needed. RTC in six months with labs. What diagnosis code(s) are reported?

" I10

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Hypertensive heart disease

" I11.9 The main term is disease. In the ICD-10-CM Alphabetic Index, look for Disease, diseased/heart (organic)/hypertensive and you are directed to see Hypertension, heart. Hypertension, hypertensive/heart directs you to I11.9. Review the code in the Tabular List to verify the code accuracy. Note: There is a category note for I10-I15 to use additional code to identify exposure to, use of, or dependence of tobacco. This is coded if known.

" What ICD-10-CM code is reported for angina pectoris with a documented spasm?

" I20.1 Look in the ICD-10-CM Alphabetic Index for Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor)/with/documented spasm which directs you to I20.1. Verify code selection in the Tabular List.

"CASE 8 S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia. His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn't feel he's eating more, but his wife says he's eating more. We've been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD 2. Hyperlipidemia P: 1. The plan is samples of Lipitor using the two months' supply that I have given him. 2. We've increased his Coreg to 25mg bid. He'll recheck with us in six months. What diagnosis code(s) are reported? [a] [b] [c] [d]

" I25.10, E78.5, Z87.891, Z79.899

"CASE 6 Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on. 0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. Assessment: Atrial fibrillation, currently stable Plan: 1. Prothrombin time to monitor long term use of anticoagulant. 2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today. What diagnosis code(s) are reported? [a] [b] [c]

" I48.91, Z79.01, Z51.81

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Novel H1N1 flu

" J10.1 The main term is flu. In the ICD-10-CM Alphabetic Index, look for Flu there are no subentries for Novel or H1N1. It does instruct you to see also Influenza. Look for Influenza/novel (2009) H1N1 influenza. You are referred to J10.1. Review the code in the Tabular List to verify the code accuracy. Note: There is a use additional code note for associated pleural effusion or sinusitis, if applicable.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Acute asthma exacerbation

" J45.901 The main term is asthma. In the ICD-10-CM Alphabetic Index, look for Asthma, asthmatic/with/exacerbation (acute) J45.901. Review the code in the Tabular List to verify the code accuracy. Note: There is a category note for J45 to use additional code to identify exposure to, use of, or dependence of tobacco. This is coded if known.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: GERD

" K21.9 GERD is an acronym for gastroesophageal reflux disease. The main term is disease. This diagnosis can be located in the index under the acronym or the main term. In the ICD-10-CM Alphabetic Index, look for GERD (gastroesophageal reflux disease) or look for Disease/gastroesophageal reflux (GERD). You are referred to K21.9. Review the code in the Tabular List to verify the code accuracy.

"CASE 1 PROGRESS NOTE This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum(Patient's presenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid(This is reported by the patient, but not documented in the exam or assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy. Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding(Report the code documented in the assessment.) PLAN: We'll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported?

" K62.5

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Acute cholecystitis with chronic cholecystitis

" K81.2 The main term is cholecystitis. In the ICD-10-CM Alphabetic Index, look for Cholecystitis/acute/with/chronic cholecystitis. You are referred to K81.2. Review the code in the Tabular List to verify the code accuracy. Two codes are not reported for the acute and chronic cholecystitis because there is a combination code that fully identifies all the elements documented in the diagnosis.

"Documentation: Suprapatellar recess showed no evidence of loose bodies or joint pathology. What anatomic location does this refer to?

" Knee (above the patella)

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Cellulitis of the arm

" L03.119 The main term is cellulitis. In the ICD-10-CM Alphabetic Index, look for Cellulitis/arm - see Cellulitis, upper limb. Look for Cellulitis/upper limb and you are referred to L03.11-. The dash indicates another character is required for a complete code. Review the code in the Tabular List to report the 6th character and verify the code accuracy. The diagnosis does not specify if the cellulitis is in the left or right arm, so report L03.119.

A 77 year-old patient was scheduled for a total hip replacement due to degenerative joint disease (DJD) and the anesthesiologist documented the DJD as primary. The pre-anesthesia assessment indicates the patient had surgery in 2015 for gastroesophageal reflux disease (GERD). What ICD-10-CM code(s) is/are reported?

" M16.10 The patient's previous surgery (GERD) has no relevance to the anesthesia care provided for the hip surgery and is not reported with a diagnosis code. In the ICD-10-CM Alphabetic Index look for Degeneration/joint disease which states to see Osteoarthritis. Look for Osteoarthritis/hip or Osteoarthritis/primary/hip which directs you to M16.1-. In the Tabular List confirm the subcategory code. M16.1- indicates that a 5 th character is needed to indicate laterality. We are not told which hip has the DJD so the coder would report M16.10.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Epigastric pain

" R10.13 The main term is pain. In the ICD-10-CM Alphabetic Index, look for Pain/epigastric, epigastrium. You are referred to R10.13. Review the code in the Tabular List to verify the code accuracy.

"CASE 2 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes. Cardiovascular: RRR, no MRGs, no edema. Respiratory: Lungs CTA, normal respiratory effort. GI: NABS, no HSM. Skin: Warm and dry, decreased turgor. Psychiatric: A&OX3 with appropriate affect. Labs: BUN = 99, creatinine = 3.6, HCO3 = 14, K = 5.9. IMPRESSION 1. New, acute renal failure, due to dehydration 2. Underlying stage III CKD 3. Mild hypotension (Code the definitive diagnoses documented by the provider.) PLAN 1. Bolus with another liter of NS wide open. 2. Then start D5W with 3 amps of HCO3 at 150 cc/hr. 3. Repeat labs in eight hours. 4. Further diagnostic testing will be ordered if there is no improvement of volume repletion. What diagnosis code(s) are reported? [a] [b] [c] [d]

" N17.9, E86.0, N18.3, I95.9

" Using your ICD-10-CM Alphabetic Index, what is the diagnosis code for a patient with a postoperative diagnosis of uterus mass?

" N85.8 In the Alphabetic Index look for Mass, you will see there is no subterm for uterus. There is a subterm for specified organ NEC which states to see Disease, by site. Look for Disease/uterus/specified NEC which directs you to code N85.8. Confirm code in the Tabular list. You will not select code D39.8, uncertain behavior from the Table of Neoplasms because to report this code we need to see a pathology report to support the findings of a neoplasm of uncertain behavior.

" A 68-year-old female presents with vaginal bleeding. It has been 5 years since her last period. Choose the code to describe her bleeding.

" N95.0 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 7 HPI: 20-year-old female, estimated gestational age 25.3 weeks, who presents with red staining after wiping with toilet paper this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present. ROS: Constitutional: Negative. Headache: Negative. Urinary: Negative. Nausea: Negative. Vomiting: Negative. Past Medical/Family/Social History: Medical History: Negative. Surgical History: Negative. Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies. EXAM: General Appearance: No acute distress. Abdominal: Soft. Non-tender. Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink. No hyphae, BV, or TRICH, and CX not irritated. Cervix: Deferred. Uterus: Fundal height: 24 cm. MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU. Labs reviewed and WNL. Ultrasound: Negative for placenta previa. NOTES: Patient continues with contractions mildly, but does not feel it. Patient given Celestone I/M. D/C and to return tomorrow for repeat Celestone injection. Diagnosis: Threatened premature labor What diagnosis code(s) are reported? [a] [b]

" O47.02, Z3A.25

" " 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?

" O66.5, O34.212, Z3A.00, Z37.0 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.

"Documentation: There was no cleft of the uvula or submucosal palate by visual and palpable exam. What is being examined?

" Oral cavity

"Documentation: The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. In this statement, what does "os" stand for?

" Ostium (opening)

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Physical status modifier for a patient with a severe systemic disease Do not type the word "Modifier" for your answer.

" P3

" Which gland in the male reproductive system is partly muscular and partly glandular?

" Prostate The prostate gland is the gland that is partly muscular and glandular.

"CASE 6 PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus. POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus. CLINICAL HISTORY: The patient is a 2-month-old boy who was born and was IUGR. He did well for the first several weeks; however, he then developed a large head. Mom noticed full fontanelle arid in the last week or so, and they have noticed the eyes have decreased mobility. He tends to stare straight and has some trouble looking up and even to the sides bilaterally, so she reported it to her pediatrician. Pediatrician ordered a CT scan and referred the patient. I saw the patient yesterday in clinic. We ordered an MRI; MRI was done this morning. Initial read shows the congenital hydrocephalus; however, it is not a Dandy-Walker. We had a discussion with the family about risks, benefits, potential complications and also different procedures. We talked about a third ventriculostomy however, given the patient's age and the fact was hydrocephalus, he has elected to go with the shunt, Family is comfortable with this and will bringing him to the OR today for shunting. What diagnosis code(s) are reported?

" Q03.9

" "CASE 4 Subjective: The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches. The patient complains of cephalgias,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes or any smell changes. The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. Assessment: 1. Cephalgia 2. Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan: The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We'll recheck her in one month. What diagnosis code(s) are reported? [a] [b] [c]

" R51, M99.02, W20.8XXA

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Syncope

" R55 Look for Syncope in the ICD-10-CM Alphabetic Index. You are referred to R55. Review the code in the Tabular List to verify the code accuracy.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Left outer cheek abrasion, initial encounter

" S00.81XA The main term is abrasion. In the ICD-10-CM Alphabetic Index, look for Abrasion/cheek. You are referred to S00.81-. Review the code in the Tabular List to assign the 7th character and to verify the code accuracy. Because this code needs seven characters, the letter X is used as a placeholder for the 6th character, and the 7th character A is reported because the injury is an initial encounter.

"CASE 9 PREOPERATIVE DIAGNOSIS: 1. 2 cm transverse laceration of right forehead. 2. 3 cm stellate laceration of right upper eyelid. 3. 3 cm trap door laceration of right lower eyelid. OPERATIVE DIAGNOSIS: OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm. Anesthesia: Local. PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she was thoroughly evaluated by Dr. Tim and is in the process of getting C-spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is linear, deep, but otherwise uneventful. The upper right eyelid laceration is approximately 3 cm in length and the medial aspect of it is somewhat dusky because it is very thin and devoid of vasculature. The lower eyelid laceration is trap door and somewhat deep. It also becomes very thin at the medial aspect; however, there appears to be no duskiness. It seems to be well vascularized. In any event, we chose to immediately repair these with local anesthesia. DETAILS OF OPERATIVE PROCEDURE: Approximately a total of 6 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the three wounds. They were then thoroughly cleansed with soap, and closure was begun on the upper eyelid. We used 6-0 vicryl subcutaneous sutures to attack the flap back into position, and once this was accomplished, we used individual 6-0 Prolene sutures on the skin to complete the closure. Attention was then turned to the right lower eyelid laceration where essentially an identical procedure was done. The wounds were somewhat similar in that they were flaps pedicled to the lateral towards the medial. Again, we used 6-0 vicryl subcutaneous and 6-0 Prolene individual skin sutures. Finally, attention was turned to the forehead laceration which was similarly closed with these same sutures, 6-0 vicryl subcutaneous and 6-0 Prolene on the skin. The wounds were then dressed with Bacitracin ophthalmic. Patient was instructed to keep them moist at all times and to not let crust form. She was also instructed in the appropriate analgesics to be taken orally and given my office number for a follow-up appointment. At the end of the procedure, she was then sent back to x-ray for CT scan of her C-spine. What diagnosis code(s) are reported? [a] [b] [c]

" S01.111A, S01.81XA, V00.811A The patient has multiple lacerations. In the ICD-10-CM Alphabetic Index, look for Laceration/eyelid. You are referred to S01.11-. A review in the Tabular List reveals that you need to report 6th and 7th characters. The correct code is S01.111A to indicate the laceration is on the right eyelid without foreign body, and this is the initial encounter. Although there are two lacerations of the eyelid, both the upper and lower are reported with the same code and according to the ICD-10-CM guidelines I.B.12, it is only reported once. The code for the eyelids is sequenced first because they were the longest in length. Next, look for Laceration/forehead, you are referred to S01.81-. When verifying the code in the Tabular List, you are instructed to report a 7th character to indicate the type of encounter. The correct code is S01.81XA. An external cause code is reported to identify how the injury occurred. Documentation in the preoperative note indicates the patient fell from her motorized wheelchair. In the ICD-10-CM External Cause of Injuries Index, look for Fall, falling/out of/wheelchair/powered - see Accident, transport, pedestrian, conveyance, specified type NEC; look for Accident/transport/pedestrian/conveyance/wheelchair (powered)/fall. You are referred to V00.811. In the Tabular List, a 7th character is assigned. The complete code is V00.811A. The location where the accident occurred is not documented, so an additional external cause code is not reported. Verify all the codes in the Tabular List.

"Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Right eyebrow laceration, subsequent encounter

" S01.111D The main term is laceration. In the ICD-10-CM Alphabetic Index, look for Laceration/eyebrow and you are directed to see Laceration, eyelid. Look for Laceration/eyelid, and you are referred to S01.11-. Review the code in the Tabular List to report 6th and 7th characters and to verify the code accuracy. S01.111D is the correct code to report because the laceration is on the right side. The 7th character D is reported to indicate subsequent encounter.

" The patient reports she turned her head quickly while pruning a dogwood tree in her yard and a branch entered her right ear. She states that when she performs a Valsalva maneuver (exhaling with the mouth and nose firmly closed), she can hear air course through her ear. On examination, there is no foreign body present. A small perforation of the right eardrum is noted, which should heal independent of treatment. Her ear will be re-evaluated in two weeks. Select the correct diagnosis codes.

" S09.21XA, W60.XXXA, Y92.017, Y93.H2 This is an acute injury and in ICD-10-CM injuries have different categories for open wounds, lacerations, bites, and are specific to with or without a foreign body. In the ICD-10-CM Alphabetic Index, look for Wound/puncture wound - see Puncture. Look for Puncture/ear/drum directing you to S09.2-. In the Tabular List subcategory S09.2- requires a 5th digit for laterality and a 7th character for the type of encounter. Because S90.21 is a five-character code, the place holder X is needed to maintain the 7th character position. The complete code is S09.21XA. Codes in the H72.0- subcategory are for perforations persisting after an illness or injury is resolved. Code S00.401- is for a superficial injury, but this isn't superficial because it is in the middle ear. Do not confuse simple with superficial. External cause codes describe the circumstance of the injury. These codes are found in External Cause Of Injuries Index. Look for Contact/with/plant thorns, spines, sharp leaves or other mechanisms W60.Category W60 requires a 7th character for type of encounter. Because this is a three-character code, the placeholder X is needed to maintain the 7th character position. The complete code is W60.XXXA.. Next, in the External Cause Of Injuries Index for look for Place of occurrence/yard, private/single family house Y92.017. In the same index look for Activity/gardening Y93.H2. Verify these codes in the Tabular List. These External cause codes help establish the cause of the injury for the payer.

"CASE 10 PREOPERATIVE DIAGNOSIS: Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation. POSTOPERATIVE DIAGNOSIS: Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation. ANESTHESIA: Axillary block with general anesthesia. OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes. DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively. A dorsal/posterior approach to the fracture was performed with a standard recommended incision, location and technique. The interval between the extensor carpi radialis brevis and extensor digitorum communis was developed. The extensor pollicis brevis and the abductor pollicis were gently retracted one way or the other to expose the fracture site, and the fracture was just beneath this area. The radial sensory nerve was identified and protected throughout the procedure. The fracture was exposed with minimal soft tissue stripping. The bone holding forceps were placed on either side of the fracture, the overriding fracture was manipulated with gentle traction, and the fracture reduced. This effectively reduced the distal radioulnar joint. A small fragment, Synthes DCP locking plate was utilized to fix the fracture. Eight holes were utilized. Due to the nature of the fracture and the anatomy, there were three screws distal, four screws proximal, and the last hole was at the area of the fracture. Initially to achieve satisfactory bone to plate contact, three lag screws were required and these were placed initially. This was followed by placement of the remaining screws that were utilized proximal and distal to the fracture site to be locking screws. Intraoperative X-rays utilizing the C-arm were performed throughout the procedure to guide fracture reduction and hardware replacement. Final X-rays demonstrated excellent alignment of the fracture in the distal radioulnar joint. Excellent coaptation of the bony surfaces was obtained. Final irrigation of the wound was performed. The wound was closed in layers in a standard fashion. Splints were applied. Total tourniquet time was approximately 60 minutes. The patient tolerated the procedure well and went to the recovery room in satisfactory condition. Sponge and needle count is correct x2. Estimated blood loss is minimal. What diagnosis code(s) are reported?

" S52.351A

" A 65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening. CHIEF COMPLAINT: CHF INTERVAL HISTORY: CHF symptoms worsened since yesterday. Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome. REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins. PHYSICAL EXAMINATION: GENERAL: Mild respiratory distress at rest VITAL SIGNS: BP 168/84, HR 58, temperature 98.1. LUNGS: Worsening bibasilar crackles CARDIOVASCULAR: RRR, no MRGs. EXTREMITIES: Show worsening lower extremity edema. LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12. IMPRESSION: 1. Severe exacerbation of CHF 2. Poorly controlled HTN 3. Worsening ARF due to cardio-renal syndrome PLAN: 1. Increase BUMEX to 2 mg IV Q6. 2. Give 500 mg IV DIURIL times one. 3. Re-check usual labs in a.m. Total time: 20 minutes. What E/M Category is used for this visit?

" Subsequent Hospital Visit (99231-99233) This is a subsequent hospital visit which is reported with code range 99231-99233; because the patient was admitted in the hospital two days ago and the primary care physician has been seeing the patient since he has been admitted to the hospital. Initial Hospital Visit (99221-99223) is when the physician is admitting the patient to the hospital. Inpatient Consultation (99251-99255) is when the provider requests for another provider to see the patient to recommend care for a specific condition or to accept ongoing management for the patient's condition. Established Patient Office/Outpatient Visit (99211-99215) is when the patient is being seen in the office setting, not the hospital.

"List the CPT® or HCPCS Level II modifier(s) for the definition given. Left foot, great toe Do not type the word "Modifier" for your answer.

" TA

" The two structures that make up the uterus are

" The cervix and uterine fundus 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).

"Diagnosis: Kyphosis What anatomic location does this diagnosis most often refer to?

" Thoracic Spine

"Diagnosis: Vesicoureteral reflux. What is this a reflux of?

" Urine backflow from bladder into ureters

"Hysterosalpingogram report: "Right cornual contour abnormality." Where is the cornu (plural cornua) found anatomically for this case?

" Where the fallopian tubes connect to the fundus.

"Colles' fracture What anatomic location does this refer to?

" Wrist

"CASE 8 This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed. Past Medical History: Two vaginal deliveries, one in 1965 and another in 1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband. Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact. Neck: Thyroid not palpable. No jugular distention. Carotid pulses are present bilaterally. Breasts: Manual breast exam reveals no masses, tenderness or nipple discharge. The breasts are asymmetrical with no nipple discharge. Abdomen: No masses or tenderness noted. No hernias appreciated. No enlargement of the liver or spleen. Pelvic: Vaginal examination reveals no lesions or masses. Discharge is noted and a sample was collected for testing and sent to an outside laboratory for testing. No bleeding noted. Examination of the external genitalia reveals normal pubic hair distribution. The vulva appears to be within normal limits. There are no lesions noted. A speculum is inserted. There is no evidence of prolapse. The cervix appears normal. A cervical smear is obtained and will be sent to pathology. The speculum is removed and a manual pelvic examination is performed. It appears that the uterus is smooth and no masses can be felt. Rectal examination is within normal limits. Screening occult blood is negative. Uterus is not enlarged. Urinary: Urethral meatus is normal. No masses noted for urethra or bladder. Assessment and Plan: Routine Pap and pelvic; vaginal discharge. Patient had Pap and pelvic examination one year ago. Patient was sent to our in-house lab for blood draw today, and she is to follow-up in one week for lab results. What diagnosis code(s) are reported? [a] [b]

" Z01.411, N89.8

What surgical status indicator represents the Global Surgical Package for endoscopic procedures (without an incision) where there is no postoperative period after the day of the surgery?

"000" For endoscopic procedures (except procedures requiring an incision), there is no postoperative period. Surgical status indicator 000 is for endoscopies or minor surgical procedures with no preoperative or postoperative period. Any related services on the day of the procedure are generally included in the fee schedule payment amount and not paid separately; including evaluation and management services on the day of the procedure.

Using the CPT® Index, look for anesthesia for a modified radical mastectomy with internal mammary node dissection. Which of the following is the correct anesthesia code?

"00406 Anesthesia/Mastectomy is not listed in the CPT® Index. Look for Anesthesia/Breast to see the code range. Code 00406 is the appropriate anesthesia code for a radical mastectomy with internal mammary node dissection.

A 59 year-old patient is having surgery on the pericardial sac, without use of a pump oxygenator. The perfusionist placed an arterial line. What CPT® code(s) is/are reported for anesthesia?

"00560 In the CPT® Index look for Anesthesia/Heart which directs you to codes 00560-00567, 00580 or look for Anesthesia/Intrathoracic System which directs you to multiple code ranges. Refer to the numeric section to determine 00560 is the correct code without use of a pump oxygenator. The arterial line placement is NOT reported because the service was not provided by the anesthesiologist.

Using the CPT® Index, locate the anesthesia code for laparoscopic cholecystectomy. Which of the following is the correct anesthesia code?

"00790 A cholecystectomy is the surgical removal of the gallbladder. The gall bladder is an intraperitoneal organ located in the upper abdomen. Look in the CPT® Index for Anesthesia/Abdomen/Intraperitoneal and you are directed to code range 00790-00797, 00840-00851. A review of the codes verifies 00790 as the correct code. Another index option Is to look for Anesthesia/Laparoscopy.

Mr. Johnson, age 82, having been in poor health with diabetes and associated peripheral neuropathy, is having a fem-pop bypass. The anesthesiologist documents he has severe systemic disease. What code(s) is/are correct for anesthesia?

"01270-AA-P3, 99100 Fem-pop bypass is an abbreviation for femoral-popliteal bypass of arteries in the upper leg. Look in the CPT® Index for Anesthesia/Bypass Graft/Leg, Upper which directs you to code 01270. Review the code in numeric section to determine the correct code is 01270. The qualifying circumstance code 99100 is added to indicate the extreme age of the patient. Physical status modifier P3 indicates the patient has severe systemic disease.

A patient is diagnosed with actinic keratosis of the chest and arms. She presents to her physician's office for destruction of these lesions. Using cryosurgery, the physician destroys 4 lesions on the right arm, 4 lesions on the left forearm and 4 lesions on the chest. What CPT® and ICD-10-CM codes are reported?

"17000, 17003 x 11, L57.0 In the CPT® Index look for Destruction/Lesion/Skin/Premalignant, and you are directed to code ranges 17000-17004, 96567, 96573, 96574. 96567, 96573, and 96574 are for photodynamic therapy. Actinic keratosis is a premalignant lesion, so a code is chosen from code rage 17000-17004. Code selection is based on the number of lesions destroyed. In this case, 12 lesions were destroyed making CPT ® codes 17000, 17003 the correct code choices. Add-on code 17003 has the word each in its code description meaning this code can be reported in units when each lesion is destroyed from the second lesion through 14 lesions. In this case report 17003 x 11. Note: Code 17004 is only reported once when 15 or more lesions are removed and is not reported with codes 17000, 17003. In the ICD-10-CM Alphabetic Index look for Keratosis/actinic and you are directed to code L57.0. Verification of the code in the Tabular List confirms code selection.

" Mrs. Jones is a 90 year-old female having laparoscopic surgery on her gallbladder. Dr. Lot, the anesthesiologist for this case, documents she is a normal healthy person and begins to prepare the patient for surgery at 07:30 am. Surgery begins at 08:00 am. The surgery is concluded at 09:30 am. The anesthesiologist releases the patient to the PACU nurses at 09:45 am. How many minutes of anesthesia time transpired and what is the appropriate anesthesia code?

"2 hrs. 15 minutes, 00790-AA-P1, 99100 Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In this case the start time is 07:30 am and the end time is 09:45 am equaling a total of 2 hours and 15 minutes or 145 minutes of total anesthesia time. In the CPT® Index look for Anesthesia/Abdomen/Intraperitoneal which directs you to code ranges 00790-00797, 00840-00851. Review the numeric section to determine that the correct code is 00790 as the gallbladder is located behind the liver in the upper abdomen. AA modifier is to indicate the anesthesiologist performed the procedure. The physical status modifier is P1 for a normal healthy patient and the Qualifying Circumstances due to the patient age of 90 should be coded to 99100. The correct reporting for this procedure is 00790-P1, 99100 for 2 hrs. 15 minutes.

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

"20526, J3301 x 4 For the CPT® code, look in the CPT® Index for Injection/Carpal Tunnel/Therapeutic, 20526. Verify in the numeric section. Look in your HCPCS Level II codebook in the Table of Drugs and Biologicals for Kenalog, and you are referred to See Triamcinolone Acetonide, which refers you to J3300 and J3301. Check the tabular listing to verify. Kenalog-10 is not listed; however, Kenalog is listed under J3301. Code J3301 is reported for 10 mg, and 4 units are reported to cover the 40 mg given.

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

"24579-RT, S42.451A In the CPT® Index look for Fracture/Humerus/Condyle/Open Treatment which refers to 24579. The manipulation and internal fixation is included in 24579. The application of the first cast is always bundled with the initial surgical service and not reported separately. In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/humerus/lower end/condyle/lateral (displaced) referring you to S42.45-. In the Tabular List seven characters are required to report the code. The 6 th character is specific to left or right. Documentation supports this as the right elbow, and the 7 th character A is supported as this is the initial surgical procedure. The complete code is S42.451A. This is the open treatment of a closed fracture, so the 7 th character B is not reported.

A patient with partial vocal cord paralysis requires bilateral removal of the arytenoids cartilage to improve breathing. The laryngoscope with operating microscope is inserted. Adequate visualization is established and the arytenoid cartilage is exposed by excision of the mucosa overlying it. What diagnosis and procedure codes are reported for this procedure?

"31561, J38.02 In the CPT® Index look for Laryngoscopy/Fiberoptic/Operative/Arytenoidectomy, referring you to codes 31560, 31561. 31561 is appropriate for a direct operative laryngoscopy with arytenoidectomy using an operating microscope. There is a parenthetical note under code 31561 that states, "Do not report code 69990 in addition to code 31561". In the ICD-10-CM Alphabetic Index look for Paralysis/vocal cords/bilateral directing you to code J38.02 which is confirmed in the Tabular List.

" The pulmonologist in a multispecialty group refers a patient to the otolaryngologist because he thinks that the shortness of breath that the patient is experiencing may be due to sinusitis and laryngopharyngeal reflux (LPR). The otolaryngologist decides to perform a rigid bilateral nasal endoscopy to get a better look at what is going on in the sinuses and a flexible laryngoscopy to determine if (LPR) is contributing to the problems because he could not get adequate visualization on manual exam. First the bilateral nasal endoscopy is performed and the otolaryngologist diagnosis chronic pansinusitis. Next a flexible fiberoptic laryngoscope is introduced nasally and the larynx and trachea are inspected. The diagnosis is chronic laryngitis/tracheitis and LPR. He prescribes Singulair and Nexium and proposes endoscopic surgery will be considered in the future if the current treatment does not fully take care of the problems experienced by the patient. What CPT® and ICD-10-CM codes are reported for the procedure?

"31575, 31231-59, J32.4, J37.1 The nasal endoscopy and laryngoscopy can both be performed via the nasal cavity. In the CPT ®Index look for Laryngoscopy/Fiberoptic/Diagnostic directing you to code 31575. Next in the CPT® Index look for Endoscopy/Nose/Diagnostic which refers you to 31231, 31233, 31235. The correct code is 31231 because there is no mention of entering the maxillary or sphenoid sinuses. Modifier 50 is not needed because 31231 describes a unilateral or bilateral procedure. Code 31231 is listed as a separate procedure; therefore, modifier 59 is appended. These procedures are indeed separate because a nasal endoscope was used and then the provider used a flexible laryngoscope. The otolaryngologist has diagnosed chronic pansinusitis. In the ICD-10-CM Alphabetic Index look for Pansinusitis (chronic) directing you to J32.4. Also diagnosed is chronic laryngotracheitis. In the Alphabetic Index look for Laryngotracheitis/chronic directing you to J37.1. Code J37.1 encompasses the LPR and the chronic laryngitis and tracheitis.

An 18 month-old patient is seen in the ED unable to breathe due to a toy he swallowed which had lodged in his throat. Soon brain death will occur if an airway is not established immediately. The ED provider performs an emergency transtracheal tracheostomy. What CPT® and ICD-10-CM codes are reported?

"31603, T17.290A In the CPT® Index look for Tracheostomy/Emergency and you are directed to code range 31603-31605. Code selection is based on the approach. In this case, the approach is transtracheal making 31603 the correct code choice. Because the toy is a foreign body that was lodged in his throat, in the ICD-10-CM Alphabetic Index look for Foreign Body/pharynx/causing/asphyxiation/specified type NEC and you are directed to T17.290. The foreign body was causing an obstruction or suffocation in the respiratory tract. Verification in the Tabular List indicates that the code requires seven characters. 7 th character A, initial encounter, is the correct choice because this is an emergency department encounter.

" A surgeon performs a high thoracotomy with resection of a single lung segment on a 57 year-old who is currently a heavy smoker who had presented with a six-month history of right shoulder pain that radiates to the chest. An apical lung biopsy had confirmed lung cancer. What CPT® and ICD-10-CM codes are reported?

"32484, C34.10, F17.210 A segment of the lung is removed. In the CPT® Index look for Removal/Lung/Single Segment which refers you to code 32484. We have a confirmed diagnosis of apical lung cancer, a cancer in an upper lobe, which is code C34.10 (no indication of right or left lung). The term apical means the tip of a pyramidal or rounded structure, so apical lung cancer means the tumor/cancer is located at the top or upper lobe of the lung. We find this by looking in the Table of Neoplasms for Neoplasm, neoplastic/lung/upper lobe and select from the Primary Malignant column referring you to code C34.1-. Verification in the Tabular List indicates the code requires five characters. There is no indication which side of the lung has cancer, report code C34.10 for unspecified lung. There is also an instructional note under category C34 to use additional code for tobacco use. Code F17.210 is reported to indicate the patient is a smoker. Look for Dependence/drug NEC/nicotine/cigarettes which refers you to code F17.210. Verification in the Tabular List confirms code selection.

" A 33 year-old male patient presents to the endoscopy suite to determine if he has an ulcer. The physician performs a diagnostic scope through the esophagus, stomach and into the duodenum and jejunum. During the scope, the patient has a severe drop in blood pressure and the physician discontinues the procedure, but not before observing and diagnosing a bleeding ulcer on the stomach lining as well a perforated ulcer in the jejunum. A repeat examination is planned. What CPT® and ICD-10-CM codes are reported?

"43235-53, K25.4, K28.5 Code 43235 represents an Upper GI down into the small intestine or esophagogastroduodenoscopy (EGD). In the CPT® Index, look for Endoscopy/Gastrointestinal/Upper/Exploration. We append modifier 53 since the procedure was terminated after anesthesia due to extenuating circumstances and a repeat examination is planned. The first code reported is for the bleeding ulcer. Look in the ICD-10-CM Alphabetic Index for Ulcer/stomach/with/hemorrhage referring you to K25.4. The second code reported is for the jejunum perforated ulcer. Look in the ICD-10-CM Alphabetic Index for Ulcer/gastrojejunal/with/perforation referring you to K28.5. Verify all code selections in the Tabular List.

A patient suffering from cirrhosis of the liver from alcohol abuse, presents with a history of coffee ground emesis (bleeding). The surgeon diagnoses the patient with esophageal gastric varices. Two days later, in the hospital GI lab, the surgeon ligates the varices with bands via an UGI endoscopy. What CPT® and ICD-10-CM codes are reported?

"43244, K70.30, I85.11, F10.10 Ligation of esophageal gastric varices endoscopically is coded with CPT® code 43244. Look in the CPT® Index for Ligation/Esophageal Varices. In the ICD-10-CM Alphabetic Index, look for Varices that has a note - see Varix. Look for Varix/esophagus/in (due to)/cirrhosis of liver/bleeding, you are directed to I85.11. In the Tabular List there are two instructional notes. The first one is under subcategory code I85.1-. It instructs you to code first underlying disease, which in this case, is the cirrhosis of the liver from the alcohol. Look for Cirrhosis/liver/alcoholic and you are directed to K70.30. The other instructional note is under category code I85 which says to use an additional code to report alcohol abuse and dependence. Alcohol abuse is reported with code F10.10. Verify code selections in the Tabular List.

" A 49 year-old female was brought to the emergency department. She was lethargic, but awake. She is four years post liver transplant. Neurology was consulted who determined the patient was encephalopathic with altered mental status. There was some question whether she had a seizure. An EEG and WADA test were performed. What CPT® and ICD-10-CM codes are reported?

"95958, G93.40, R41.82, Z94.4 In the CPT® Index look for WADA Activation Test which refers you to code 95958. You can also look for Electroencephalography (EEG)/Monitoring/with WADA Activation. The WADA activation test is coded as 95958 and includes EEG monitoring. For the diagnoses, look in the ICD-10-CM Alphabetic Index for Encephalopathy which refers you to G93.40. Next, look for Alteration (of), Altered/mental status directing you to R41.82. The patient is also status post liver transplant, which is found in the Alphabetic Index by looking for Transplant(ed) (status)/liver that refers you to Z94.4. Verification of the codes in the Tabular List confirms code selections.

" A patient is admitted for a simple primary examination of the gastrointestinal system to rule out GI cancer. An Esophagogastroduodenoscopy (EGD) is performed, which includes examination of the esophagus, stomach and portions of the small intestine. During the examination, a stricture of the esophagus is identified and subsequently dilated via balloon dilation (20 mm). What CPT® and ICD-10-CM codes are reported?

"43249, K22.2 In the CPT® Index, look for Esophagogastroduodenoscopy/Flexible Transoral/Dilation of Esophagus which directs you to 43233, 43249. The procedure began as a diagnostic EGD which is represented by code 43235. During the exam, a stricture of the esophagus is identified and a surgical endoscopic balloon dilation is performed. The stricture of the esophagus is dilated 20 mm confirming 43249 is the correct code for the procedure. Surgical endoscopy always includes diagnostic endoscopy. Look in the ICD-10-CM Alphabetic Index for Stricture/esophagus referring you to K22.2. Reviewing the code descriptor in the Tabular List indicates stricture of esophagus as one of the conditions listed. We do not code GI cancer because it has not been established as a definitive diagnosis and rule-out diagnoses are not reported in outpatient coding.

What is the correct CPT® coding for a partial distal gastrectomy with Roux-en-Y reconstruction with vagotomy?

"43633, 43635 In CPT® Index, look for Gastrectomy/Partial, which directs us to several codes including 43631-43635. When reviewing these codes in the main section of CPT®, code 43633 code descriptor represents a partial gastrectomy with Roux-en-Y reconstruction. Next, look for Vagotomy/with Partial Distal Gastrectomy in the CPT® Index. Code 43635 represents the vagotomy. Modifier 51 is not used as code 43635 is an add-on code and is modifier 51 exempt.

What CPT® and ICD-10-CM codes are reported for a hemicolectomy performed on a patient with colon cancer?

"44140, C18.9 For the CPT® code, hemi- means half or partial and colectomy is the removal of the colon. Look in the CPT® Index for Colectomy/Partial which directs you to code 44140. Next, look in the ICD-10-CM Alphabetic Index for Carcinoma, which directs you to see also, Neoplasm, by site, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/colon which directs you to see also Neoplasm/intestine/large and report code C18.9 under the Malignant Primary column. There is no documentation the cancer is secondary or had metastasized from another site, it is considered primary. Verify the code in the Tabular List.

" A 28 year-old female had symptoms of RLQ abdominal pain, fever and vomiting. She was diagnosed with acute appendicitis. The surgeon makes an abdominal incision to remove the appendix. The appendix was not ruptured. The incision is closed. What CPT® and ICD-10-CM codes are reported for this encounter?

"44950, K35.80 In the CPT® Index, look for Appendectomy/Appendix Excision, you are directed to 44950, 44955, 44960. Look for the description for these codes in the main section of CPTÒ. 44950 is Excision, Appendectomy which correlates with the procedure performed. The appendectomy was performed via open incision and not laparoscopically According to the ICD-10-CM Official Coding Guidelines Section I.B.4, I.B.5, and I.C.18, if a definitive diagnosis is established, it is reported. Any signs or symptoms that would be an integral part of a definitive diagnosis/disease process would not be separately reported. RLQ abdominal pain, fever and vomiting are signs and symptoms of acute appendicitis; only the definitive diagnosis code, K35.80, is reported. In the ICD-10-CM Alphabetic Index, look for Appendicitis/acute which refers you to K35.80. Verification in the Tabular List indicates this code is for unspecified acute appendicitis which includes: Acute appendicitis NOS and Acute appendicitis without (localized) (generalized) peritonitis.

" A 57 year-old patient with chronic pancreatitis presents to the operating room for a pancreatic duct-jejunum anastomosis by the Puestow-type operation. What CPT® and ICD-10-CM codes are reported for the encounter?

"48548, K86.1 In the CPT® Index, look for Puestow Procedure. Code 48548 represents a Puestow-type procedure for the anastomosis of the pancreatic duct to the jejunum. Code K86.1 represents the chronic pancreatitis. Look in the ICD-10-CM Alphabetic Index for Pancreatitis/chronic (infectious). Verify the code selection in the Tabular List.

" The patient has malignant ascites due to ovarian cancer. She is coming back to the operating room for a planned ultrasound guided abdominal paracentesis. This is the second time she has needed fluid removed from her abdominal cavity. The global days for the initial abdominal paracentesis are zero. What CPT® and ICD-10-CM codes are reported?

"49083, C56.9, R18.0 The patient is coming in for a subsequent (second or staged) abdominal paracentesis. In the CPT® Index look for Paracentesis/Abdomen directing you to 49082, 49083. Code 49083 includes imaging guidance so the radiology codes are not separately reported. 49083 does not have a post-operative period because it has 000 for the global days indicator. Modifier 58 is not required. Look in the ICD-10-CM Alphabetic Index for Cancer and you are directed to see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/ovary and select from the Malignant Primary (column) guiding you to code C56.-. In the Tabular List a 4 th character is reported to complete the code. Malignant ascites is found by looking for Ascites/malignant which directs you to code R18.0. In the Tabular List there is a code first note under code R18.0 indicated to "Code first malignancy, such as: malignant neoplasm of ovary (C56.-); secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6)." This means the malignant ascites is reported as a secondary code and the ovarian cancer is reported as the primary diagnosis code.

How many components are included in an effective compliance plan?

"7 The following list of components, as set forth in previous OIG Compliance Program Guidance for Individual and Small Group Physician Practices, can form the basis of a voluntary compliance program for a provider practice: Conducting internal monitoring and auditing through the performance of periodic audits; Implementing compliance and practice standards through the development of written standards and procedures; Designating a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards; Conducting appropriate training and education on practice standards and procedures; Responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate Government entities; Developing open lines of communication, such as (1) discussions at staff meetings regarding how to avoid erroneous or fraudulent conduct, and (2) community bulletin boards, to keep practice employees updated regarding compliance activities; and Enforcing disciplinary standards through well-publicized guidelines. These seven components provide a solid basis upon which a provider practice can create a compliance program.

" A 42 year-old patient is brought to the operating room for a repair of a recurrent incarcerated incisional hernia using mesh. What CPT® and ICD-10-CM codes are reported?

"49566, 49568, K43.0 An incisional hernia (ventral hernia) is a bulging of the abdominal wall at the site of a past surgical incision. This is an incarcerated incisional hernia which means the intestine is protruding through an abnormal opening in the abdominal wall. This repair was performed by an open approach because it is not documented as being performed laparoscopically. In the CPT® Index look for Hernia Repair/Incisional/Recurrent/Incarcerated referring you to code 49566. When a recurrent incisional hernia is repaired, the age of the patient is not a factor in choosing the correct CPT® code. Mesh was used in the repair. Coding Tip note under code 49566 states, "with the exception of the incisional hernia repairs (see 49560-49566) the use of mesh or other prostheses is not separately reported". This means the coder can use two codes for this operative case. Look in the CPT® Index for Hernia Repair/Incisional/Implantation, Mesh or Prosthesis directing you to 49568. 49568 is an add-on code and an instructional note beneath the code states, "Use 49568 in conjunction with 11004-11006, 49560-49566." The CPT codes for the operative session are 49566 and 49568. Look in the ICD-10-CM Alphabetic Index for Hernia/incarcerated ( see also Hernia, by site, with obstruction). Look for Hernia/incisional/with/obstruction which directs you to K43.0. Review of the Tabular List verifies that code K43.0 is reported for an incarcerated incisional hernia.

Tomographic axial images (CT or CAT scan) through the abdomen were obtained without administration of intravenous contrast. This showed a 3 cm diameter mass in the upper pole of the right kidney abutting the liver. Cryoablation of the lesion was performed utilizing two freezing cycles with good cosmetic results. What CPT® codes are reported?

"50250, 77013-26 A kidney (renal) mass, not tumor, is being destroyed (ablation) by freezing (cryoablation) the lesion to remove it. This procedure was performed under CT (computed tomography) guidance to ablate parenchymal (vital organ-example: kidney) tissue. Look in the CPT® Index for Ablation/Cryosurgical/Renal Mass directing you to 50250. Cryosurgery/Lesion/Kidney also leads to 50250. 50250 includes ultrasound guidance if performed. The CT guidance was performed to locate the mass and not to accomplish the ablation. CT guidance is found in the CPT® Index by looking for Ablation/CT Scan Guidance directing you to code 77013. Modifier 26 denotes the professional service.

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?

"57120, N81.4 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.

" An ED physician treats a 30 year-old patient who was a victim of a rape. She has bruises and other trauma as well as a laceration of the vaginal wall, which is repaired with sutures (colporrhaphy) by the ED physician. What are the CPT® and ICD-10-CM codes reported for this procedure?

"57200, S31.41XA, T74.21XA Suturing of the vaginal wall is a colporrhaphy. In the CPT® Index, look for Colporrhaphy/Nonobstetrical and you are referring to 57200. Verify in the numeric section. The diagnosis is laceration of the vagina (S31.41XA) and rape (T74.21XA). In the ICD-10-CM Alphabetic Index look for Laceration/vagina and Rape/adult/confirmed. You can also look in the ICD-10-CM External Cause of Injuries Index for Rape. Both codes are seven characters. Placeholder X is used for the 6 th character and A is for the 7 th character to indicate initial encounter.

Patient has a LEEP conization for CIN II. What are the CPT® and ICD-10-CM codes reported for this procedure?

"57522, N87.1 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.

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?

"58563, 57511-51, R87.612 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 is diagnosed with an injury to the right side facial nerve. In the OR suite the surgeon performs a neurorrhaphy with nerve graft to restore innervation to the face using microscopic repair. The surgeon created a 2 cm incision over the damaged nerve, dissected the tissues and located the nerve. The damaged nerve was resected and removed. The 3.0 cm graft taken from the sural nerve was sutured to the proximal and distal ends of the damaged nerve. What CPT® and ICD-10-CM codes are reported?

"64885, 69990, S04.51XA A neurorrhaphy is a repair of the nerve that has been divided. In the CPT® Index look for Repair/Nerve/Graft directing you to code range 64885-64911. You can also look for Neurorrhaphy/Peripheral Nerve/with Graft. Code selection is based on the number of strands, location and length of the grafts. This is a 3 cm graft in the head which is coded with 64885. 69990 is reported to indicate the use of an operating microscope. In the ICD-10-CM Alphabetic Index look for Injury/nerve/facial and you are directed to S04.5-. Verification in the Tabular List indicates that seven characters are needed to complete the code. The 5 th character is for laterality, reporting 1 for the right side. The placeholder X is reported for the 6 th character and A for the 7 th character extension supporting surgery for initial encounter.

A patient was admitted to observation status after losing control and crashing his motorcycle into the guardrail on the highway. A CT scan of the brain without contrast and the chest is performed. It revealed a fracture of the skull base with no hemorrhage in the brain. There was no puncture of the lungs. Three views of the right and left sides of the ribcage reveal fractures of the left third and fifth rib. What CPT® and ICD-10-CM codes are reported?

"70450-26, 71250-26, 71110-26, S02.109A, S22.42XA, V27.4XXA, Y92.411 First, look in the CPT® Index for CT Scan/without contrast/Brain. The first radiological code is 70450 because a CT scan without contrast of the brain was performed. Next, look in the CPT® Index for CT Scan/without contrast/Thorax. Code 71250 is correct because thorax is a synonym for chest, and the CT was performed without contrast. Code 71275 is a CTA (computed tomographic angiography) which is used for imaging vessels to find a blood clot, aneurysm and other vascular irregularities in the chest making it an inappropriate code to report for this scenario. Then, look in the CPT® Index for X-ray/Ribs. Confirmation in the numeric section shows 71110 is correct for the three views taken bilaterally (left and right side) of the ribs. Modifier 26 denotes the professional service performed in a facility setting. The first diagnosis is found in the ICD-10-CM Alphabetic Index by looking for Fracture, traumatic/skull/base directing you to code S02.10-. Verification in the Tabular List indicates the codes needs seven characters to be complete. Report 9 for the 6th character and then A for 7th character to indicate initial encounter. Two left ribs were fractured. Look in the Alphabetic Index for Fracture, traumatic/rib/multiple guiding you to S22.4-. Verification in the Tabular List indicates the need for seven characters to complete the code. Report 2 for as the 5th character for the left side. Report placeholder X for the 6th character and then an A for initial encounter as the 7th character. The next two codes are found in the External Cause of Injuries Index. Look for Accident/transport/motorcyclist/driver/collision with/stationary object (traffic) guiding you to V27.4-. In the Tabular List seven characters are required to complete the code. An X placeholder is used for the 5th and 6th characters and a 7th character of A indicates this is for initial encounter or active treatment. The last external cause code is found by looking for Place of occurrence/highway which directs you to code Y92.411.

A 65 year-old female has a 2.5 cm x 2.0 cm non-small cell lung cancer in her right upper lobe. The tumor is inoperable due to severe respiratory conditions. She will be receiving stereotactic body radiation therapy under image guidance. Beams arranged in 8 fields will deliver 25 Grays per fraction for 4 fractions. What CPT® and ICD-10-CM codes are reported?

"77373, Z51.0, C34.11 Patient is having stereotactic radiation therapy technique delivered, not managed, in a large radiation dose to tumor sites in the upper right lobe of the lung. In the CPT® Index look for Radiation Therapy/Stereotactic Body which directs you to 77373. Codes 77371-77373 do not need modifier TC or 26, because they are facility only codes. 77373 is correct with stereotactic body radiation not exceeding 5 fractions. According to ICD-10-CM guideline I.C.2.a. "If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.-code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis." In the ICD-10-CM Alphabetic Index look for Encounter/radiation therapy (antineoplastic) which directs you to Z51.0. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/lung/upper lobe and select from the Malignant Primary column referring you to C34.1-. Verification in the Tabular List indicates a 4 th character is needed, report 1 for the right lung.

A couple with the inability to conceive has fertility testing. The semen specimen is tested for volume, count, motility and a differential is calculated. The findings indicate infertility due to oligospermia. What CPT® and ICD-10-CM codes are reported?

"89320, N46.11 Choose the CPT® code that completely identifies the service. Look in the CPT® Index for Semen Analysis. Code 89320 reports all of the tests performed. Only use multiple codes if there is no code describing everything performed. In this case, a very specific diagnosis is known. For the ICD-10-CM diagnosis code, look in the ICD-10-CM Alphabetic Index for Infertility/male/oligospermia referring you to N46.11. Verification in the Tabular List confirms this code is reported for Oligospermia NOS.

" A teenager has been chronically depressed since the separation of her parents 1 year ago and moving to a new city. Her school grades continued to slip and she has not made new friends. She has frequent crying episodes and is no longer interested in her appearance. She has attended the community mental health center and participates in group sessions. Recently her depression exacerbated to the point inpatient admission was required. The provider diagnosed adjustment disorder with emotional and conduct disturbances. Due to the length of the depression and no real improvement, the provider discussed electroconvulsive therapy with her mother. After discussing benefits and risks, the mother consented to the procedure. What CPT® and ICD-10-CM codes are reported for the electroconvulsive therapy?

"90870, F43.25 In the CPT® Index look for Electroconvulsive Therapy which directs you to 90870. For the diagnosis, in the ICD-10-CM Alphabetic Index look for Disorder/adjustment/with/conduct disturbance/with emotional disturbance and you are directed to F43.25. F43.25 includes disturbances of conduct, so F43.24 is not reported separately. Verification in the Tabular List confirms code selection.

" A patient had several panic attacks at work disturbing her coworkers. She had been unable to explain any particular reason for her behavior. Her employer requested she be referred for counseling. After several sessions, her psychiatrist provided reports for her primary care provider and her insurer about her status and prognosis. What CPT® and ICD-10-CM codes are reported for the preparation of the report?

"90889, F41.0 other individuals, agencies, or insurance carriers. In the CPT® Index look for Psychiatric Treatment/Report Preparation and you are directed to code 90889. By definition in the code, this is not used for legal or consultative purposes. Panic attacks not defined are reported as F41.0. In the ICD-10-CM Alphabetic Index look for Attack, attacks/panic. Verification in the Tabular List confirms code selection.

A 70 year-old patient with chronic obstructive asthma is brought to the urgent care center with increased wheezing and coughing. The provider initiated an albuterol inhalation treatment, one dose, delivered by nebulizer. After treatment, the patient's exacerbation was somewhat improved but the provider determined a second treatment was necessary. What codes are reported?

"94640, 94640-76, J7609 x 2, J44.1 In the CPT® Index look for Inhalation Treatment/for Airway Obstruction/Pressured or Nonpressured which directs you to 94640. Inhalation treatment was given therapeutically in treating the acute airway obstruction. Two treatments were given so code 94640 is reported twice. Under code 94640 there is a parenthetical instruction stating to use modifier 76 if more than one inhalation treatment is performed on the same date. Because treatment is in the office (urgent care is considered office treatment), the provider will also bill for the medication used. In this case, it is albuterol. In the HCPCS Level II codebook go to the Table of Drugs and Biologicals and look for Albuterol, unit dose form which directs you to J7609, J7613. J7609 is reported for albuterol per dose. Two doses were given reporting J7609 x 2. For the diagnosis in the ICD-10-CM Alphabetic Index look for Asthma/chronic obstructive/with exacerbation (acute) directing you to J44.1. There is no mention of status asthmaticus, but exacerbation is mentioned. The diagnosis code is J44.1. Verification in the Tabular List confirms code selection.

" A patient with hypertensive end stage renal failure, stage 5, and secondary hyperparathyroidism is evaluated by the provider and receives peritoneal dialysis. The provider evaluates the patient once before dialysis begins. What CPT® and ICD-10-CM codes are reported?

"90945, I12.0, N18.6, Z99.2, N25.81 In the CPT® Index look for Dialysis/Peritoneal which directs you to codes 90945, 90947, 4055F (an outcomes measurement code). The peritoneal dialysis with one provider evaluation is reported with 90945. In the ICD-10-CM guideline I.C.9.a.2 codes from category I12 is assigned when both hypertension and a condition from the chronic kidney disease codes N18 are both present. In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/kidney/stage 5 chronic disease (CKD) or end stage renal disease (ESRD) which directs you to I12.0. The instructions in the ICD-10-CM guidelines and in the Tabular List for code I12.0 indicate to use an additional code to identify the stage of CKD. In the Alphabetic Index look for Disease, diseased/kidney/chronic/stage 5 leading to N18.5. In the Tabular List, according to the Excludes1 note below N18.5 when the patient has stage 5 CKD but requires dialysis it is reported with N18.6. Coding note under N18.6 states to use an additional code to identify the dialysis status with code Z99.2. Look for Status/Dialysis (hemodialysis) (peritoneal) which directs the coder to Z99.2. The patient also has secondary hyperparathyroidism reported with N25.81. Look in the Alphabetic Index for Hyperparathyroidism/secondary (renal). Verification in the Tabular List confirms code selection.

" A 49 year-old patient had several episodes of esophageal reflux and underwent a gastroesophageal reflux test to measure the pH balance (a measure of the degree of acidity or alkalinity). The test was performed with a mucosal attached capsule. The provider provided an interpretation and report. The provider stated the diagnosis as gastroesophageal reflux. What CPT® and ICD-10-CM codes are reported?

"91035, K21.9 In the CPT® Index look for Acid Reflux Test/Esophagus. The provider measured the pH balance and used a mucous capsule, which attaches the electrode to the mucous in the esophagus which is reported with code 91035. Catheter placement of the electrode is becoming rare with the development of the mucous attaching capsule. In the ICD-10-CM Alphabetic Index look for Reflux/gastroesophageal. The diagnosis code for gastroesophageal reflux without esophagitis is K21.9. Reflux is regurgitation of gastric contents into the mouth, caused by incompetence of the lower esophageal sphincter. Verification in the Tabular List confirms code selection.

" A 50 year-old male is coming in for an eye examination for iritis. His last visit to the office was two years ago. The ophthalmologist performs a review of history, external ocular and adnexal examination, routine ophthalmoscopy and a biomicroscopy. Iritis is not found. The eye examination is completely normal. What CPT® and ICD-10-CM codes are reported?

"92012, Z01.00 Codes 92002-92014 are for Ophthalmological Services and are reported by new vs. established patient and if the service is intermediate vs. comprehensive. The description of intermediate supports the services performed and 92012 is correct. This is an established patient, above code 92002 there is a parenthetical that tells you to refer to the E/M guidelines to distinguish between a new and established patient. The ophthalmoscopy code is included in codes 92002-92014. Above code 92201 there is information that tells you that routine ophthalmoscopy is included in the ophthalmologic services and not reported separately. In ICD-10-CM Alphabetic Index look for Examination/Eye directing you to Z01.00.

" A 5 week-old infant shows signs of fatigue after eating and has poor weight gain. He is suspected to have a congenital heart defect. The neonatologist ordered a transthoracic echocardiogram (TTE). TTE is showing a shunt between the right and left ventricles. The neonatologist read and interpreted the study and indicated the patient has a ventricular septal defect (VSD). What are the CPT® and ICD-10-CM codes for the TTE read?

"93303-26, Q21.0 In the CPT® Index look for Echocardiography/Transthoracic/Congenital Cardiac Anomalies which directs you to 93303, 93304. Code selection is based on whether it is a complete study, follow up or limited study. This is a complete study therefore code 93303 the correct code choice. Since we are only reporting reading and interpretation of the report, a modifier 26 is appended. In ICD-10-CM Alphabetic Index look for Defect, defective/ventricular septal which directs you to Q21.0. Verification in the Tabular List confirms code selection.

" A baby was born with a ventricular septal defect (VSD). The provider performed a right heart catheterization and transcatheter closure with implant by percutaneous approach. What codes are reported?

"93581, Q21.0 In the CPT® Index look for Septal Defect/Closure/Ventricular. Reading the descriptions code 93581 describes percutaneous transcatheter closure of a congenital ventricular septal defect using an implant. There is a parenthetical note under code 93581 stating that the right heart catheterization is included in this procedure and not to report code 93530 with code 93581. VSD is a congenital condition (present at birth). In the ICD-10-CM Alphabetic Index look for Defect/ventricular septal which refers you to Q21.0. Verification in the Tabular List confirms code selection.

" A patient with severe atrial fibrillation presents for an EPS study. The cardiologist performs the professional component of a comprehensive EPS study, including right atrial and ventricular pacing/recording, bundle of His recording and induction of atrial fibrillation, and insertion and repositioning of multiple electrode catheters. What CPT® code(s) is/are reported?

"93620 -26 An EPS study is an electrophysiology study evaluating the electrical system of the heart. In the CPT® Index look for Electrophysiology Procedure. It is important to read code descriptions carefully to avoid coding each element separately when there is a code combining all elements performed. 93620 includes all the elements described. Modifier 26 is appropriate to indicate the professional component was performed by the provider.

" A 5 year-old is brought in to see an allergist for generalized urticaria. The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child's skin was scratched with two different allergens. The provider waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen. The provider included the test interpretation and report in the record.

"95004 x 2 In the CPT® Index look for Allergy Tests/Skin Tests/Allergen Extract. Code selection is based on the method of testing performed. Code 95004 describes the scratch test with allergenic extracts. The test is reported twice for the number of substances that were tested.

" A patient with sickle cell anemia with painful sickle crisis received normal saline IV 100 cc per hour to run over 5 hours for hydration in the provider's office. She will be given Morphine & Phenergan, prn (as needed). What codes are reported?

"96360, 96361 x 4, J7050 x 2, D57.00 In the CPT® Index look for Hydration/Intravenous and you are directed to codes 96360-96361. The hydration will run 5 hours at 100 cc per hour. Codes are time based. Code the hydration therapy as 96360 for the first hour, and 96361 x 4 for a total infusion time of 5 hours. In the HCPCS Level II look for Saline Solution referring you to codes J7030-J7050. Code for the normal saline with J7050 x 2 units for 500 cc. The type of sickle cell anemia is not identified, but the patient has painful sickle crisis. In the ICD-10-CM Alphabetic Index, look for Disease, diseased/sickle-cell/with crisis directing you to D57.00. Verification in the Tabular List confirms code selection.

A 54 year-old female with uncontrolled type 1 insulin dependent diabetes and related peripheral vascular disease presents with a deep diabetic ulceration on the bottom of her right foot. The wound reaches into the fascia and appears to be draining. She acknowledges going barefoot frequently and is not certain how or when the wound occurred. After the provider discusses the seriousness of her condition he debrides the wound, using a water jet and surgical scissors. Size of wound is 70 sq. cm. He applied topical ointment and a sterile dressing. He counseled the patient about the need to wear shoes at all times and inspect her feet daily. He advised the patient to wear a water protective covering on her lower leg when taking a shower and to change the dressing daily, using ointment provided. A surgical shoe was provided. Patient is to return weekly until the wound heals and continue her insulin regime. If satisfactory progress does not occur, a graft may be considered. What codes are reported?

"97597, 97598 x 3, L3260, E10.621, E10.51, L97.513 In the CPT® Index look for Wound/Care/Debridement/Selective which refers you to 97597, 97598. Code selection is based on the size of the area debrided. 70 sq. cm were debrided. Code 97597 is reported for the first 20 sq. cm and 97598 is reported 3 times to show the remaining area debrided (20 sq. cm, 20 sq. cm, 10 sq. cm). In the HCPCS Level II codebook look for Boot/Surgical, ambulatory referring you to L3260. The patient has type 1 diabetes and peripheral vascular disease with a diabetic foot ulcer. According to ICD-10-CM guidelines, there is a casual cause and effect relationship between diabetes and peripheral vascular disease. The ulcer is also a diabetic complication. In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/foot ulcer and you are directed to E10.621. In the Tabular List there is an instructional note to code from L97.4- or L97.5- for the location and type of ulceration. The ulcer is on the bottom of the right foot. Look in the Alphabetic index for Ulcer, ulcerated, ulcerating, ulceration, ulcerative/lower limb/foot/right/with/muscle necrosis which directs you to L97.513. In the Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/peripheral angiopathy and you are directed to E10.51. ICD-10-CM guideline 1.C.4.a. states to assign as many diabetic codes as necessary to describe all complications. Verification in the Tabular List confirms code selection. Long term insulin usage (Z79.4) is not coded with type I diabetes.

A patient sustained a neck strain as a driver in an automobile accident, losing control, hydroplaning and hitting a tree off the highway which caused the car to overturn. He has continued to have neck pain and stiffness. He sees a chiropractor who assesses the patient and manipulates his neck. The diagnosis is neck strain. What CPT® and ICD-10-CM codes are reported for the chiropractor?

"98940, S16.1XXA, V47.0XXA In the CPT® Index look for Manipulation/Chiropractic. The neck is the cervical spine and code selection is based on the number regions treated. In this case, 1 region is treated making 98940 is the correct code choice. In the ICD-10-CM Alphabetic Index look for Strain/cervical or Strain/neck and you are directed to code S16.1-. The Tabular List shows seven characters are needed to complete the code. X is used as a placeholder for the 5 thand 6 th characters. A is the 7 th character for the initial encounter receiving active treatment. Next, report the external cause. The patient was the driver in a non-collision vehicle accident when he lost control of the car. Look in the ICD-10-CM External Cause of Injuries Index for Accident/car which states to see Accident, transport, car occupant. Look for Accident/transport/car occupant/driver/collision (with)/stationary object/nontraffic. When referring to the Tabular List, subcategory code V47.0 is used and it shows seven characters are needed to complete this code. X is used as the 5 th and 6 thcharacters and A, initial encounter, is used for the 7 thcharacter.

" A patient has an open wound on his left lower leg caused by a cat bite. The animal tested negative for rabies, but the wound has failed to heal and became infected by Clostridium perfringens. The patient underwent hyperbaric oxygen therapy attended and supervised by the provider. What CPT® and ICD-10-CM codes are reported?

"99183, S81.852A, B96.7, W55.01XA In the CPT® Index look for Hyperbaric Oxygen Pressurization and you are directed to code 99183. The wound is complicated due to the infection. In the ICD-10-CM Alphabetic Index look for Bite(s) (animal) (human)/leg (lower) and you are directed to S81.85-. Tabular List shows seven characters are needed to complete the code. The 6 th character 2 indicates the left leg. 7 th character A indicates initial encounter for receiving active treatment. The infectious agent is identified as Clostridium perfringens. Look for Infection/Clostridium/perfringens/as cause of disease classified elsewhere directing you to code B96.7. The external cause is the cat bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/cat which directs you to code W55.01-. Tabular List shows seven characters are needed to complete the code. A placeholder X is assigned to the 6 th character and A is assigned for initial encounter for the 7 th character.

" A 42 year-old patient presented to the urgent care center with complaints of slight dizziness. He had received services at the clinic about 2 years ago. The patient related this episode happened once previously and his 51 year-old brother has a pacemaker. A chest X-ray with 2 views and an EKG with rhythm strip were ordered (equipment owned by the urgent care center). The provider detected no obvious abnormalities, but the patient was advised to see a cardiologist within the next two-three days. The provider interpreted and provided a report for the rhythm strip and chest X-ray. What CPT® and ICD-10-CM codes are reported for the provider employed by the urgent care center who performed a level 3 office visit in addition to the ancillary services?

"99213-25, 71046, 93040, R42 The patient is an established patient to an urgent care clinic. A code from 99211-99215 is reported. Level three is reported with 99213. Because an EKG was also performed, a modifier 25 is appended to the office visit. The X-ray & EKG equipment are owned by the clinic. In the CPT® Index look for X-ray/Chest referring you to 71045-71048. The chest X-ray, 2 views, is reported with 71046. The EKG and rhythm strip are read, interpreted and a report is written by the provider. Modifiers 26 and TC are not appended to the radiology codes because the urgent care center owns the equipment and the radiologist is an employee of the urgent care center. In the CPT® Index look for Electrocardiography/Rhythm/Tracing and Evaluation and you are referred to CPT® code 93040. With no confirmed diagnosis, refer to the initial signs and symptoms. The symptom is dizziness. In the ICD-10-CM Alphabetic Index look for Dizziness which refers you to R42. Verification in the Tabular List confirms code selection.

" A patient with congestive heart failure and chronic respiratory failure with hypoxia is placed on home oxygen. Prescribed treatment is 2L nasal cannula oxygen at all times. A home care nurse visited the patient to assist with his oxygen management. What CPT® and ICD-10-CM codes are reported?

"99503, I50.9, J96.11 In the CPT® Index look for Home Services/Respiratory Therapy which directs you to code 99503. In the ICD-10-CM Alphabetic Index look for Failure/heart/congestive and you are directed to I50.9. Then look for Failure, failed/respiration, respiratory/chronic/with/hypoxia which directs you to J96.11. Verification in the Tabular List confirms code selection.

When surgery is performed, what services are included and not billed separately?

"All of the above Services included in the surgical package include: Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physcial) Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals Writing orders Evaluating the patient in the post-anesthesia recovery area Typical postoperative follow-up care

The minimum necessary rule applies to

"Covered entities taking reasonable steps to limit use or disclosure of PHI The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose. The minimum necessary standard does not apply to the following: Disclosures to or requests by a health care provider for treatment purposes. Disclosures to the individual who is the subject of the information. Uses or disclosures made pursuant to an individual's authorization. Uses or disclosures required for compliance with the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Rules. Disclosures to the Department of Health & Human Services (HHS) when disclosure of information is required under the Privacy Rule for enforcement purposes. Uses or disclosures that are required by other law.

" Which of the following choices is NOT a benefit of an active compliance plan?

"Eliminates risk of an audit. Although voluntary, a compliance plan may offer several benefits, among them: Faster, more accurate payment of claims. Fewer billing mistakes. Diminished chances of a payer audit. Less chance of violating self-referral and anti-kickback statutes. Additionally, the increased accuracy of provider documentation that may result from a compliance program actually may assist in enhancing patient care.

" How do you report a screening colonoscopy performed on a 65 year-old Medicare patient with a family history of colon cancer? The physician was able to pass the scope to the cecum. What CPT® and ICD-10-CM codes are reported?

"G0105, Z12.11, Z80.0 For a Medicare patient the preferred code to report a screening colonoscopy is HCPCS code G0105 Colonoscopy/Screening/Individual at high risk. In the ICD-10-CM Alphabetic Index, look for Screening/colonoscopy which directs you to Z12.11. In the Tabular List, an instructional note under Z12 instructs the coder, "Use additional code to identify any family history of malignant neoplasm (Z80.-)". The patient is high risk due to a family history of colon cancer, look for Z80 in the Tabular List. Category Z80 required a 4th character to identify the organ system of the cancer. Fourth character 0 is used for Family history of primary malignancy neoplasm of digestive organs. To find the code from the Alphabetic Index look for History/family (of)/malignant neoplasm/gastrointestinal tract.

What ICD-10-CM code is reported for acute gastritis with bleeding?

"K29.01 In ICD-10-CM, Gastritis is identified by specific 4th character codes to indicate with or without bleeding. Look in the ICD-10-CM Alphabetic Index for Gastritis (simple)/acute (erosive)/with bleeding which refers you to K29.01. Verify code selection in the Tabular List.

Which word describes the study of small life forms?

"Microbiology The root words micro (small) and bio (life) combined with the suffix -logy describe the study of small life forms.

A woman comes in for her annual exam with a cervical Pap smear. The results are abnormal, although they are not diagnostic of any specific disease. A second Pap smear is obtained and this test identifies only normal cells. What diagnosis code identifies the medical necessity for the second Pap smear?

"R87.619 Choose a code that identifies unspecified previous abnormal findings on cervical Pap smear. Although the second test results came back normal, the previous abnormal finding supports the need for a repeat test. Look in the ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/Papanicolaou cervix directing you to R87.619. Verify this code in the Tabular List.

A 4 year-old is brought into the ED crying. He cannot bend his left arm after his older sister pulled it. The provider performs an X-ray and it shows the patient has Nursemaid's elbow. The ED provider reduces the elbow successfully. The patient can move his arm again after the reduction. What ICD-10-CM codes are reported?

"S53.032A, X50.9XXA In the ICD-10-CM Alphabetic Index look for Nursemaid's elbow directing you to S53.03-. In the Tabular List, 6 th character 2 is reported for the left elbow and 7 th character A is applied for the initial encounter. The patient's arm was injured due to his sister pulling on it. In the ICD-10-CM External Cause of Injuries Index look for Pulling, excessive which directs you to X50.9-. In the Tabular List, the code needs seven characters. Two Xs are needed as place holders for the 5th and 6th characters. The 7th character is A.

Which option below is NOT a covered entity under HIPAA?

"Workers' Compensation The definition of health plan in the HIPAA regulations excludes any policy, plan or program that provides or pays for the cost of excepted benefits. Excepted benefits include: Coverage only for accident or disability income insurance, or any combination thereof; Coverage issued as a supplement to liability insurance; Liability insurance, including general liability insurance and automobile liability insurance; Workers' compensation or similar insurance; Automobile medical payment insurance; Credit-only insurance; Coverage for on-site medical clinics; Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost?

$100 or 25 percent CMS instructions stipulate, "Notifiers must make a good faith effort to insert a reasonable estimate...the estimate should be within $100 or 25 percent of the actual costs, whichever is greater."

The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. She developed severe vomiting secondary to the radiation. What ICD-10-CM code(s) is/are reported?

.0, C79.51, C80.1, R11.10 The reason for the encounter is for radiation therapy. ICD-10-CM guideline I.C.2.e.3 states if a patient admission is for the purpose of radiotherapy, immunotherapy, or chemotherapy and develops complications, assign code Z51.0 Encounter for antineoplastic radiation therapy, or Z51.11 Encounter for antineoplastic chemotherapy, or Z51.12 Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis, followed by any codes for the complications. ICD-10-CM guideline I.C.2.b states the secondary cancer is listed first when the treatment is directed toward the secondary site only. In the ICD-10-CM Alphabetic Index look for Encounter (with health service) (for)/radiation therapy (antineoplastic), guiding you to code Z51.0. Next, look in the Alphabetic Index for Metastasis, metastatic/cancer/from specified site and you are directed to see Neoplasm, malignant, by site. In the ICD-10-CM Table of Neoplasms. Look for Neoplasm, neoplastic/bone (periosteum) and select the code from the Malignant Secondary column which directs you to C79.51. When the site of the primary cancer is unknown, look for Neoplasm, neoplastic and select from the Malignant Primary column which directs the coder to C80.1. The last code is for the vomiting that developed during treatment. Look in the Alphabetic Index for Vomiting directing you to code R11.10. Verify the code selection in the Tabular List.

" What is the CMS global period status indicator for endoscopies?

0 Status Indicator 000 - Endoscopies or minor procedures

" A 94 year-old patient is having surgery to remove his parotid gland with dissection and preservation of the facial nerve. The surgeon has requested the anesthesia department place an arterial line. What CPT® code(s) is/are reported for anesthesia?

00100, 36620, 99100 In the CPT® Index look for Anesthesia/Salivary Glands which directs you to code 00100. Reference the code in the numeric section to confirm that 00100 is the correct code. Hint - Coders may need to use the Surgery Section to determine that the parotid gland is included in the salivary glands. The arterial line placement is NOT included in the base value and may be reported separately with code 36200. In the CPT® Index look for Catheterization/Arterial System/Percutaneous. Due to patient's advanced age of 94, qualifying circumstance add-on code 99100 is also reported. Furthermore, the patient's age implies he is on Medicare, therefore we do not use Physical Status Modifiers as they are not accepted.

A 78-year-old patient is undergoing lens surgery for cataracts. An anesthesiologist personally performed monitored anesthesia care (MAC). Which modifier(s) appropriately report(s) the anesthesiologist's service

00142-AA-QS An anesthesiologist who is personally performing administration of anesthesia reports the service with an AA modifier. Because the service was performed using MAC, a QS modifier is also reported.

A 72 year-old patient is undergoing a corneal transplant. An anesthesiologist is personally performing monitored anesthesia care. What CPT® code and modifier(s) are reported for anesthesia?

00144-AA-QS, 99100 In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. An anesthesiologist who is personally performing services reports the service with a modifier AA and when the service performed is Monitored Anesthesia Care (MAC) modifier QS is also reported. The modifiers are sequenced first by the anesthesia provider then the MAC modifier which are attached to the appropriate anesthesia code. The Qualifying Circumstances add-on code 99100 is assigned for extreme age of the patient being older than 70 years of age.

A 22-year-old patient delivered a healthy baby boy by cesarean delivery with general anesthesia. The anesthesiologist performed all required steps for medical direction and was medically directing two other cases concurrently. Which modifier(s) report(s) the anesthesiologist and CRNA services?

01961-QK and 01961-QX An anesthesiologist who is medically directing reports the service separately from the CRNA, depending on the number of concurrent cases. Because there was more than one concurrent (QY) case and fewer than five concurrent (AD) cases, the appropriate modifiers to report are QK for the physician claim and QX for the CRNA claim. A QZ modifier is reported when indicating a case is performed by a CRNA without medical direction by a physician.

Patient presents with a cyst on the arm. Upon examination the physician decides to incise and drain the cyst. The site is prepped and the physician takes a scalpel and cuts into the cyst. Purulent fluid is extracted from the cyst and a sample of the fluid is sent to the laboratory for evaluation. The wound is irrigated with normal saline and is covered with a bandage. The patient is to return in a week to ten days to re-examine the wound.

10060 Codes 10060-10061 describe the incision and drainage of abscess of a cyst; simple or complicated/multiple. There is no indication the cyst is complicated resulting in 10060. Look in the CPT® Index for Incision and Drainage/Cyst/Skin.

The patient is here because the cyst in her chest has come to a head and is still painful even though she has been on antibiotics for a week. I offered to drain it for her. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, prepped the area with Betadine and incised and opened the cyst in the relaxed skin tension lines of her chest, and removed the cystic material. There was no obvious purulence. We are going to have her clean this with a Q-tip. We will let it heal on its own and eventually excise it. I will have her come back a week from Tuesday to reschedule surgery. What CPT® and ICD-10-CM codes are reported?

10060, L72.9 The physician performed an incision and drainage (I & D) of a cyst on the chest. To find the code, look in the CPT® Index for Incision and Incision and Drainage/Cyst/Skin and you are directed to codes 10040, 10060, 10061. 10040 is for acne surgery. 10060 and 10061 are for I & D of a cyst. Only one cyst was drained making 10060 the correct code. In the ICD-10-CM Alphabetic Index look for Cyst/skin and you are referred to L72.9. Verification in the Tabular List confirms code selection.

The performance measure code for history obtained regarding new or changing moles

1050F

A patient presents to the Dermatologist with a suspicious lesion on her left arm and another one on her right arm. After examination the physician feels these lesions present as highly suspicious and obtains consent to perform punch biopsies on both sites. After prepping the area, the physician injects the sites with Lidocaine 1% and .05% Epi. A 3 mm punch biopsy of the lesion of the left arm and a 4mm punch biopsy of the lesion of the right arm is taken. The sites are closed with a simple one-layer closure and the patient is to return in 10 days for suture removal and to discuss the pathology results. The patient tolerated the procedure well.

11104, 11105 Look in the CPT Index for Biopsy/Skin/Punch or Skin/Biopsy/Punch and you are directed to 11104, 11105. Code 11104 is reported for biopsy of the first lesion of the left arm and add-on code 11105 is reported for the biopsy of the lesion on the right arm. The simple one-layered closure (simple repair) is included in the codes and is not reported separately.

A 63 year-old patient arrives for skin tag removal. As previously noted at her last visit, she has 3 located on her face, 4 on her shoulder and 15 on her back. The physician removes all the skin tags with no complications. What CPT® code(s) is/are reported for this encounter?

11200, 11201 Look in the CPT® Index for Removal/Skin Tags and you are directed to codes 11200 and 11201. Based on the documentation, the total number of skin tags removed is 22. Code 11200 is reported for the removal of up to and including 15 lesions. Notice the wording for 11201, which includes each additional 10 lesions, or part thereof. The words part thereof in the code description means you do not need to have a complete total of 10 skin tags to report the add-on code. The add-on code can be reported if the additional skin tags removed are 10 and under; so it is not necessary to append modifier 52 to this add-on code. Modifier 51 is not appended to add-on codes. Report 11200, 11201 for the removal of 22 skin tags.

A patient presents with a recurrent seborrheic keratosis of the left cheek. The area was marked for a shave removal. The area was infiltrated with local anesthetic, prepped and draped in a sterile fashion. The lesion measuring 1.8 cm was shaved using an 11-blade. Meticulous hemostasis was achieved using light pressure. The specimen was sent for permanent pathology. The patient tolerated the procedure well. What CPT® code is reported?

11312 In the CPT® Index look for Shaving/Skin Lesion and you are referred to range 11300-11313. Code selection is based on location and size. This lesion is on the left cheek narrowing the range to 11310-11313. The size is 1.8 cm making 11312 the correct code choice.

A patient presents to the dermatologist with a suspicious lesion of the left cheek. Upon examination the physician discusses with the patient that the best course of treatment is to remove the lesion by shave technique. Consent is obtained and the physician preps the area and using an 11-blade scalpel makes a transverse incision and slices the lesion at the base. The wound is cleaned and a bandage is placed. The physician indicates the size of the lesion is 1.4 cm. The lesion is sent to pathology for evaluation and the patient is to return in 10 days to discuss the findings.

11312 The lesion is removed by the shave technique. Look in the CPT® Index for Shaving/Skin Lesion and you are referred to 11300-11313. Shaving of lesions is based on anatomical location and lesion size in centimeters. The shaving of a 1.4cm cheek lesion is reported with 11312. Code 11102 is reported for a skin biopsy.

Patient presents to the physician for removal of a squamous cell carcinoma of the right cheek. After the area is prepped and draped in a sterile fashion the surgeon measured the lesion and documented the size of the lesion as 2.3 cm at its largest diameter. Additionally, the physician took margins of 2 mm on each side of the lesion. Single layer closure was performed. The patient tolerated the procedure well. What CPT® code(s) is/are reported?

11643 Squamous cell carcinoma is a malignant neoplasm. In the CPT® Index look for Skin/Excision/Lesion/Malignant and you are directed to many codes including code range 11600-11646. Code selection is based on location and size. The lesion is on the right cheek, narrowing the range to 11640-11646. The largest diameter is 2.3 cm plus 0.4 cm (2 mm + 2 mm on each side; 1 mm equals 0.1 cm) making the excised diameter 2.7 cm. The correct code selection is 11643. Simple one-layer repair is not reported separately.

What is the correct CPT® code for the wedge excision of a nail fold of an ingrown toenail?

11765 In the CPT® Index, look for Excision/Nail Fold referring you to 11765.

A 14 year-old boy was thrown against the window of the car on impact. The resulting injury was a star-shaped pattern cut to the top of his head. In the ED, the MD on call for plastic surgery was asked to evaluate the injury and repair it. The total length of the intermediate repair was 5+4+4+5 cm (18 cm total). The star-like shape allowed the surgeon to pull the wound edges together nicely in a natural Y-plasty in two spots. What CPT® code is reported for the repair?

12035 Category guidelines in the Adjacent Tissue Transfer or Rearrangement state that these codes are not to be used when the repair of a laceration incidentally results in a configuration such as a Y-plasty. Look in the CPT® Index for Repair/Skin/Wound/Intermediate and you are directed to code range 12031-12057. Instructions in the category guidelines for Repair state to add up all the lengths when in the same repair classification and anatomical sites grouped together into the same code descriptor. Based on the documentation, the total length is 18 cm. An intermediate repair of this length on the top of the head is reported with code 12035.

Patient is an 81 year-old male with a biopsy-proven basal cell carcinoma of the posterior neck just near his hairline; additionally, the patient had two other areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck. I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed it in layers using 4.0 Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5 cm. Attention was then directed to the other two suspicious lesions on his cheek. After administering local anesthesia, I proceeded to take a 3 mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported?

13132, 11623-51, 11104-59, 11105 Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range 11600-11646. The range is narrowed by the location of neck, 11620-11626. The lesion size is 2.6 cm making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of multiple suture materials support use of a complex closure. Complex repairs are found by looking in the CPT® Index for Repair/Skin/Wound/Complex referring you to code range 13100-13160. The range is narrowed again by location of neck, 13131-13133. The repair length is 4.5 cm making 13132 the correct code. After the lesion of the neck was removed the provider took two biopsies on the cheek. Look in the CPT® Index for Biopsy/Skin Lesion/Punch, which refers you to codes 11104 and 11105. 11104 is used for the first biopsy and add-on code 11105 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use modifier 59 for the first biopsy indicating it was performed at a different location than the excision. Modifier 59 is not used on the second biopsy code because it is an add-on code.

A patient is in the OR for an arthroscopy of the medial compartment of his left knee. A meniscectomy is performed. What is the correct code used to report for the anesthesia services?

1400 In the CPT® Index, look for Anesthesia/Knee where there are multiple codes to choose from. Turn to these codes in the Anesthesia section and review them. Code 01400 represents anesthesia for a surgical arthroscopic procedure performed on the knee joint, not otherwise specified.

Patient is a 69 year-old woman with a biopsy proven squamous cell carcinoma of her left forearm measuring 2.3 cm in greatest diameter. The area was marked with 4 mm gross normal margins. This area was removed as drawn, and the surgeon then incised his planned rhomboid flap, elevating the full-thickness flap into the defect and closing the sites in layers using 3-0 Monocryl, 4-0 Monocryl and 5-0 Prolene. The patient tolerated the procedure well. Final measurements were 2.7 cm x 2.1 cm. What CPT® code(s) is/are reported?

14020 Rhomboid flap is a flap in the shape of a rhomboid used for a rotation flap skin graft. A rotation flap is considered an adjacent tissue transfer. In the CPT® Index look for Skin Graft and Flap/Tissue Transfer and you are directed to 14000-14350. Code selection is based on location and flap size. The size of the flap is calculated in square cm and includes both the size of the primary defect and secondary defect created by the flap. CPT® guideline indicates the excision of the lesion is included in the adjacent tissue transfer. The final measurement in this case is 2.7 cm x 2.1 cm, which equals 5.67 cm 2 (2.7 x 2.1 = 5.67). 14020 is the correct code.

Patient is a 53 year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure, which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea. Then, Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound, the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported?

14301, 15004-51 A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq cm. 14301 is reported for the first 30 sq cm - 60.0 sq cm. Wound preparation was also performed. In the CPT® Index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed.

What CPT® code(s) would best describe treatment of 9 plantar warts removed and 6 flat warts all destroyed with cryosurgery during the same office visit?

17111 Cryosurgery is a method of destruction using extreme cold to destroy the lesion. In the CPT® Index look for Destruction/Warts/Flat referring you to CPT® codes 17110 and 17111. In the numeric section guidelines under the Integumentary section, subheading Destruction, flat warts and plantar warts are both included in the definition of lesions. Warts are considered benign lesions; they are coded from code range 17110-17111. A total of 15 lesions were destroyed by cryosurgery. Code 17111 represents the destruction of 15 or more lesions.

Destruction of a malignant lesion on the face with a lesion diameter of 1.2 cm

17282

A 56 year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon performs the surgery with two stages. The first stage includes 4 tissue blocks and the second stage includes 6 tissue blocks. What are the codes for both stages?

17311, 17312, 17315 Mohs codes are selected based on location and number of stages, each including up to five blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the CPT® Index look for Mohs Micrographic Surgery and you are directed to codes 17311-17315. Code 17311 is for the first stage with four tissue blocks and code 17312 for the second stage with five tissue blocks, based on the documentation of the site forehead. The remaining 6 th tissue block prepared in the 2 nd stage is reported with the add-on code 17315.

What is the anesthesia code for a cast application to the wrist?

1860 In the CPT® Index for Anesthesia/Cast Application/Forearm, Wrist and Hand which directs you to 01860. Verify code selection in the numeric section.

A localization wire placement in the lower outer aspect of the right breast was performed by a radiologist the day prior to this procedure. During this operative session, the surgeon created an incision through the wire track and the wire track was followed down to its entrance into breast tissue. A nodule of breast tissue was noted immediately adjacent to the wire. This entire area was excised by sharp dissection, sent to pathology and returned as a benign lesion. Bleeders were cauterized and subcutaneous tissue was closed with 3-0 Vicryl. Skin edges were approximated with 4-0 subcuticular sutures and adhesive strips were applied. The patient left the operating room in satisfactory condition. What is/are the correct code(s) for the surgeon's service?

19125-RT Documentation indicates a localization wire was placed prior to the surgery by a radiologist. You are asked to select the code for the surgeon's service; therefore, code 19285 is not reported. In the CPT® Index look for Excision/Breast/Lesion referring you to codes 19120, 19125, 19126. Code 19125 describes excision of breast lesion identified preoperatively with a radiology marker. Modifier RT is appended to indicate the right side.

Report the appropriate anesthesia code for an obstetric patient who had a planned general anesthesia for cesarean hysterectomy.

1963 Use the CPT® Index look for Anesthesia/Hysterectomy/Cesarean which directs you to 01963, 01969. Review the codes in the numeric section to determine that code 01963 is the appropriate code. Note: Code 01969 is an add-on code and cannot be coded without a primary procedure code.

In what year was the AAPC founded?

1988 The AAPC was founded in 1988.

A 63 year-old man sustained a gunshot wound through the right maxillary sinus penetrating into the right neck. CT scan revealed no hard evidence of arterial injury but a bullet was directly in line with the internal jugular vein. He was sent to the operating room for neck exploration to rule out vascular injury and injury to the aerodigestive tract (respiratory and digestive tracts). A sternocleidomastoid incision was performed and carried down through the platysma muscle. There was no penetration of the internal jugular vein, but a foreign body was identified resting on the internal jugular vein at approximately the level of the angle of the mandible and it was removed. The parotid gland was noted to have a blast injury near the tail. This was not surgically repaired or resected. Once all bleeding was controlled, a 10 French round drain was placed in the wound. The wound was copiously irrigated. The platysma muscle was closed and the skin was closed with subcuticular closure. What CPT® code is reported?

20100 In the CPT® Index, look for Exploration/Neck/Penetrating Wound. You are referred to 20100. Review the code to verify accuracy. 20100 is the correct code because the patient was sent to the operating room for exploration of a gunshot (penetrating trauma) wound to identify damaged structures. The category guidelines for Wound Exploration-Trauma indicate that these codes include removal of foreign bodies, ligation or coagulation of minor subcutaneous and muscular blood vessels, damaged tissue debridement, repair and wound closure.

A patient is given Xylocaine, a local anesthetic, by injection in the thigh above the site to be biopsied. A small bore needle is then introduced into the muscle, about 3 inches deep, and a muscle biopsy is taken. What CPT® code is reported for this service?

20206 In the CPT® Index, look for Biopsy/Muscle. You are referred to 20200-20206. The biopsy is taken through the skin, or percutaneously, with a needle. Although the biopsy is deep, it is performed by percutaneous technique, which is reported with 20206.

The patient has developed plantar fasciitis, a painful condition in his heel and the sole of his foot. He has tried using shoe inserts and over-the-counter pain relievers, but is still having pain. His physician performs an injection of the tendon sheath on the bottom of his foot. What procedure code is reported?

20550 An injection of a single tendon sheath, or ligament, aponeurosis (for example: plantar fascia) is coded with a 20550. Look in the CPT® Index for Tendon Sheath/Injection.

A 27 year-old presents with right-sided thoracic myofascial pain. A 25-gauge 1.5-inch needle on a 10 cc controlled syringe with 0.25% bupivacaine was used. After negative aspiration, 2 cc were injected into each trigger point. A total of four trigger points were injected. A total of 8 cc of bupivacaine was used on the rhomboid major, rhomboid minor, and levator scapular muscles. What CPT® code(s) is/are reported for this procedure?

20553 In the CPT® Index look for Injection/Trigger Point(s)/Three or More Muscles. You are referred to 20553. Review the code to verify accuracy. 20553 covers the three muscles (rhomboid major, rhomboid minor and scapular muscles) with a total of four (multiple) trigger point injections. Codes for trigger point injections are determined by the number of muscles injected not the number of injections administered.

The patient came to the office for a therapeutic injection, left shoulder subacromial space. What procedure code is reported?

20610 Code 20610 describes an arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee, subacromial bursa), without ultrasound guidance. The code indicates that the arthrocentesis is for aspiration and/or injection. The drug used in the injection (usually a steroid) is coded separately. Look in the CPT® Index for Arthrocentesis/Large Joint.

A patient presents with a healed fracture of the left ankle. The patient was placed on the OR table in the supine position. After satisfactory induction of general anesthesia, the patient's left ankle was prepped and draped. A small incision about 1 cm long was made in the previous incision. The lower screws were removed. Another small incision was made just lateral about 1 cm long. The upper screws were removed from the plate. Both wounds were thoroughly irrigated with copious amounts of antibiotic- saline solution. Skin was closed in a layered fashion and sterile dressing applied. What CPT® code(s) should be reported?

20680-LT When reporting the removal of hardware (pins, screws, nails, rods), the code is selected by fracture site, not the number of items removed or the number of incisions made. To report 20670 or 20680 more than once, there must be more than one fracture. In this case, there is only one fracture site requiring two incisions. We know the removal is deep because the screws were in the bone. In the CPT® Index look for Removal/Implantation and you are referred to 20670-20680. Verify the correct code is 20680. Modifier LT is appended to indicate the procedure is performed on the left side.

Osteotomy, humerus, with internal fixation

24400 In the CPT® Index, look for Osteotomy/Humerus and you are directed to 24400-24410. Code 24400 indicates "with or without internal fixation." No modifiers are necessary for this exercise but because we have two arms, this service should be reported with a modifier to indicate laterality: RT for the right side, LT for the left side, or 50 for bilateral.

A 44 year-old male with biplanar deformity, acquired limb length discrepancies and tibial nonunion has undergone deformity correction. He now requires exchange of an external fixation strut 45 days postoperatively. One of the struts for his multiplane external fixation device is removed and then replaced with an adjustable strut. The intraoperative mounting parameters, deformity parameters and initial strut settings are entered into the computer prior to Jim's discharge and a daily schedule is generated for him to perform the gradual deformity correction necessary. What CPT® code(s) is/are reported?

20697 The exchange of an external strut guided by stereotactic computer-assisted adjustment is coded with 20697. There is a parenthetical note under code 20697 that it is not used in combination with 20692 or 20696. In the CPT® Index look for External Fixation/Application/Stereotactic Computer Assisted directing you to 20696-20697.

Mrs. Smith underwent an arthrodesis of her spine for spinal deformity, posterior approach, segments L3-L5. What procedure code is reported?

22800 Spinal arthrodesis is coded based on the approach; L3-L5 is considered three segments. Instrumentation is also coded, if performed. Look in the CPT® Index for Arthrodesis/Vertebra/Spinal Deformity/Posterior Approach.

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

23075-RT Look in the CPT® Index for Excision/Tumor/Shoulder and you are referred to 23071-23078. Code 23075 reports the excision of a soft tissue mass (tumor), subcutaneous. The mass was removed with deep, blunt dissection; however, there is no mention of the depth and you cannot assume that the mass was subfascial because of the word deep. The measurement of the mass is not documented resulting in the default to the smallest measurement of less than 3 cm for code 23075. It is a rule of thumb that if a coder cannot ask the physician to document the size of a mass, lesion or repair in order to give the physician credit, the smallest measurement is reported. Modifier RT is appended to indicate the procedure is performed on the right side.

" A 49 year-old female had two previous rotator cuff procedures and now has difficulty with shoulder function, deltoid muscle function and axillary nerve function. An arthrogram is scheduled. After preparation, the shoulder is anesthetized with 1% lidocaine, 8 cc without epinephrine. The needle was placed into the shoulder area posteriorly under image intensification. It appeared as if the dye was in the shoulder joint. A good return of flow was obtained. The shoulder was then mobilized and there was no evidence of any cuff tear from the posterior arthrogram. What CPT® codes are reported?

23350, 73040-26 Contrast material is being injected into the shoulder joint for a radiographic look of the joint and internal structures (arthrogram). Look in the CPT® Index for Arthrography/Shoulder/Injection referring you to 23350. In the Musculoskeletal section, there is a parenthetical note under code 23350 that indicates to use code 73040 for radiographic arthrography. Modifier 26 is required to indicate the radiologic professional service.

A 6 year-old male suffered a fracture after falling off the monkey bars at school. He fell on an outstretched hand and suffered a transcondylar fracture of the left humerus. After prep and drape, a manipulation was done to achieve anatomic reduction. Once the joint was adequately reduced, pins were placed through the skin distally and proximally into the bone to maintain excellent fixation and anatomic reduction. The pins were bent, trimmed and covered with a sterile dressing and a posterior splint was placed on the patient's arm. What CPT® code is reported?

24538-LT Fracture codes are based on the location of the fracture and the treatment method. Documentation describes a closed reduction of a transcondylar fracture with percutaneous placement of pins. This is described with code 24538. This can be found in the CPT® Index by looking for Fracture/Humerus/Transcondylar/Percutaneous directing you to code 24538. Modifier LT is appended to indicate the procedure is performed on the left side.

A 22 year-old female sustained a dislocation of the right elbow with a medial epicondyle fracture while on vacation. The patient was given general anesthesia and the elbow was reduced and was stable. The medial epicondyle was held in the appropriate position and was reduced in acceptable position and elevated. A long arm splint was applied. The patient is referred to an orthopedist when she returns to her home state in a few days. What CPT® code(s) are reported?

24565-54-RT, 24605-54-51-RT In the CPT® Index look for Fracture/Humerus/Epicondyle/Closed Treatment. You are referred to code 24560-24565. Review the codes to choose the appropriate service. 24565 is the correct code to report the alignment of an epicondyle fracture with manipulation (reduced) without a surgical incision. In the CPT® Index, look for Dislocation/Elbow/Closed Treatment. You are referred to 24600, 24605. Review the codes to choose appropriate service. 24605 is the correct code because the patient was given general anesthesia for the procedure. Modifier 54 is appended to report the physician performed the surgical portion only. The patient is referred to an orthopedist for follow up or postoperative care. Modifier 51 is needed to report multiple procedures were performed. Append modifier RT to indicate the procedure is performed on the right side.

What is the correct code for the application of a short arm cast?

29075 In the CPT® Index, look for Cast/Type/Ambulatory/Short Arm. The code you are directed to use is 29075.

The patient is a 17 year-old male who was struck on the elbow by another player's stick while playing hockey. He is found to have a fracture of the olecranon process. The patient was brought to the OR, anesthetized and intubated. The right upper extremity was prepped with Betadine scrub and draped free in the usual sterile orthopedic manner. The arm was then elevated and exsanguinated and the tourniquet inflated to 250 mm/Hg. A five-inch incision was made with the scalpel on the extensor side of the elbow, beginning distally and proceeding in an oblique fashion up the proximal forearm. Dissection was carried through subcutaneous tissue and fascia, and bleeding was controlled with electrocautery. We then subperiosteally exposed the proximal ulna and olecranon to visualize the fracture site. The fracture could be seen at the base of the olecranon process. We irrigated the site thoroughly and reduced the fracture fragments without difficulty. Extending the elbow, we inserted two smooth K-wires across the fracture site. Through a drill hole in the proximal ulnar shaft, we threaded an 18-gauge wire through it and wrapped it around the K-wires in a figure-of-eight manner to further stabilize the fixation. Wires were then twisted and placed into soft tissues. The K-wires in the olecranon were advanced slightly after being bent and cut. Sterile dressing was applied and the patient was placed in a splint. What CPT® code is reported?

24685-RT This is a fracture of the olecranon process which is located at the upper end of the ulna. An incision was made to expose the fracture site, making it an open treatment. Look in the CPT® Index for Fracture/Ulna/Olecranon/Open Treatment 24685. Modifier RT is appended to indicate the procedure was performed on the right side.

An 85 year-old has developed a lump in her right groin. An incision over the lesion was made and tissue was dissected through the skin and subcutaneous tissue going deep through the femoral fascia. Sharp dissection of the mass was performed, freeing it from surrounding structures. The 3 cm mass was isolated and excised. The incision was closed, the area was cleaned and dried, and a dressing applied. What CPT® code is reported?

27048 In the CPT® Index look for Excision/Tumor/Pelvis. You are referred to 27043, 27045, 27047, 27048, 27049 and 27059. Review the codes to choose the appropriate service. 27048 is the correct code to report the removal of the 3 cm mass below the fascia.

Physician replaces a single chamber permanent pacemaker with a dual chamber permanent pacemaker. What CPT® code(s) is/are reported?

33214 Code 33214 is used for the conversion of a single chamber system to a dual chamber system which includes removal of the previously placed pulse generator, testing of existing lead, insertion of new lead, and insertion of new pulse generator. Look in the CPT® Index for Cardiac Assist Device/Pacemaker System/Upgrade which refers you to code 33214.

A 68 year-old female with long-standing degenerative arthritis in her right knee presented. Risks and benefits were discussed. She was agreeable to surgery. After adequate anesthesia, the patient was prepped and draped in usual sterile fashion with DuraPrep1 and Betadine scrub. The leg was exsanguinated and tourniquet inflated. An anterior incision was made and carried through the skin and bursa, cauterizing all bleeders. The bursa was elevated medially and a medial parapatellar incision was made. The proximal tibia was cleaned. The knee had an 18-degree flexion contracture. The cruciate ligaments were debrided along with the menisci. The proximal tibial cutting guide was placed and the proximal tibial cut made. The femoral canal was entered and a 6 degree cut was made for the anterior jig. The distal cut was made at 6 degrees. The femur measured a size 2. The 2 cutting block was placed and the anterior, posterior and chamfer cuts were made. The notch cut was made and the trial component was placed with a size 2 tibia and 12 mm spacer and was found to fit beautifully and it tracked well. The patella was cut and measured to be a 32. The holes were drilled and the proximal tibial cuts were made. All the excess meniscal tissue and hypertrophic synovium were debrided. The wound was thoroughly irrigated and the bone dried. The cement was mixed; the size 2 tibia with a 12 mm tibial tray, size 2 femur and a size 32 patella were all cemented in place removing all excess cement. After the cement was hard, the tourniquet was released. The knee was placed through a range of motion and was found to track beautifully. The knee was thoroughly irrigated. The retinaculum was closed with interrupted figure-of-eight 1 Vicryl. The bursa was closed with 1 and 0. The subcutaneous layers were closed with 0 and 2-0 and the skin with staples. Sterile dressing was applied. The patient was taken to the recovery room in stable condition. What CPT® code is reported?

27447-RT The procedure performed was an arthroplasty of the knee found in the CPT® Index by looking for Arthroplasty/Knee referring you to 27437-27447. This was a total knee arthroplasty with patella resurfacing reported with 27447. Modifier RT is appended to indicate the procedure is performed on the right side.

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

27506 Documentation shows the patient had a fracture of his left femoral shaft. The fracture was repaired with open reduction and internal fixation (ORIF) using an intramedullary nail and interlocking screws. Selection of codes depends on the fracture site and the method of treatment (closed, open, or percutaneous). The range of codes can be found in the CPT® Index by looking for Fracture/Femur/Peritrochanteric/Intramedullary Implant Shaft. Check the numeric section to select the correct code. Code 27245 is not correct, because this was not a peritrochanteric fracture; it is a femoral shaft fracture. The approach is from the peritrochanteric region. The application of the first cast or splint is included in 27506. See the guidelines for Application of Casts and Strapping in the CPT® codebook.

Deep biopsy of soft tissue of the ankle

27614

What is the correct code for a total ankle arthroplasty with an implant?

27702 In the CPT® Index, look for Arthroplasty/Ankle referring you to codes 27700-27703. Review the codes in the numeric section; code 27702 is the correct code.

A patient presented with a right ankle fracture. After induction of general anesthesia, the right leg was elevated and draped in the usual manner for surgery. A longitudinal incision was made parallel and posterior to the fibula. It was curved anteriorly to its distal end. The skin flap was developed and retracted anteriorly. The distal fibula fracture was then reduced and held with reduction forceps. A lag screw was inserted from anterior to posterior across the fracture. A 5-hole 1/3 tubular plate was then applied to the lateral contours of the fibula with cortical and cancellous bone screws. Final radiographs showed restoration of the fibula. The wound was irrigated and closed with suture and staples on the skin. Sterile dressing was applied followed by a posterior splint. What CPT® code is reported?

27792-RT In the CPT® Index look for Fracture/Fibula/Open Treatment and you are referred to 27784, 27792, 27814. Code 27784 reports open treatment of a proximal fibular fracture or shaft fracture. The correct code is 27792 for the open treatment and internal fixation. Modifier RT is appended to indicate the procedure is performed on the right side.

Mrs. Williams has had a bunion on her right foot for many years, and is scheduled for surgery to correct this condition. The doctor plans to do a double osteotomy of the metatarsal bone. What procedure code(s) is/are reported?

28299-RT A double osteotomy can be performed on the phalanx and the metatarsal, or by making two incisions on the metatarsal bone. Look in the CPT® Index for Osteotomy/Phalanges/Toe.

A young female patient was taken to the operative suite and was placed under appropriate anesthesia. She has been suffering from pain and a potential rotator cuff tear of the right shoulder. The right arm was sterilely draped and prepped. Arthroscopic portals were created anteriorly-posteriorly. The joint line was carefully examined. The biceps insertion was noted to be normal. The middle and inferior glenohumeral ligaments were visualized and noted to be normal. The undersurface of the rotator cuff was clearly visualized and also noted to be normal. There was a large anterior spur formation. The burr was introduced through a lateral portal and the anterior lip of the acromion was resected. The undersurface of the clavicle was noted to be quite prominent and part of the impinging process. There was intense bursitis and a bursectomy was performed, allowing for acromial decompression and release. Spurs were removed from the distal clavicle. All instruments were removed, skin incisions were closed and a dressing was applied. The patient was placed in a sling and returned to the recovery room. What CPT® code(s) is/are reported?

29822-RT, 29826-RT In the CPT® Index, look for Arthroscopy/Surgical/Shoulder. You are referred to 29806-29828. The procedure performed was a decompression of the subacromial space with partial acromioplasty, 29826. The report states that the anterior lip of the acromion was resected and a bursectomy was performed. Also mentioned is the removal of spurs from the distal clavicle. The report does not state that a distal claviculectomy was performed; therefore, 29824 is not reported. The debridement of the distal clavicle is performed and reported with 29822. Modifier RT is appended to indicate the procedure is performed on the right side. Code 29826 is an add-on code and modifier 51 exempt.

A patient's nose was hit with a baseball during a high school baseball game. At that time reconstruction was performed with local grafts. Patient returns now as an adult, discontent with the bony prominence along the bony pyramid and flat look of the tip of the nose. He underwent major repair with osteotomies and nasal tip work. What CPT® code is reported?

30450 The procedure performed now is a secondary rhinoplasty due to unfavorable results from the initial rhinoplasty. In the CPT® Index look for Rhinoplasty/Secondary directing you to code range 30430-30450. Code selection is based on the reason for the repair and the extensiveness of the repair. 30450 reports a major secondary revision including osteotomies and nasal tip work.

Physician changes the old battery to a new one on a patient's dual chamber permanent pacemaker. What CPT® code(s) is/are reported?

33228 CPT® guidelines state "When the battery of a pacemaker is changed, it is actually the pulse generator that is changed." It is reported with one code. In the CPT® Index look for Pacemaker. This will direct you to see Cardiac Assist Devices. Look for Cardiac Assist Devices/Pacemaker System/Replacement/Pulse Generator referring you to codes 33227-33229. Code 33228 is reported for dual chamber (dual lead system).

The patient has a torn medial meniscus. An arthroscope was placed through the anterolateral portal for the diagnostic procedure. The patellofemoral joint showed grade 2 chondromalacia on the patellar side of the joint only, this was debrided with a 4.0-mm shaver. The medial compartment was also entered and a complex posterior horn tear of the medial meniscus was noted. It was probed to define its borders. A meniscectomy was carried out to a stable rim. What CPT® code(s) is/are reported?

29881 In the CPT® Index look for Arthroscopy/Surgical/Knee. You are referred to 29866-29868, 29871-29889. Review the codes to choose appropriate service. 29881 is the correct code because the tear was in the medial meniscus. A meniscectomy as well as debridement with a shaver (or chondroplasty) were performed. 29877 is not reported as this is included in 29881. 29880 is not appropriate because a meniscectomy was not performed in both the medial and lateral compartments. The surgery started out as a diagnostic procedure, but changed when the physician decided to perform surgical procedures on the knee.

The physician performs arthroscopic meniscus repair with partial medial and lateral repairs. What procedure code is reported?

29883 Code 29883 is for an arthroscopy, knee, surgical; with meniscus repair (medial AND lateral). Look in the CPT® Index for Arthroscopy/Surgical/Knee, which gives a range of codes for procedures on the knee that can be done with an arthroscope.

" This 36 year-old female presents with an avulsed anterior cruciate ligament off the femoral condyle with a complete white on white horizontal cleavage tear of the posterior horn of the medial meniscus, causing instability. A general endotracheal anesthesia was performed, and the patient was placed supine on the operating table. The right lower extremity was prepped with Betadine and draped free. Standard arthroscopic portals were created, and the knee was systematically examined and probed. The posterior horn of the medial meniscus was noted to be buckled and frayed. This area was carefully probed and found to be irreparable. It was decided that our best option was to proceed with a limited partial meniscectomy, with the goal being to leave as much viable meniscal tissue as possible. Therefore, a medial infrapatellar portal was developed with a longitudinal stab wound. A series of straight-angled and curved basket punches was used to perform a saucerization of the damaged portion of the meniscus, leaving the intact portion of the medial meniscus in place. Debris was meticulously removed with the 4.0 meniscal cutter. Approximately 50% of the medial meniscus remained. Next, our attention was turned to the ACL repair. Through a 5 cm longitudinal anterior incision, a central one-third tendon bone was harvested. A 10 mm graft was taken and bone plug sculpted. Anterolateral notchplasty was done with a curette and polished with the burr. All debris was removed and instruments were used to ensure proper isometry. The graft was tightened in extension about 2.5 mm and actually lengthened in flexion, and this was considered acceptable. Endoscopic guides were used to create the tibial and femoral tunnels, and the edges were rasped smooth. Using a percutaneous guide pin, the graft was placed retrograde to the knee and secured proximally with an 8 x 25 mm interference screw. The knee was put through range of motion, and with the leg in 30 degrees of flexion with the posterior drawer applied to the proximal tibia; an 8 x 20 mm interference screw was used to secure the bone plug distally. The graft was tight, isometric and without adverse features. The wound was copiously irrigated with Kantrex1. Cancellous bone fragments from bone plugs were used to graft the donor site defect in the patella. The paratenon was closed over this to house the graft with a running #1 Vicryl. The edge of the distal bone plug was beveled with the rongeur. The subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. Steri-Strips, sterile dressing, cryo cuff and hinged knee brace were applied. The patient was awakened and taken to the recovery room in satisfactory condition. What CPT® codes are reported?

29888-RT, 29881-51-RT The anterior cruciate ligament repair can be found in the CPT® Index by looking for Cruciate Ligament/Repair/Arthroscopic Repair 29888, 29889. This was the anterior cruciate ligament; 29888 is the correct code. A medial meniscectomy was also performed which is reported with 29881. In the CPT® Index look for Arthroscopy/Surgical/Knee referring you to 29866-29868, 29871-29889. This is a medial meniscectomy 29881. Modifier -51 is required to report multiple procedures performed during the same session. The patellar tendon bone graft is included in 29888. The notchplasty (29999) is also bundled as only one procedure can be reported per compartment (patellofemoral). Modifier RT is appended to indicate the right side.

Most nasal passages have how many turbinates present on the lateral wall of each nasal cavity?

3 There are three turbinates on each side of the nose: superior, middle and inferior. These turbinates may become swollen and require surgery to restore airflow.

What is the correct CPT® code for the extensive excision of nasal polyps?

30115 In the CPT® Index, look for Excision/Polyp/Nose which directs you to 30110, 30115. You may also look in the CPT® Index for Excision/Nose/Polyp and get the same codes. Looking at the description for each code in the Respiratory numeric section, code 30115 is selected for extensive. If you look up Polyp/Nose/Excision/Extensive in the CPT® Index, code 30115 is listed.

What code represents a secondary rhinoplasty where a small amount of work is performed on the tip of the nose?

30430 In the CPT® Index, look for Rhinoplasty/Secondary, which directs you to codes 30430-30450. Look at the codes in the Respiratory numeric section. Code 30430 represents a small amount of work for a secondary rhinoplasty when performed on the tip of the nose.

According to the parenthetical instructions for CPT® code 33690, how should right and left pulmonary artery banding in a single ventricle be reported?

33620 The parenthetical instructions under CPT® code 33690 include: (For right and left pulmonary artery banding in a single ventricle [eg, hybrid approach stage 1], use 33620) and (Do not report modifier 63 in conjunction with 33690).

" A patient underwent bilateral nasal/sinus diagnostic endoscopy. Finding the airway obstructed the provider fractures the middle turbinates to perform the surgical endoscopy with total bilateral ethmoidectomy and nasal septoplasty. What CPT® codes are reported?

30520, 31255-50-51 According to the CPT® guidelines for coding of endoscopies, a surgical sinus endoscopy includes a sinusotomy and diagnostic endoscopy. In the CPT® Index look for Ethmoidectomy/Endoscopic directing you to 31254, 31255. Code 31255 represents a total ethmoidectomy. In the CPT® Index look for Septoplasty which directs you to code 30520. The fracturing of the turbinates is inclusive to the procedures and not reported separately because the provider is fracturing the turbinates to perform the endoscopy. Modifier 50 indicates the ethmoidectomy was performed bilaterally and modifier 51 is reported with code 31255 to indicate multiple procedures performed at same session, for maximum reimbursement.

Which code(s) describe(s) bilateral endoscopic nasal procedure to diagnoses breathing problems?

31231 Code 31231 is a diagnostic nasal endoscopy, unilateral or bilateral.; No modifier is necessary. In the CPT® Index, look for Endoscopy/Nose/Diagnostic which directs you to 31231-31235.

Emergency endotracheal intubation

31500

What modifier is used to report an evaluation and management service mandated by a court order?

32 Modifier 32 is used for services related to mandated consultation and/or related services by a third party payer, governmental, legislative or regulatory requirements.

When procedures are "mandated" by third party payers, what modifier would you use?

32 Modifier 32 reports "mandated services".

A thoracotomy procedure was performed for repair of hemorrhage and lung tear. What CPT® code is reported?

32110 Thoracotomy main code is 32100; control of the hemorrhage and lung tear would be code 32110. In the CPT® Index, look for Thoracotomy/Hemorrhage.

What CPT® code is reported for open decortication and parietal pleurectomy?

32320 In the CPT® Index look for Decortication/Lung/with Parietal Pleurectomy. This directs you to code 32320.

What CPT® code is reported for a percutaneous needle biopsy of mediastinum?

32405 In the CPT® Index look for Biopsy/Mediastinum/Needle referring you to code 32405. Confirm code selection in the numeric section.

Which CPT® code describes a pneumonectomy?

32440 A pneumonectomy is removal of a lung. In the CPT® Index, look for Pneumonectomy 32440-32445. Read the code descriptors to se-lect the correct code.

What CPT® codes are reported for an extrapleural pneumonectomy as well as empyemectomy performed during the same surgical session?

32445, 32540-51 In the CPT® Index, look for Pneumonectomy. By looking at codes 32440-32445 we see that code 32445 represents the extrapleural pneumonectomy. Next in the CPT® Index look for Empyemectomy which directs us to code 32540. There is also a parenthetical statement under code 32540 instructing us to report the correct lung removal code with 32540 if performed.

A 45 year-old presents with acute pericarditis. The surgeon makes a small incision between two ribs and enters the thoracic cavity. An endoscope is introduced and the pericardial sac is examined by direct visualization. Using an instrument introduced through the endoscope, the surgeon creates an opening in the pericardial sac for drainage purposes. What CPT® code is reported?

32659 This procedure is performed endoscopically. A small opening (window) is made in the pericardial sac to facilitate drainage of inflammatory fluid from the pericarditis. An incision is made only to create an opening; nothing is excised. In the CPT® Index, look for Pericardial Sac/Drainage and you are directed to code 32659.

A patient presents for epicardial lead placement via median sternotomy to the right atrium and right ventricle. A dual pacemaker generator is then inserted subcutaneously. The patient has bundle branch block and sinoatrial node dysfunction. What CPT® and ICD-10-CM codes are reported?

33202, 33213-51, I45.4, I49.5 Because leads were placed on the right atrium and right ventricle, it is a dual chamber system. Two codes are necessary to report placement of an epicardial system. The parenthetical note under 33203 directs the coder to report codes 33202 and 33203 with 33212, 33213, 33221, 33230, 33231, and 33240. Look in the CPT® Index for Cardiac Assist Devices/Pacemaker System/Insertion/Pulse Generator. You are referred to 33212, 33213, and 33221. For the placement of the epicardial electrodes look in the CPT® Index for Cardiac Assist Device/Pacemaker System/Insertion/Electrode. Code 33202 is reported. In the ICD-10-CM Alphabetic Index look for Block, blocked/bundle-branch referring you to code I45.4. Look in the Alphabetic Index for Dysfunction/sinoatrial node referring you to code I49.5. Verify codes in the Tabular List.

Patient presents for removal and replacement of her permanent dual chamber transvenous pacemaker system (generator and leads). What CPT® codes are reported?

33235, 33208-51, 33233-51 Multiple codes are needed to show the entire procedure. 33235 is for removing the electrodes, 33208 is for putting in the new system, and 33233 is for removing the pacemaker pulse generator. These codes are all found under Cardiac Assist Devices/Pacemaker System in the CPT® Index. Modifier 51 reports multiple procedures performed during the same session.

Due to infections from hemodialysis, the physician replaces a dual chamber implantable defibrillator system with a multi-lead system with an epicardial lead and transvenous dual chamber lead defibrillator system. The original dual leads are extracted transvenously. The generator pocket is relocated. What CPT® codes are reported?

33244, 33202-51, 33264-51, 33223-5 When a new system is placed after removal of an old system, report the codes for removal of the components and insertion of the new system. This is a transvenous system. The removal of the dual chamber implantable defibrillator electrodes is reported with 33244. Look in the CPT® Index for Cardiac Assist Devices/Implantable Defibrillators/Transvenous Implantable Pacing Defibrillator (ICD)/Removal/Electrodes referring you to 33244. The insertion of the epicardial electrode is reported with 33202. In the CPT® Index look for Cardiac Assist Device/Implantable Defibrillators/Transvenous Implantable Pacing Defibrillator (ICD)/ Insertion/Electrode referring you to 33202-33203, 33216-33217,33224-33225. The dual defibrillator generator was replaced with a multi-lead defibrillator generator 33264. Look in the CPT ® Index for Cardiac Assist Devices/ Transvenous Implantable Pacing Defibrillator (ICD)/ Replacement, Pulse Generator referring you to 33262-33264. Code 33264 describes the removal and replacement of an implantable defibrillator pulse generator. Two leads were replaced. Look in the CPT® Index for Cardiac Assist Devices/Implantable Defibrillators/ Transvenous Implantable Pacing Defibrillator (ICD)/ Insertion/Electrode referring you to 33202, 33203, 33216, 33217, 33224, 33225. Code 33217 describes the insertion of two transvenous electrodes for an implantable defibrillator; however, the notes under 33264 tell you not to report 33217. Code 33217 is bundled with 33264. The notes for this section of CPT® tell you to use 33223 for the relocation of the skin pocket for clinical situations such as infection. Modifier 51 is needed on 33202 and 33264. Modifier 59 is needed on 33223 to show that it is separate from 33244.

MAZE procedure is performed on a patient with atrial fibrillation. The physician isolates and ablates the electric paths of the pulmonary veins in the left atrium, the right atrium and the atrioventricular annulus while on cardiopulmonary bypass. What CPT® code is reported?

33256 The procedure described above is extensive according to CPT® definition. Look in the CPT® Index for Maze Procedure/Open and you are referred to 33254-33256. The patient was on bypass; therefore, the correct code is 33256.

Patient had mitral valve prolapse, and a mitral valve ring was inserted with cardiopulmonary bypass. What CPT® code is reported?

33426 The mitral valve was repaired, not replaced. Look in the CPT® Index for Repair/Heart/Mitral Valve 0345T, 33418-33420, 33422, 33425-33427 Code 33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring, is correct. Cardiopulmonary bypass is included in the code description and not coded separately

A physician performs a four-vessel autogenous (one venous, three arterial) coronary bypass on a patient who had a previous CABG two years ago, utilizing the saphenous vein, radial artery and the left and right internal mammary arteries. Select the CPT® codes for this procedure.

33535, 33517, 33530, 35600 Because this is a combo graft, codes 33517-33523 must be coded for the venous portion of the graft. Also, this is a redo more than one month after the original surgery, so the add-on code 33530 is appropriate. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial-Venous Bypass which directs you to 33517-33519, 33521-33523, 33531, and Arterial Bypass which directs you to 33533-33536. In this CPT® Index look for CABG is Harvest/Upper Extremity Artery which directs you to 35600. Look for the codes in the numeric section and you see all additional codes are add-on codes; therefore, no modifiers are required. To code for the reoperation look in the CPT® Index for Reoperation/Coronary Artery Bypass/Valve procedure which directs you to 33530.

Patient undergoes a three artery CABG. A surgical assistant procures the artery used for the grafts. What CPT® coding is reported for the assistant surgeon.

33535-80 Procurement of the arterial conduit is bundled into 33535 and reported with modifier 80 for the surgical assistant according to the guidelines. An add-on code, 35600, is used for harvesting an artery of the upper extremity; however, there is no mention of this in the report. The guidelines in the codebook above 33535 instruct you to use modifier 80 when a surgical assistant performs an arterial graft procurement. Look in the CPT® Index for Coronary Artery Bypass Graft (CABG)/Arterial Bypass referring you to 33533-33536. There are three arterial grafts; therefore, 33535 is correct.

A patient in the ED was found to have a ruptured abdominal aortic aneurysm. He was taken to emergency surgery; a physician performed a direct repair. The physician documented that the aneurysm involved the common iliac. Select the proper CPT® code for this procedure.

35103 You must read the question carefully because this is a ruptured aortic aneurysm involving the common iliac not a ruptured aneurysm of the common iliac. Look in the CPT® Index for Aneurysm Repair/Abdominal Aorta which directs you to multiple codes. On review of the code ranges, code 35103 is correct. Code 35102 is a repair of an aneurysm not ruptured.

A 5-French pigtail catheter was placed in the abdominal aorta and a run-off was performed following injection of 80cc of contrast. Oblique DSA images of the iliofemoral circulation were performed following 2 injections, each 15cc. The catheter was not moved to another position within the aorta for the additional injections. What CPT® codes are reported?

36200, 75630-26 Nonselective catheter placement in the aorta is reported with 36200. Look in the CPT® Index for Aorta/Catheterization/Catheter. Contrast was injected from one catheter placement site, and there is a report for the aorta and the lower extremities, making this an abdominal aortogram with bilateral iliofemoral lower extremity angiography, 75630. Look in the CPT® Index for Aortography/with Iliofemoral Artery referring you to 75630, 75635. Modifier 26 is required for the professional service.

In the cath lab a physician places a catheter in the aortic arch from a right femoral artery puncture to perform an angiography. Fluoroscopic imaging is performed by the physician. What CPT® code(s) is/are reported?

36221 The aorta is the trunk of the system, so this is a non-selective catheterization. Look in the CPT® Index for Angiography/Cervicocerebral Arch. Only one code is reported for the catheterization and fluoroscopic imaging which is 36221.

Catheter advanced from the left femoral artery into the aorta, manipulated into both the left and right renal arteries for imaging. What CPT® code(s) is/are reported?

36252 Look in the CPT® Index for Angiography/Renal Artery referring you to 36251-36254. Code 36252 includes selective catheter placement (first-order) of the main renal artery and any accessory artery(s) for renal angiography, including arterial puncture, catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral.

A 56 year-old patient who has been admitted requires a tunneled CV catheter insertion. The physician uses ultrasound guidance to perform the insertion. The physician documented vessel patency and that permanent recordings are in the patient's record. What CPT® codes are reported for the physician's services?

36558, 76937-26 The physician inserts a tunneled CV catheter (central venous). The patient is 56 years-old and there is no indication that a port or pump is involved. In the CPT® Index look for Central Venous Catheter Placement/Insertion/Central/Tunneled without Port or Pump 36557, 36558, 36565. The correct code is 36558. The physician uses ultrasound guidance, which is reported with 76937. In the coding guidelines for Central Venous Access Procedures, it states that imaging can be reported separately. The codes you are referred to are 76937 and 77001. Because the imaging used is ultrasound, report with 76937. Note that 76937 is an add-on code and it can only be reported if the physician documents selected vessel patency and permanent ultrasound recordings are in the patient records. Modifier 26 is appended to report the professional component.

A physician places a centrally inserted, tunneled central venous access device with a subcutaneous pump in a 7 year-old patient.

36563 Look in the CPT® Index for Venous Access Device/Insertion/Central which directs the coder to 36560-36566. The code for insertion of a tunneled central venous access device with a subcutaneous pump is 36563.

A 35 year-old patient presented to the outpatient hospital for PTA of an obstructed hemodialysis AV graft in the venous anastomosis and the immediate venous outflow. The procedure was performed under moderate sedation administered by the physician performing the PTA. The physician performed all aspects of the procedure, including radiological supervision and interpretation. Code for all services performed.

36902 PTA is the abbreviation for percutaneous transluminal angioplasty. This procedure involves the peripheral dialysis segment, which in the upper extremity extends through the axillary vein or the entire cephalic vein in the case of cephalic venous outflow. The correct code is 36902, which includes angioplasty and all radiological supervision and interpretation. Moderate sedation is not included in this code; however, 99152 is not reported, because the documentation does not indicate who monitored the patient, the medication, the dosage, or the time of the moderate sedation.

An 82 year-old female with a right leg medial malleolar non-healing ulcer elected to proceed with peripheral angiography. Using a RIM catheter, from a left femoral artery access, the contralateral right iliac artery was accessed and the catheter was gradually advanced to the right common femoral artery. The right lower extremity angiography was performed with both C02 injection and subsequently localized pictures of femoral distal bypass grafts were performed using contrast injections. This revealed the right superficial femoral artery is 100% occluded at its origin. Decision for angioplasty was made and intervention was performed through this area with a 7 mm x 20 mm balloon inflated up to 7 atmospheres. The gradual inflation resulted in enlarging the artery to a more normal flow of blood. What CPT® codes is/are reported?

37224, 75710-26-59 In the CPT® Index look for Angioplasty/Femoral Artery/Intraoperative which directs you to 37224. The second order selective catheterization (36246) for the diagnostic angiography will not be reported as an additional code because the catheterization was performed through the same access site as the interventional angioplasty, code 37224. Next, look for Angiography/Leg Artery. The diagnostic angiography is reported with 75710-26-59. Because the decision to perform the angioplasty was made after reading the films for the diagnostic angiography, modifier 59 is appended to show that it is not bundled with code 37224. This information is found in the Vascular Procedures Guidelines of the Radiology Section in the CPT® code book

A patient has a mass in her left axilla that is a suspected recurrence of lymphoma. She has a left axillary node excisional biopsy. The lymph node biopsied is under the pectoralis minor. What CPT® code is reported?

38525 The patient has an excisional biopsy of the left axillary node. Because the lymph node biopsied is under the pectoralis minor muscle, it is considered a deep lymph node. Look in the CPT® Index for Biopsy/Lymph Nodes/Open and you are directed to 38500, 38510-38530. 38525 is for biopsy of the deep axillary nodes.

How many lobes are in the liver?

4 lobes The human liver has four lobes: the right lobe and left lobe, which may be seen in an anterior view, plus the quadrate lobe and caudate lobe.

What CPT® code is reported for an intraoral incision and drainage of a hematoma of the tongue, submandibular space?

41008 CPT® code 41008 is specifically for Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space. Look in the CPT® Index for Drainage/Hematoma/Mouth/Submandibular Space. The code selection is made because it is intraoral, not extraoral.

Margaret has a cholecystoenterostomy with a Roux-en-Y. Five hours later, she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and was demonstrating early signs of peritonitis. What is the correct coding for the subsequent services on this date of service? (The same surgeon took her back to the OR as the one who performed the original operation.)

49402-78 CPT® code 49402 represents the removal of a foreign body (sponge from previous surgery) from the peritoneal cavity. In the CPT® Index, look for Removal/Foreign Body/Peritoneum. Modifier 78 indicates this was an unplanned return to the OR by the same physician for a related procedure following an initial procedure during the initial procedure's postoperative period.

What CPT® coding is reported for a peritoneoscopy with laparoscopic partial colectomy and anastomosis?

44204 A peritoneoscopy is a separate procedure and is not separately reportable when it is performed with a more extensive procedure. It is incidental to the laparoscopic partial colectomy and anastomosis. Look in the CPT® Index for Colectomy/Partial/with Anastomosis/Laparoscopic. The code is selected based on whether additional procedures, such as a coloproctostomy, is performed. There are no additional procedures in this case making 44204 the correct code choice.

A 43-year-old male has a chronic posterior anal fissure. The posterior anal fissure was excised down to the internal sphincter muscle. Which CPT® code is reported?

46200 In the CPT® Index, look for Anus/Fissure/Excision. You are referred to 46200. This is the correct code. There was a removal (excision) of a fissure, not fistula, without a sphincterotomy or hemorrhoidectomy.

If a perianal abscess is identified, incised and drained during the course of performing an internal and external hemorrhoidectomy, what CPT® codes are reported?

46255, 46050-51 The hemorrhoidectomy is indexed in CPT® under Hemorrhoidectomy/Simple which directs you to code 46255. When you read all the code descriptions for hemorrhoidectomies, code 46255 is correct to report for the procedure since internal and external hemorrhoids were removed. The I&D code for the perianal abscess is indexed under Incision and Drainage/Abscess/Anal referring you to codes 46045-46050. Reviewing the descriptions of the codes directs you to code 46050 for Incision and drainage of the perianal abscess. Modifier 51 is appended to indicate multiple procedures during the same operative session.

A 55-year-old patient underwent a repair of an initial left inguinal hernia. An incision was made at the groin. A hernia sac was readily identified and cleared from the surrounding tissue, inverted into the preperitoneal space, and plugged. Mesh was tacked to the surrounding muscle layers and then placed over the entire floor. What CPT® code(s) is/are reported?

49505-LT In the CPT® Index, look for Hernia Repair/Inguinal/Initial, Child 5 Years or Older. You are referred to 49505 and 49507. Review the codes to choose the appropriate service. 49505 is the correct code. The repair was through an incision (not by laparoscopy) on an initial inguinal hernia on a patient over five years of age and the hernia was not incarcerated or strangulated. According to CPT® guidelines, "With the exception of the incisional hernia repairs (49560-49566), the use of mesh or other prosthesis is not separately reported." It is inappropriate to code the mesh in this scenario. Modifier LT is appended to indicate the hernia is on the left side.

Which CPT® modifier should you append to a procedure code for a bilateral procedure?

50 50 Bilateral Procedure

What is the correct CPT® code for a percutaneous pyelostolithotomy with dilation and basket extraction measuring 1 cm?

50080 Pyelostolithotomy/Percutaneous in the CPT® Index refers you to code range 50080-50081. Code selection is based on the size of the kidney stone (calculus). Code 50080 is a percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm.

Renal biopsy, percutaneous, needle

50200

Patient is a 68 year-old male admitted for left flank nephrectomy with partial ureterectomy. He has left renal atrophy and chronic renal inflammation. The pathology report reveals marked glomerulosclerosis, chronic inflammation of the kidney, renal pelvis and ureter. What CPT® and ICD-10-CM codes are reported for this service?

50220-LT, N26.9, N28.89 In the CPT® Index look for Nephrectomy/with Ureters. CPT® code 50220 describes the nephrectomy including a partial ureterectomy. CPT® code 50230 describes a radical nephrectomy procedure with regional lymphadenectomy, and in this case, there is no documentation to support a radical procedure. HCPCS Level II modifier LT is used to indicate the left side.

What is the correct CPT® code for a MRI performed on the brain first without contrast and then with contrast?

70553 In the CPT® Index, look for Magnetic Resonance Imaging (MRI)/Diagnostic/Brain. You are directed to see codes 70551-70555. Upon review of the codes in the Radiology numeric section, code 70553 represents an MRI performed on the brain first without contrast material, then with contrast material.

Patient presents for excision of multiple kidney cysts. Three cysts are excised. What CPT® code(s) is/are reported for this service?

50280 In the CPT® Index look for Cyst/Kidney/Excision. CPT® description of 50280 describes the excision of cyst(s). The letter s in parenthesis in the code description indicates one or multiple cysts. You do not report 50280 three times or 50280 x 3. CPT® code 50290 describes the excision of perinephric cyst and 50060 describes the open removal of a kidney stone.

The urologist is called to the operating room to repair a kidney laceration, status post MVA. The urologist examines the kidney and repairs a small 2 cm laceration of the kidney. What CPT® code is reported for this service?

50500 Kidney repair or nephrorrhaphy codes are reported with CPT® 50400-50540. CPT® code 50500 clearly states repair of kidney laceration. Tip: You do not use the integumentary codes, but look at the repair codes listed within each body/organ system of the CPT® code book. In the CPT® Index see Repair/Kidney/Wound.

The patient has a 3.6 cm tumor in the lower pole of the right kidney. A percutaneous right renal cryosurgical ablation is performed. What CPT® code is reported for this service?

50593-RT In the CPT® Index look for Ablation/Cryosurgical/Renal Tumor/Percutaneous and you are directed to 50593. CPT® codes 50541 and 50542 describe laparoscopic procedures and are not considered because the procedure was performed percutaneously. CPT® code 50250 is ablation of renal mass lesion(s). HCPCS Level II modifier RT is used to indicate the right side.

The patient has significant morbid obesity and her pannus has been retracted to help with dissection. The planned procedure is to place a catheter/tube to drain the bladder. It is apparent she has quite a bit of scarring from her previous surgeries and appears to have an old sinus tract just above the symphysis. A midline incision is made following her old scar from just above the symphysis for a length of about 4-6cm. The sinus tract was excised, as this was also in the midline, and carefully dissected down to the level of the fascia. It does not appear to be an actual hernia, as there are no ventral contents within it. Again, there is quite a bit of distortion from previous scarring because of the obesity, but staying in the midline, the fascia is incised just above the symphysis of a length of about 2cm. The fat and scar are incised above the fascia more superiorly and with palpation, mesh from a previous hernia repair is felt. This was not palpable prior to the incision because of her body habitus. The mesh was not exposed or entered, it comes down quite close to the symphysis and certainly is too close to place a suprapubic (SP) tube. There is concern the mesh may become infected with an SP tube tract right there. Therefore, decision to abort the procedure is made. What CPT® code and modifier are reported for this service?

51040-53 In the CPT® Index look for Prosthesis/Penis/Replacement for the code range. To report code 54411, you will need to see the word multi-component to report it. The correct code is 54417 which indicates the replacement of inflatable penile prosthesis through an infected field. Documentation does not support debridement of a necrotizing soft tissue infection eliminating 11004 as an option.

A frontal and lateral chest X-ray is performed in the office for a patient with chest pain

71046

A partial cystectomy is performed due to the prior administration of radiation. It is complicated due to extensive adhesions and required an additional 2 hours beyond the usual cystectomy procedure. What CPT® code is reported for this service?

51555 In the CPT® Index look for Cystectomy/Partial/Complicated. The description of code 51555 is Cystectomy, partial; complicated (for example, post radiation, previous surgery, difficult location). Modifier 22 is not appended to the code as it already includes the additional work involved in the procedure.

" When a bilateral procedure is performed as unilateral, what modifier is reported?

52 Modifier 52 is used to report reduced services. This is used when a bilateral procedure is performed unilaterally.

The urologist is asked by the general surgeon to place ureteral catheters for visualization of ureters during a complicated bowel surgery. Cystoscopy is performed and ureteral catheters are inserted. The general surgeon removes the catheters at the end of the case. What CPT® code is reported?

52005 Placement of the ureteral catheters was performed via cystoscopy; CPT® 50605 would not be appropriate as this code is for an open insertion of indwelling stent into the ureter. CPT® 52332 describes the insertion of an indwelling ureteral stent and is not reported for temporary catheter insertion. CPT® 52310 describes the removal of a ureteral stent but does not cover the insertion of the catheters. CPT® 52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation or ureteropyelography, exclusive of radiologic services is correct. There would be no additional code reported for removal of these catheters. Look in the CPT® Index for Catheterization/Cystourethroscopy/Ureteral. No modifier is used, because this code includes both ureters.

A Urologist examines the urinary collecting system with a cystourethroscope and removes four bladder tumors by fulguration. Two tumors measured 1.5 cm and the other two tumors measured 2.5 cm and 3.0 cm. What code(s) should be reported?

52235 Look in the CPT® Index for Fulguration/Cystourethroscopy with/Tumor. You are referred to 52234-52235, 52240, 52250. When different size bladder tumors are removed in one surgical session, the code selection is based on the largest tumor size. In this example, the largest tumor removed is 3.0 cm. Only one code is reported regardless of the number of tumors removed.

Transurethral resection of bladder neck and nodular prostatic regrowth. What CPT® code is reported for this service?

52630 CPT® 52630 is reported for a transurethral resection of residual or regrowth of the prostatic tissue. In the CPT® Index look for Transurethral Procedure/Prostate/Resection. CPT® code 52500 is a separate procedure and considered an integral part of the prostate resection. CPT® code 52640 is used for the transurethral resection of a postoperative bladder neck contracture.

Patient is a sweet 2 1/2 year-old boy with meatal stenosis. Patient is brought to the operating room and placed supine on the operating room table. After adequate general endotracheal anesthesia was accomplished, he was prepped and draped in the usual sterile fashion. A clamp was placed just inferior ventrally to his stenotic meatus after the dorsal penile block had been administered. We then cut the clamped area to allow for a widely spatulated urethral meatus. Skin edges were approximated and patient was sent to the recovery room in good condition. What CPT® code is reported for this service?

53020 The procedure to report is a meatotomy. In the CPT® Index look for Meatotomy/Urethral. The correct code choice is 53020 to describe the cutting of the meatus, except infant. Code 53020 is classified as a separate procedure and since this is the only procedure performed, it can be coded and stand on its own. Urethroplasty codes 53410 and 53400 are used to report reconstruction or repair of the urethra and are not meatotomy codes. Code 54161 is used for a circumcision procedure.

Patient is a 40 year-old female presenting for repeat urethral dilation for urethral stricture using the instillation of a saline solution. What CPT® code is reported for this service?

53661 In the CPT® Index look for Urethra/Dilation/Suppository and/or Instillation. CPT® code 53660 is for the initial dilation. CPT® codes 53605 and 53665 are reported when general or spinal anesthesia is provided. No type of anesthesia is indicated in the note. This is a repeat procedure and the subsequent CPT® code 53661 is reported.

A clamp circumcision is performed without dorsal block on a newborn. What CPT® code is reported for this service?

54150-52 The circumcision used a clamp as described in CPT® code 54150. Code 54160 describes a surgical excision other than clamp. The parenthetical note beneath 54150 says to report the code with modifier 52 when the circumcision is performed without a penile or ring block. In the CPT® Index look for Circumcision/Surgical Excision/Neonate.

Patient presents to the emergency room with complaints of an erection lasting longer than two hours. Saline solution is used to irrigate the corpora cavernosa. What CPT® code is reported for this service?

54220 Priapism is a condition marked by a prolonged erection. This condition must be treated, or permanent damage may result. Usually the penis is irrigated to reduce the erection; however, in some cases, surgical intervention may be necessary. In the CPT® Index look for Irrigation/Penis/for Priapism directing you to 54220.

Patient is status post radical retropubic prostatectomy with erectile dysfunction, presenting for penile implant. An inflatable penile prosthesis is inserted. What CPT® code is reported for this service?

54401 Penile prosthesis insertion codes are described as either noninflatable or inflatable. CPT® code 54416 is removal and replacement of an inflatable penile prosthesis. CPT® code 54408 is for repair of an inflatable penile prosthesis. Code 54400 is reported for the insertion of a noninflatable prosthesis. Code 54401 is the correct code to report for the initial insertion of an inflatable penile prosthesis. Look in the CPT® Index for Prosthesis/Penis/Insertion.

A right side epididymectomy and spermatocelectomy are performed on a 15 year-old male. What CPT® code is reported?

54840 Code 54840 describes the excision of spermatocele, with or without epididymectomy and is the correct code. The epididymectomy codes (58460-58461) are not reported as the procedure is included in 54840. A lesion was not removed from the epididymis, making 54830 incorrect. Look in the CPT® Index for Spermatocele/Excision 54840.

Vasectomy reversal is performed, bilaterally, using the operating microscope. Choose the procedure code(s).

55400-50, 69990 In the CPT® Index look for Vasectomy/Reversal which refers you to see Vasovasorrhaphy directing you to code 55400. There are two parenthetical instructions beneath the code instructing us to use modifier 50 for a bilateral procedure and to use 69990 when an operating microscope is used.

Cryosurgical ablation of the prostate is performed for prostate cancer. What CPT® and ICD-10-CM codes are reported for this service?

55873, C61 In the CPT® Index look for Cryosurgery/Prostate or Ablation Prostate. Code 55873 describes the cryosurgical ablation of the prostate. Ultrasonic guidance and monitoring are not reported separately. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/prostate (gland) and select from the Malignant Primary column directing you to C61. Without mention of the cancer as in situ or as secondary/metastasized, ICD-10-CM codes C79.82 and D07.5 are not reported.

A 67 year-old gentleman with localized prostate cancer will be receiving brachytherapy treatment. Following calculation of the planned transrectal ultrasound, guidance was provided for percutaneous perineal placement of 1-125 seeds into the prostate tissue. What CPT® code is reported for needle placement to insert the radioactive seeds into the prostate?

55875 Brachytherapy is a form of radiation in which radioactive seeds or pellets are implanted directly into the tissue being treated to deliver their dose of radiation in a direct fashion and longer period of time. The placement of the seeds is performed percutaneously. The code is indexed in the CPT® Index under Prostate/Insertion/Needle guiding you to code 55875.

Physician performs an incision and drainage of an abscess located on the labia majora. What CPT® code is reported?

56405 The vulva consists of the external female genitalia, which includes the labia minora and majora, clitoris and vestibule. Code 56405 re-ports the I & D of the abscess of the vulva or perineal abscess. Because there is a specific code for an ID 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.

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?

58120 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.

A woman with abdominal pain and bleeding has a diagnosis of multiple fibroid tumors and undergoes laparoscopic resection without hysterectomy. After the abdomen is entered and inspected it is found she has 5 separate intramural fibroid tumors. The fibroid tumors are successfully removed, with a total weight of 300 grams. Pathology confirms leiomyoma (myomas or fibroids). What are the CPT® and ICD-10-CM codes reported for this service?

58546, D25.1 Surgical laparoscopy is performed to remove the five fibroid tumors weighing over 250 grams. Look in the CPT® Index for Laparoscopy/Removal/Leiomyomata referring you to 58545, 58546. 58546 is correct for 5 or more fibroid tumors. In the ICD-10-CM Alphabetic Index, look for Leiomyoma/uterus/intramural referring you to code D25.1. Verify this code 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?

58570-53 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.

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?

58940 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.

Mrs. Jones, G1P0, is diagnosed with polyhydramnios and is scheduled for amniocentesis to aspirate some of the excessive fluid from the amniotic sac. The amniocentesis is performed under ultrasound guidance. What is/are the code(s) for the procedure performed?

59001 In the CPT® Index look for Amniocentesis/Therapeutic/Amniotic Fluid Reduction directing you to code 59001. Read the parentheses in the code descriptor; this code includes the ultrasound guidance. The ultrasound guidance is not separately reported. 59000 is for diagnostic amniocentesis.

The provider removes the thymus gland in a 27 year-old female with myasthenia gravis. Using a transcervical approach the blood supply to the thymus is divided and the thymus is dissected free from the pericardium and the thymus is removed. What CPT® code is reported for this procedure?

60520 Excision of the thymus gland is a thymectomy and is coded based on the approach. Code 60520 is for a transcervical approach, as documented. In the CPT® Index look for Thymectomy/Transcervical Approach.

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?

59400, 59409-51 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 patient has a total thyroidectomy to remove thyroid cancer. Removal of all the lymph nodes along with the spinal accessory nerve, jugular vein and sternocleidomastoid muscles are performed to remove a malignant lymphatic chain. What CPT® and ICD-10-CM codes are reported?

60254, C73 In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Radical Neck Dissection directing you to 60254. A radical neck dissection includes removal of all lymph nodes. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/thyroid (gland) and select from the Malignant Primary column directing you to C73. Verification in the Tabular List confirms code selection.

A patient with MEN1 (Multiple Endocrine Neoplasia 1) has surgery to remove three of her parathyroid glands and part of the fourth parathyroid gland. What CPT® and ICD-10-CM codes are reported?

60500, E31.21 n the CPT® Index look for Parathyroid/Excision directs you to 60500-60502. There is no mention of this being a re-exploration or mediastinal exploration, making 60500 the correct code. In the ICD-10-CM Alphabetic Index look for Neoplasia/endocrine, multiple (MEN)/type 1 directing you to E31.21. MEN is multiple endocrine neoplasia, this is also known as Wermer's Syndrome and also indexes to E31.21. Verification in the Tabular List confirms code selection.

Chapter 12 Questions

Answers Rationale:

A patient with McCune-Albright syndrome has a fibrous tissue neoplasm of the frontal bone (skull of cranium) extending into the orbit on the left. The surgeon excises the fibrous tissue neoplasm off the bone and down through the dura mater. Prophylactic decompression of the optic nerve was also performed. What CPT® and ICD-10-CM codes are reported?

61564, Q78.1 The frontal bone is part of the cranium. In the CPT® Index look for Excision/Cranial Bone/Tumor directing you to code range 61563-61564. Because decompression of the optic nerve was also performed, 61564 is the correct code. In the ICD-10-CM Alphabetic Index, look for McCune-Albright syndrome which directs you to Q78.1. Verification in the Tabular List confirms code selection.

The ENT surgeon performs an anterior skull base LeFort I osteotomy approach for the intradural removal of a meningioma by a neurosurgeon. What CPT® code is reported by the ENT surgeon?

61586 In the CPT® Index look for Skull Base Surgery/Anterior Cranial Fossa/LeFort I Osteotomy Approach directing you to 61586. The only portion of the surgery that the ENT provided was the anterior skull base approach. The next to last paragraph in the guidelines for surgery of the skull base instructs that each surgeon reports the code for only his portion. Since each procedure is separate, modifier 62 Two Surgeons is not needed. Modifier 62, as explained in the CPT® appendix A, is to be used when two surgeons are working together to perform a single procedure. Skull base surgery has been divided so that each part of the procedure is reported with its own code.

A patient with a neoplasm of the spinal meninges has a programmable pump implanted for chemotherapy administration. What CPT® and ICD-10-CM codes are reported?

62362, C70.1 In the CPT® Index look for Insertion/Infusion Pump/Spinal Cord directing you to code range 62361-62362. This is a programmable pump making 62362 the correct code selection. In ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/spine, spinal (column)/meninges and select from the Malignant Primary column directing you to C70.1. Verification in the Tabular List confirms code selection.

A patient with a displaced cervical disc undergoes a cervical laminotomy with a partial facetectomy and excision of the herniated disc at cervical interspace C3-C4. What CPT® and ICD-10-CM codes are reported?

63020, M50.21 A laminotomy is also known as a hemilaminectomy. In the CPT® Index look for Hemilaminectomy directing you to code range 63020-63044. The procedure performed was a cervical (C3-C4) laminotomy with partial facetectomy and excision of the herniated disc which makes 63020 the correct code. In the ICD-10-CM Alphabetic Index, look for Hernia/intervertebral cartilage or disc directing you to see Displacement, intervertebral disc. Look for Disorder/disc (intervertebral)/cervical/displacement/C3-C4 referring you to code M50.21. Verification in the Tabular List indicates a 5th character is reported to identify the intervertebral interspace of C3-C4. The 5th character 1 is chosen.

A patient is having a decompression of the nerve root involving two segments of the lumbar spine via transpedicular approach. What CPT® code(s) is/are reported?

63056, 63057 In the CPT® Index look for Decompression/Nerve/Root and directing you to a series of codes. The transpedicular approach is defined by codes 63055-63057 and 63056 specifies the lumbar spine. Add-on code 63057 is used for the second segment and a modifier 51 is not used with add-on codes.

A provider uses cryotherapy for removal trichiasis of the right upper eyelid. What CPT® and ICD-10-CM codes are reported?

67825-E3, H02.051 In the CPT® Index, look for Trichiasis/Repair/Epilation, by Other than Forceps. Verify this code in the numeric section. Code 67825 describes the correction of trichiasis by other than forceps, for example cryotherapy. HCPCS Level II modifier E3 indicates Upper right eyelid. In the ICD-10-CM Alphabetic Index look for Trichiasis (eyelid)/right/upper directs you to code H02.051 and is verified in the Tabular List as Trichiasis without entropion right upper eyelid

Chapter 20 Questions

Answers Rationale:

A 27 year-old triathlete is thrown from his bike on a steep downhill ride. He suffered a severely fractured vertebra at C5. An anterior approach is used to dissect out the bony fragments and strengthen the spine with titanium cages and arthrodesis. The surgeon places the patient supine on the OR table and proceeds with an anterior corpectomy at C5 with discectomy above and below. Titanium cages are placed in the resulting defect and morselized allograft bone is placed in and around the cages. Anterior Synthes plates are placed across C2-C3, C4-C5, and C5-C6. What CPT® codes should be reported?

63081, 22554-51, 22846, 22854, 20930 Anterior approach is used to perform several procedures on the cervical spine. The corpectomy has the highest RVUs and is listed first. Code 63081 is the removal of one single cervical segment by anterior approach. In the CPT® Index look for Vertebral/Body/Excision/Decompression directing you to 63081-63103. Arthrodesis, anterior interbody technique is coded with 22554. In the CPT® Index, look for Arthrodesis/Cervical/below C2 referring you to several codes including 22551-22554. Plates are used for anterior instrumentation and placed over a total of five segments (C2, C3, C4, C5, and C6), 22846. In the CPT® Index, look for Instrumentation/Spinal/Insertion or Spinal Instrumentation/Anterior. Report only one unit of 22846, regardless of how many devices placed at one level. Modifier 51 is appended to 22554 to indicate multiple procedures. The application of the titanium cages is described by add-on code 22854. In the CPT® Index look for Application/Intervertebral Device. The morselized allograft is described by 20930. In the CPT® Index look for Allograft/Bone/Spine Surgery/Morselized.

A patient presents to the emergency room with a severely damaged eye. The injury was sustained when the patient was a passenger in a multi-car accident on the public highway. The patient sustained a large open lacerated wound to the left eye. The posterior chamber was ruptured and significant vitreous and some intraocular tissue was lost. The eyeball was not repairable and was removed, en masse. A permanent implant was inserted but not attached to the extraocular muscles. The patient was released with an occlusive eye patch. What CPT® and ICD-10-CM codes are reported?

65103-LT, S05.22XA, V49.59XA, Y92.411 Enucleation is the removal of the eye. At the time of surgery, an implant was inserted and extraocular muscles were not attached to it. In the CPT® Index look for Enucleation/Eye which gives codes 65101, 65103, 65105. Code 65103 best describes this procedure. The LT modifier is appended to indicate that this was the left eye. In the ICD-10-CM Alphabetical Index look for Laceration/eye (ball)/with prolapse or loss of intraocular tissue directing you to S05.2-. Tabular List indicates that seven characters are reported to complete the code. The 5 th character 2 is reported to indicate left eye. X is used as placeholder for the 6 th character position. The 7 th character is A to report initial encounter for the patient receiving active treatment in the ED. Documentation does not provide sufficient details of the multi-car accident to specify whether the other cars were in motion and if a collision occurred with other objects/persons. Look in the ICD-10-CM External Cause of Injuries Index for Accident/transport/car occupant/passenger/collision (with)/motor vehicle NOS (traffic)/specified type NEC (traffic) V49.59-. The 6 th character X is used as a placeholder and 7 th character A for initial encounter in the ED. Look for Place of occurrence/highway (interstate) directing you to Y92.411.

A 65 year-old male with a history of chronic glaucoma has progressive optic nerve damage and elevated intraocular pressure. A clear corneal incision is made and viscoelastic material is injected into the anterior chamber over the lens to increase and maintain anterior chamber depth. The endoscope is inserted through the temporal incision to view the nasal ciliary processes, which is coagulated with the endpoint of shrinkage and whitening. The endoscope is moved in an arc, allowing treatment of the processes over an arc of 180° and a second corneal incision is made 90° away and 180° of ciliary processes are destroyed with laser therapy. The surgeon has completed coagulation of 270° of angle. The eye is reformed with balanced salt solution. Wounds are checked for leakage and sutures are placed to seal the wound. What CPT® code is reported?

66711 In the CPT® Index look for Ciliary Body/Destruction/Cyclophotocoagulation 66710, 66711. Code 66711 is the correct code because using an endoscopic approach, ciliary processes were coagulated and were destroyed by laser therapy.

Chapter 3 Questions

Answers Rationale:

Repair of right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. Vitrectomy, drainage of subretinal fluid, silicone oil tamponade, and endolaser photocoagulation are performed to correct the tear. What are the procedure and diagnosis codes for this service?

67113, H33.031, W21.03XA In the CPT® Index look for Retina/Repair/Detachment/with Vitrectomy referring you to 67108, 67113. Code 67113 is used for the repair of a giant tear of the retina, with vitrectomy, and endolaser photocoagulation. In the ICD-10-CM Alphabetical Index look for Detachment/retina/with retinal/break/giant referring you to H33.03-. In the Tabular List a 6th character 1 is reported for the right eye. In the ICD-10-CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/baseball referring you to W21.03-. In the Tabular List seven characters are reported to complete the code. The 6th character is a placeholder X and the 7th character A is used to identify the initial encounter. Surgical management represents an initial encounter.

A patient had another recession strabismus procedure of the lateral rectus muscle. This muscle had previously been recessed during an operative session six months ago which resulted in scarring of the extraocular muscle. What CPT® code(s) is/are reported?

67311, 67332 In the CPT® Index look for Strabismus/Repair/One Horizontal Muscle (the lateral rectus muscle is a horizontal muscle). You are directed to 67311. Strabismus surgery add-on code 67332 is used to indicate the procedure is performed on a patient with scarring of the extraocular muscles. The parenthetical note for this code states to use 67332 in conjunction with 67311-67318.

Under general anesthesia, a provider excises one chalazion from each upper eyelid. What are the procedure and diagnosis codes for the service?

67808-E1-E3, H00.11, H00.14 In the CPT® Index look for Chalazion/Excision/Under Anesthesia directing you to 67808. Code 67808 describes the use of general anesthesia to excise single or multiple chalazion(s). Modifiers E1 and E3 can be reported to indicate which eyelids were operated on. In the ICD-10-CM Alphabetic Index look for Chalazion/right/upper H00.11 and Chalazion/left/upper H00.14. Verify code selection in the Tabular List.

A 65 year-old patient presents with an ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also has an ectropion of the left lower eyelid which is repaired by suture repair. What CPT® code(s) is/are reported?

67916-E4, 67914-E2 In the CPT® Index look for Ectropion/Repair/Excision Tarsal Wedge which directs you to code 67916. Then further down in the same list Suture directs you to 67914. Modifier E4 is appended to 67916 to show it was performed on the right lower eyelid. Modifier E2 is appended to 67914 to show it was performed on the left lower eyelid.

A patient has an oversized and embedded dacryolith in the lacrimal sac, and a dacryocystoectomy is performed. What CPT® code(s) is/are reported for this procedure?

68520 In the CPT® Index, look for Dacryocystectomy referring you to 68520. The stone was embedded in the sac, which was removed. Only one code is used for removal of the stone and removal of the sac. The lacrimal gland is located near the eyebrow; the lacrimal sac is the upper dilated end of the lacrimal duct, aligned with the nostril.

Patient had an abscess in the external auditory canal which was incised and drained in the office. What CPT® code is reported?

69020 In the CPT® Index, look for Abscess/Tissue/Auditory Canal, External/Incision and Drainage which directs you to 69020. Verify in the numeric section that code 69020 is the appropriate code for drainage of an abscess located in the external auditory canal of the ear. For this procedure, the provider makes an incision in the skin and drains the external auditory canal abscess.

What CPT® code is reported for removal of foreign body from the external auditory canal without general anesthesia?

69200 In the CPT® Index look for Auditory Canal/External/Removal/Foreign Body which directs you to code range 69200-69205. Verify the code in the numeric section. Code 69200 is the appropriate code for the removal of a foreign body from the external auditory canal without general anesthesia. Code 69205 is with anesthesia. Under direct visualization the foreign body is removed from the external auditory canal using delicate forceps, a cerumen spoon or suction. No anesthetic or local anesthetic is used.

A patient with right and left prominent ears presents for otoplasty on both ears. What CPT® and ICD-10-CM codes are reported?

69300-50, Q17.5 In the CPT® Index look for Otoplasty and you are directed to 69300. The parenthetical instruction below 69300 states to use modifier 50 to report a bilateral procedure. In the ICD-10-CM Alphabetical Index look for Prominence, prominent/auricle (congenital) (ear) and you are directed to Q17.5.

The patient underwent a plastic repair of the external auditory canal for stenosis, a late effect of a burn. After excising the subepithelial stenotic tissue and a wedge of skin from the floor of the external auditory canal, a rubber tube was placed inside the external canal. The patient will return in two weeks to monitor his progress. What CPT® code is reported for this procedure?

69310 In the CPT® Index, see Meatoplasty/External Auditory Canal 69310. The external opening of the ear is referred to as the meatus. A meatoplasty enlarges the opening. Another index option is to look for Auditory Canal/External/Reconstruction/for Stenosis 69310.

The provider makes an incision in the patient's left tympanic membrane in order to inflate eustachian tubes and aspirate fluid in a patient with acute eustachian salpingitis. The procedure is completed without anesthesia. What CPT® and ICD-10-CM codes are reported?

69420, H68.012 In the CPT® Index look for Myringotomy and you are directed to 69420-69421. Verify the code in the numeric section. In the ICD-10-CM Alphabetical Index, look for Salpingitis/eustachian (tube)/acute and you are directed to H68.01-. Verification in the Tabular List indicates a 5 th character is needed for laterality. 5 th character of 2 for the left ear.

Parents of a 3 year-old male who has chronic serous otitis media in the right ear have consented to surgery. Patient is placed under general anesthesia and the provider makes an incision in the tympanic membrane. Fluid is suctioned out from the middle ear and a ventilating tube is placed in the ear to provide a drainage route to help reduce middle ear infections. What CPT® and ICD-10-CM codes are reported?

69436-RT, H65.21 In the CPT® Index look for Tympanostomy/General Anesthesia directing you to 69436, then verify the code in the numeric section. Code 69436 is the correct code to report because a small incision is made in the tympanum, the fluid in the middle ear is suctioned, and an insertion of a small ventilating tube is placed into the opening of the tympanum under general anesthesia. Modifier RT is appended to indicate the side of the body the procedure was performed. In the ICD-10-CM Alphabetical Index look for Otitis/media/chronic/serous which states see Otitis, media, nonsuppurative, chronic, serous. Look for Otitis/media/nonsuppurative/chronic/serous directing you to H65.2. The Tabular List indicates a 5 th character is needed to show laterality. 5 th character 1 is for the right ear.

An ENT performs a patch repair on the left eardrum of a 10 year-old patient. What CPT® code is reported?

69610-LT The medical term for eardrum is tympanic membrane. In the CPT® Index look for Repair/Tympanic Membrane which directs you to code 69450, 69610. Repair of the tympanic membrane with or without site preparation of perforation for closure, with or without patch is the description for code 69610 is confirmed in the numeric section. Modifier LT is used to indicate the procedure was performed on the left side.

A 26 year-old female with a one-year history of a left tympanic membrane perforation has consented to have it repaired. A postauricular incision was made under general anesthesia. Dissection was carried down to the temporalis fascia and a 3 x 3 cm segment of fascia was harvested and satisfactorily desiccated. The tympanic membrane was excised. Using a high speed drill a canaloplasty was performed until the entire annulus could be seen. The ossicular chain was examined, it was found to be freely mobile. The previously harvested skin was trimmed and placed in the anterior canal angle with a slight overlapping over the temporalis fascia. Packing is placed in the ear canal, external incisions are closed, and dressings are applied. What CPT® code is reported?

69631-LT In the CPT® Index look for Tympanoplasty/without Mastoidectomy. You are referred to 69631. Review the code in the numeric section to verify accuracy. This is the correct code with LT modifier because the repair of the left ear is performed (tympanoplasty) with a canaloplasty, without an ossicular chain replacement or mastoidectomy (removal of a portion of the mastoid of the posterior temporal bone).

What CPT® code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear?

69636-RT In the CPT® Index look for Tympanoplasty/with Antrotomy or Mastoidotomy/with Ossicular Chain Reconstruction and you are directed to 69636. Append modifier RT to identify the procedure is performed on the right ear.

A patient with mixed conductive and sensorineural hearing loss in the right ear has tried multiple medical therapies without recovery of her hearing. Patient has consented to have an electromagnetic bone conduction hearing device implanted in the temporal bone. What CPT® and ICD-10-CM codes are reported?

69710-RT, H90.71 In the CPT® Index look for Hearing Aid/Implants/Bone Conduction/Implantation. You are referred to 69710. Review the code to verify accuracy. In the ICD-10-CM Alphabetical Index look for Loss (of)/hearing which states see also Deafness. Look for Deafness/mixed conductive and sensorineural/unilateral. You are referred to H90.7-. Review the code in the Tabular List to verify accuracy and 5 th character 1 is for right ear.

A patient presents to her physician with right eye pain, nasal airway obstruction, and deformity 48 hours after an assault. The physician orders an x-ray of the facial bones with a Waters view, Caldwell view, and a lateral view. What is the CPT® code for the X-ray?

70150 Three views of the facial bones (Waters view, Caldwell view, and lateral view) were ordered. Look in the CPT® Index for X-ray/Facial Bones, 70140-70150. Code 70150 is for a complete, minimum of three views X-ray of the facial bones.

What is the CPT® coding for thawing 4 units of fresh frozen plasma?

86927 x 4 In the CPT® Index, look for Plasma/Frozen Preparation and you are directed to 86927. Code 86927 is specifically for plasma rather than whole blood. The code is used per unit with 86927 x 4 as correct.

" Magnetic resonance imaging of the chest is first done without contrast medium enhancement and then is performed with an injection of contrast. What CPT® code(s) is/are reported for the radiological services?

71552 The patient is having magnetic resonance imaging in which the images were performed first without contrast and again following the injection of contrast. In the CPT® Index look for Magnetic Resonance Imaging (MRI)/Diagnostic/Chest directing you to 71550-71552.

A 38-year-old male seen in the Emergency Department sustained an injury several hours ago to his left hand when he fell, and a team member stepped on it when playing tackle football. X-ray was taken in lateral, external oblique and PA positions. The interpretation of the X-rays revealed a fracture of the shaft of the third metacarpal. What CPT® and ICD-10-CM codes are reported for the radiological services?

73130-26, S62.323A, W50.0XXA, Y93.61 A total of three views were taken of the hand. Lateral (side), oblique (diagonal) and PA (posterior-anterior) views. Look in the CPT® Index for X-ray/Hand. Code 73130 describes a radiologic examination of the hand with a minimum of 3 views. Modifier 26 denotes the professional service. The diagnosis is found in the ICD-10-CM Alphabetic Index by looking for Fracture traumatic/ metacarpal/third/shaft (displaced) guiding you to code S62.32-. Tabular List indicates a 6 th character is required to indicated laterality and a 7 th character is required for the episode of care. A for initial encounter is selected as the 7 th character for initial encounter. A review of the ICD-10-CM guideline, I.C.19.c., states " A fracture not indicated as closed or open should be classified as closed. A fracture not indicated whether displaced or not displaced should be coded to displaced." The next two codes are found in the ICD-10-CM External Cause of Injuries Index. The first external cause code is found by looking for Stepped on/by/person guiding you to code W50.0-. Tabular List indicates seven characters are needed to complete the code. The 5 th and 6 th characters will have X as placeholders and the 7 th character will report A for the initial encounter Only one code is reported for the patient falling down while playing sport activity and then getting stepped on. The second external cause code is found by looking for Activity/football (American) NOS/tackle guiding you to code Y93.61.

CT images of the abdomen and pelvis were obtained without IV contrast, as a follow up to a splenic injury. What is/are the CPT® code(s) for the CT scan?

74176 Both CT of the abdomen and of the pelvis were obtained. There is one code to report for both anatomical areas taken at the same time. The "without contrast" codes are used. Look in the CPT® Index for CT Scan/without Contrast/Abdomen or Pelvis.

A 52 year-old female is sent to radiology for a lymphangiography of both arms. The patient has swelling in both arms which is suspected to be lymphangitis. She also has a history of breast cancer having had a double mastectomy 5 years ago. What CPT® and ICD-10-CM codes are reported?

75803, M79.89, Z85.3, Z90.13 Look in the CPT® Index for Lymphangiography/Arm referring you 75801-75803. Patient is having a lymphangiography of bilateral extremities (both arms) indicating the use of code 75803. In the ICD-10-CM Alphabetic Index look for Swelling/arm referring you to code M79.89. Patient also has history of breast cancer. In the Alphabetic Index, look for History/personal (of)/ malignant neoplasm (of)/breast directing you to Z85.3. The patient had removal of both breasts. In the Alphabetic Index, look for Absence/breast(s) (and nipple(s)(acquired) directing you to Z90.1-. Verification in the Tabular List indicates a 5 th character of 3 is reported for bilateral. The lymphangitis is suspected and is not a definitive diagnosis, so it is not reported.

A parent brings her child to the ED. She thinks she swallowed a small toy figure. A radiology exam from the nose to the rectum is performed. The foreign body is not located. What CPT® code(s) is/are reported for the radiology services?

76010 The radiology exam is performed to locate a foreign body, yet no foreign body is found. In the CPT® Index look for X-ray/Nose to Rectum/Foreign Body. Refer to the code description and the correct code is 76010.

" 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?

76801 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.

A patient 20 week's pregnant with twins goes to her OB/GYN for an ultrasound to check the position of both fetuses. What CPT® code(s) is/are used for the ultrasound?

76815 The ultrasound is limited because the position of the fetuses is all that the ultrasound is verifying. Look in the CPT® Index for Ultrasound/Obstetrical/Pregnant Uterus. The description of 76815 includes one or more fetuses and the code is reported once only.

A patient with left breast pain and a lump in the breast visits her physician. After examination, the physician orders a mammogram of the left breast. The mammography is performed using computer-aided detection software. What CPT® code is reported for the mammography?

77065 The physician ordered a unilateral diagnostic mammogram with computer-aided detection (CAD). Code 77065 describes a diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.

A patient with osteoporosis reports to her physician's office for a DXA bone density study of her spine to monitor the severity of her condition. What is the correct CPT® code for the DXA scan?

77080 DXA is dual-energy X-ray absorption. The site is of the spine, which is part of the axial skeleton. For DXA-See Dual X-ray Absorptiometry (DXA); Dual X-ray Absorptiometry (DXA)/Axial Skeleton. In this case, one site (spine) is involved in the study. The correct code is 77080.

" A patient with prostate cancer has his first dose of radiation treatment of a single area that requires a single port and an energy level of 7 milli-electron volts (MeV). What CPT® code is reported?

77402 A patient with prostate cancer is receiving radiation treatment delivery by port of a single treatment area. In the CPT® Index look for Radiation Therapy/Treatment Delivery. Upon verification code 77402 is the only code that represents a single treatment area with 7 MeV of energy.

A male patient being treated for prostate cancer receives brachytherapy treatment. Twelve radioactive seeds are interstitially applied within the prostate. What is the CPT® code for the radiological component?

77778 In this case, brachytherapy is performed using interstitial application of radiation seeds. According to the Radiology Guidelines, a complex application has greater than 10 sources, which is reported with code 77778. Review the CPT® coding guidelines for the definition of simple, intermediate, and complex for clinical brachytherapy. Look in the CPT® Index for Brachytherapy/Interstitial Application 0395T, 77778.

A one year post-thyroidectomy patient who had thyroid cancer is coming in for area imaging of the neck and chest to evaluate for metastases. What CPT® code(s) is/are reported for the nuclear medicine exam?

78015 The patient is having thyroid imaging for carcinoma (cancer) metastases limited to the chest and neck only. In the CPT® Index look for Nuclear Medicine/Diagnostic/Thyroid/Imaging for Metastases. 78015 is the correct code for limited area imaging. A thyroid uptake is a test to measure the thyroid function in determining how much iodine will be absorbed by the thyroid. This is not performed therefore add-on code 78020 is not reported.

" After intravenous administration of 5.1 millicuries Tc-99m DTPA, flow imaging of the kidneys was performed for approximately 30 minutes. Flow imaging demonstrated markedly reduced flow to the kidneys bilaterally. What CPT® coding is reported?

78701 The nuclear imaging test follows the blood as it flows to the kidneys identifying any obstruction and to determine the rate at which the kidneys are filtering. The scenario does not document the function of the kidneys' tubes and ducts. In the CPT® Index look for Nuclear Medicine/Diagnostic/Vascular Flow directing you to code range 78701-78709. Only vascular flow was performed making code 78701 the correct code to report.

A patient with thickening of the synovial membrane undergoes a fluoroscopic guided radiopharmaceutical therapy joint injection on his right knee without ultrasound. What CPT® code(s) is/are reported by the physician if performed in an ASC setting?

79440-26, 20610, 77002-26 Look in the CPT ® Index Radiopharmaceutical Therapy/Intra-articular. Because the injection is intra-articular, the radiopharmaceutical therapy is reported with 79440. The CPT® guidelines in the numeric section for Radiology/Nuclear Medicine under the Therapeutic heading indicates to also use the appropriate injection and/or procedure codes as well as imaging guidance. In the CPT® Index look for Arthrocentesis/Large Joint directing you to 20610, 20611. The joint injection was performed without ultrasound guidance on the knee, which is considered a large joint reported with 20610. Then look in the CPT® Index look for Needle Localization/Fluoroscopic Guidance directing you to 77002. Fluoroscopic image guidance for a joint injection is reported with 77002. Modifier 26 is appended to both radiology codes to report the professional services performed by the physician in the ASC setting.

An electrolyte panel is performed on an 86-year-old for dizziness

80051

A patient will be undergoing a transplant and needs HLA tissue typing with DR/DQ multiple antigen and lymphocyte mixed culture. How will these services be coded?

86817, 86821 In the CPT® Index look for Tissue/Typing/Human Leukocyte Antigen (HLA)/Antibodies. Code 86817 is the correct code to report for HLA tissue typing with DR/DQ. Then, look in the CPT® Index for Tissue/Typing/Lymphocyte Culture referring you to code 86821. Codes 86805 and 86806 are for lymphocytotoxicity, not lymphocyte mixed culture.

Chapter 4 Questions

Answers Rationale:

A patient presents with right upper quadrant pain, nausea, and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders an albumin; bilirubin, both total and direct; alkaline phosphatase; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. How should this be coded?

80076, 82565 Code the panel when all of the tests listed in the panel are completed. If additional tests are also performed, they are coded separately. The first 7 tests are all listed in code 80076. This leaves creatinine, which is reported with code 82565. Look in the CPT® Index for Panel, this directs you to See Blood Tests; Organ or Disease-Oriented Panel. Look for Blood Tests/Panels/Hepatic Function you are directed to 80076. Next, look for Creatinine/Blood directing you to 82565. Verify these codes.

A patient presents with right upper quadrant pain, nausea and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders an albumin; bilirubin, both total and direct; alkaline phosphatase; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. What CPT® code(s) is/are reported?

80076, 82565 The patient was being tested for symptoms of liver disease, hepatic. Look in the CPT® Index for Blood Tests/Panels/Hepatic Function referring you to 80076. Also, see Creatinine/Blood referring you to 82565. Code the laboratory panel anytime all of the tests listed in the panel are completed. If additional tests are also performed, they are coded separately.

A patient with abnormal growth had a suppression study that included 4 glucose tests and 4 human growth hormone tests. What CPT® code(s) is/are reported?

80430, 82947 Use the Evocative/Suppressive panel codes whenever all of the tests in the panel are performed. If extra tests are performed, these should be coded separately. In the CPT® Index, look for Growth Hormone/Growth Hormone Suppression Panel. Code descriptor for code 80430 indicates this should include Glucose (82947 x 3) and Human growth hormone (HGH) (83003 x 4). There were 4 glucose tests performed. Look in the CPT® Index, look for Glucose/Blood test. Code 82947 is reported for the 4th test.

What is the code and any required modifier(s) for dipstick urinalysis, non-automated, without microscopy performed in a physician office for a Medicare patient?

81002 81002 is for dipstick urinalysis. Modifier 26 is not needed in the physician office. Code 81002 is a CLIA-waived test, but is one of the codes that does not require modifier QW. Look in the CPT® Index for Urinalysis/Routine.

What is the code and any required modifier(s) for dipstick urinalysis, automated, without microscopy performed in a physician office for a Medicare patient?

81003-QW In the CPT® Index, look for Urinalysis/Automated. Code 81003 is for dipstick urinalysis, automated, without microscopy. Modifier 26 is not needed in the physician office but QW is required as this is a CLIA waived test. Modifier QW is found in HCPCS Level II code book.

A urine pregnancy test is performed by the office staff using the Hybritech ICON (qualitative visual color comparison test). What CPT® code is reported?

81025 Look in the CPT® Index for Pregnancy Test/Urinalysis referring you to code 81025. Codes 84703 and 84702 are typically performed on blood. Code 36415 is for obtaining a blood specimen and is inappropriate with a urine test.

A patient's mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. Blood will be tested for full sequence analysis and common duplication or deletion variants (mutations) in BRCA1, BRCA2 (breast cancer 1 and 2). What CPT® code(s) is (are) reported for this molecular pathology procedure?

81162 In the CPT® Index, look for Breast/Cancer Gene Analysis/BRCA1 (BRCA1, DNA repair associate)/Duplication/Deletion or Full Sequence. The correct code is 81162 because the code description includes performing the full sequence analysis and duplication/deletion analysis for BRCA1 and BRCA2. This is a blood test performed to look for any gene mutations affecting the BRCA1 and BRCA2 genes. These human genes are known as tumor suppressors, mutation of these genes has been linked to hereditary breast and/or ovarian cancer. A woman's risk of developing breast or ovarian cancer is increased if she inherits this harmful mutation. Men with this mutation also have an increased risk of breast cancer. Be sure to read the parenthetical instructions.

A 35 year-old type II diabetic is feeling weak. The physician performs a stat glucose test in which a finger stick is done placing the drop of blood on a reagent strip. The test indicates the patient is hypoglycemic. The physician gives the patient some glucose supplements and performs another stat glucose test using the same lab test as before 30 minutes later. The second test shows the glucose levels returned to normal. How are the lab tests reported?

82948, 82948-91 Look in the CPT® Index for Glucose/Blood Test referring you to codes 82947, 82948, 82950. The lab test used a reagent strip for the glucose test reporting code 82948. Modifier 91 is the correct modifier to use when the same laboratory test is repeated on the same day for a subsequent result.

" What is the anesthesia code for an appendectomy?

840 In the CPT® Index under Anesthesia you will not see the terms appendix nor appendectomy listed separately. Look for Anesthesia/Abdomen/Intraperitoneal which directs you to code ranges 00790-00797, 00840-00851. Review the codes in numeric section to determine that code 00840 is the correct code. Note: The coder needs to know the Intraperitoneal Organs of the Lower Abdomen includes the appendix.

A patient with AIDS presents for follow up care. An NK (natural killer cell) total count is ordered. What CPT® code(s) is/are reported?

86357 Look in the CPT® Index for Natural Killer (NK) Cells/Count. Although there are a number of cells that attack viruses and other infectious organisms, NK cells are specifically identified by code 86357.

A patient with Acquired Immune Deficiency Syndrome (AIDS) presents for follow up care. A total T-cell count is ordered to evaluate progression of the disease. Choose the code(s) for this study.

86359 Code 86359 is for total T-cell count. If other studies were performed, they were not ordered and may not be billed, not matter how seemingly appropriate. Look in the CPT® Index for T-Cells/Count directs you to 86359.

A patient with AIDS presents for follow up care. The total T-cell count is ordered to evaluate any progression of the disease. What CPT® code(s) is/are reported?

86359 In the CPT® Index, look for T Cells/Count. Code 86359 is for total T-cell count. If other studies were performed and they were not ordered they may not be billed, no matter how seemingly appropriate.

Chapter 6 Questions

Answers Rationale:

A major university medical center has an International Clinic specializing in treating individuals who move to the USA bringing with them diseases and conditions native to their home countries. A Brazilian woman presents to this clinic with complaints of hematuria and fatigue. Urine analysis with microscopy identifies eggs in the urine and further testing from a stool sample identifies Schistosomiasis through direct smear to concentrate and evaluate ova. What CPT® and ICD-10-CM codes are reported?

87177, 81000, B65.0 Look in the CPT® Index for Smear and Stain/Ova and Parasites Smear. Code 87177 is correct to report for direct smear. The correct code for the urinalysis with microscopy is 81000. Look in the ICD-10-CM Alphabetic Index, look for Schistosomiasis/bladder B65.0. Verify the code in the Tabular List.

A 27-year-old male dies of a gunshot wound. An autopsy is performed to gain evidence for the police investigation and any subsequent trial. What code describes this service?

88040 Services related to legal investigations and trials are forensic examinations. Look in the CPT® Index for Autopsy/Forensic Exam you are directed to 88040. Read the code to verify this as the correct listing.

A couple has been trying to conceive for nine months without success. Preliminary studies show the woman ovulates and the husband's sperm count is good. A sperm sample is submitted for both a post coital Huhner test and a hamster penetration test. Report the codes.

89300, 89329 Look in the CPT® Index for Huhner Test/Semen Analysis. The post coital test is described by code 89300. The second test ordered and performed on the sperm sample is a hamster penetration test. Look in the CPT® Index for Hamster Penetration Test/Sperm Evaluation referring you to code 89329.

A child was bitten by a dog tested positive for rabies, and is seen for an injection of rabies immune globulin. Select the appropriate procedure codes for this service.

90375, 96372 Code for the product and the administration of rabies immune globulin. In the CPT® Index, see Immune Globulins/rabies, you are directed to 90375-90376. Since there is no mention of heat-treated, 90375 is the appropriate code. Reading the guidelines for immune globulins, a code from 96365-96372, 96374, or 96375 is reported as appropriate for the administration. This is an injection, and 96372 is the appropriate code. In the CPT® Index, look for Injection/Intramuscular/Therapeutic.

What is the correct code for the administration of one vaccine given intramuscularly for a child under eight years of age when the physician counsels the parents?

90460 In the CPT® Index, look for Immunization Administration/One Vaccine/Toxoid/with Counseling. You are directed to use code 90460.

An inpatient with ESRD is placed on a regular schedule of hemodialysis treatments. The patient receives dialysis at the hospital and is re-evaluated once by the physician for possible revision of the prescribed treatments. On re-evaluation, the physician determines no change in regimen is needed. Code for the dialysis and physician re-evaluation.

90937 90937 describes hemodialysis requiring physician re-evaluation with or without substantial revision of dialysis. In the CPT® Index, look for Hemodialysis/Procedure/ with Evaluation.

A patient is seen to have an esophageal motility procedure with acid perfusion study performed. What CPT® code(s) is/are reported?

91010, 91013 This is a diagnostic gastrointestinal procedure. Look in the CPT® Index for Gastroenterology, Diagnostic/Esophagus Tests/Motility Study which directs you to codes 91010, 91013. 91010 best describes the motility study with add-on code 91013 used to identify the acid profusion study. Parenthetical note under add-on code 91013 indicates it is reported with code 91010.

Chapter 7 Questions

Answers Rationale:

Chapter 9 Questions

Answers Rationale:

" A 15 year-old underwent placement of a cochlear implant 1 year ago. It now needs to be reprogrammed. What CPT® code is reported for the reprogramming?

92604 Cochlear implants differ from hearing aids; they bypass the damaged part of the ear. The use of a cochlear implant involves relearning how to hear and react to sounds. In the CPT® Index look for Cochlear Device/Programming which directs you to codes 92602, 92604. The code selection is based on the age of the patient and whether it is the initial programming or subsequent reprogramming. Code 92604 describes subsequent reprogramming for a patient age 7 or older.

A patient with coronary atherosclerosis underwent a PTCA in the left anterior descending and in the first diagonal of the LD. What CPT® code(s) is/are reported?

92920-LD, 92921-LD PTCA stands for percutaneous transluminal coronary angioplasty. In the CPT® Index look for PTCA directing you to see Percutaneous Transluminal Angioplasty. Under Percutaneous Transluminal Angioplasty/Artery/Coronary. Code 92920 is used for the main coronary artery which is the left anterior descending. The add-on code 92921 is used to report the PTCA to a branch off of the left anterior descending - the first diagonal.

A patient was brought to the emergency department in cardiac arrest. The physician immediately initiated CPR. What CPT® code is reported for CPR?

92950 Medical personnel usually begin cardiopulmonary resuscitation (CPR) which provides artificial breathing and chest compressions for a person in cardiac arrest. In the CPT® Index you can look for either CPR or Cardiopulmonary Resuscitation or Resuscitation/Cardiopulmonary. All indexed items direct you to code 92950.

A cardiologist provided an interpretation and report of an EKG. What CPT® code is reported?

93010 In the CPT® Index look for EKG and you are directed to see Electrocardiography. For Electrocardiography/Evaluation. Codes 93000, 93010. 93000 includes the 12 lead EKG in addition to the interpretation and report. The provider only provided the interpretation and report making 93010 the correct code choice. Modifier 52 to report reduced services is not appropriate because there are codes that can specifically report each component.

A 59 year-old male experienced left arm pain while cleaning the garage. There was no injury. His provider scheduled a 30-minute stress test using the Bruce Protocol at the hospital. There was no arm pain while on the treadmill; he did have a slight heart rhythm abnormality. The patient rested for 2 minutes. He had no further symptoms or pain. The cardiologist supervised the study, interpreted the test and dictated a report. What CPT® code(s) is/are reported?

93016, 93018 In the CPT® Index look for Stress Tests/Cardiovascular. The Bruce Protocol requires use of a treadmill. Code 93015 is used when the stress test is performed in a clinic because it includes the professional, technical component and supervision components. According to the CPT® Assistant, January 2010, when a provider performs the stress test in a hospital, the separate components of the portions the provider performed are reported. In this case, he performed supervision (93016) and interpretation with report (93018). It would be inappropriate to append modifier 52 to 93015 because there are codes available to report each component separately.

A patient has a complete TTE performed to assess her mitral valve prolapse (congenital). The physician performs the study in his cardiac clinic. Which is the correct CPT® is reported?

93303 Patient has a congenital cardiac anomaly. The procedure was performed in the physician's clinic; therefore, the global service is reported which means no modifier is necessary. Look in the CPT® Index for Echocardiography/Congenital Cardiac Anomaly/Transthoracic and you are referred to 93303-93304.

A complete transthoracic echocardiography (TTE) was performed with spectral Doppler and color flow. Report the global service. What CPT® code(s) is/are reported?

93306 A combination code exists to bundle the Doppler and color flow. Look in the CPT® Index for Echocardiography/Transthoracic referring you to 93306-93308, 93350-93352. Code 93306 is correct.

What is the CPT® code used to report a right heart cardiac catheterization for congenital anomalies?

93530 In the CPT® Index, look for Catheterization/Cardiac directs you to See Cardiac Catheterization. Cardiac Catheterization/Right Heart/Congenital Cardiac Anomalies directs you to code 93530.

The EP specialist documents that a comprehensive electrophysiologic evaluation was performed in the hospital, including induction of arrhythmia, right atrial pacing, and bundle of His recording. The specialist documented the study and wrote a report. What CPT® code(s) is/are reported?

93618-26, 93610-26, 93600-26 Although the surgeon documented a "comprehensive" study, it does not include all components listed in CPT® for 93619 or 93620; therefore, the individual procedures are reported. The only procedures performed were 93618 (induction of arrhythmia), 93610 (intra-atrial pacing), and 93600 (bundle of His recording). Look in the CPT® Index for Electrophysiology Procedure referring you to 93600-93660. The procedure was performed in the hospital; therefore, the physician must report only the professional service with modifier 26 appended to all the codes.

In the cardiac suite, an electrophysiologist performs an EP study. With programmed electrical stimulation, the heart is stimulated to induce arrhythmia. Observed is right atrial and ventricular pacing, recording of the bundle of His, right atrial and ventricular recording and left atrial and ventricular pacing and recording from the left atrium. What CPT® coding is reported?

93620, 93621, 93622 The studies performed make up a comprehensive study (93620) which includes: evaluation with right atrial pacing and recording, right ventricular pacing and recording, and His bundle recording with induction of or attempted induction of arrhythmia. Left atrial pacing and recording (93621) and left ventricular pacing and recording (93622) are add-on codes. Look in the CPT® Index for Electrophysiology Procedure which directs you to 93600-93660.

Measurement of spirometric forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age

94012

A child with suspected sleep apnea was given an apnea monitoring device to use over the next month. The device was capable of recording and storing data relative to heart and respiratory rate and pattern. The pediatric pulmonologist reviewed the data and reported to the child's primary pediatrician. What CPT® code(s) is/are reported for the monitor attachment, download of data, provider review, interpretation and report?

94774 In the CPT® Index look for Monitoring/Pediatric Apnea. Code selection is based on the components of the test performed. In this case, code 94774 describes the data storage capability, including the provider or other qualified health care professional interpretation and report. The code is to be reported each 30-day period.

A patient who suffers from nasal congestion, rhinitis and facial swelling after being stung by honeybees undergoes allergen immunotherapy. The physician provides a single dose and injection of bee venom. What is the correct code for this service?

95130 Code 95130 describes provision of allergenic extract and injection of a single stinging insect venom. In the CPT® Index, look for Allergen Immunotherapy/Allergenic Extracts/Injection and Provision/Insect Venom.

" A female patient reports repeated falls. She has no known head trauma or other injuries. She noticed some slight stiffness in her joints and weakness in her lower extremity muscles, with slight stiffness in her arm joints. The provider decided to test for possible multiple sclerosis (MS). She was sent to a clinic providing somatosensory studies. The testing included upper and lower limbs. What CPT® and ICD-10-CM codes are reported?

95938, M62.81, M25.60, R29.6 In the CPT® Index look for Somatosensory Testing. Studies are reported based on location. The list of codes range for upper limbs are 95925, 95938, 95939 and lower limbs are 95926, 95938, 95939. In this case the upper limbs and lower limbs were both performed guiding you to code 95938. MS has not been confirmed. Symptoms of weakness in her muscles and stiffness of the joints is reported. She also reports repeated falls. In the ICD-10-CM Alphabetic Index look for Weak, weakening, weakness/muscle leading to M62.81. Also, look for Stiffness, joint NEC leading to M25.60. Specific joints affected are not identified. Next, in the Alphabetic Index look for Falling, falls (repeated) R29.6. Verification in the Tabular List confirms code selection.

A 50-year-old with left internal carotid artery stenosis presents for a left carotid thromboendarterectomy with electroencephalogram monitoring. Electroencephalogram (EEG) leads were placed on his head prior to surgery. Throughout the procedure, EEG patterns were symmetrical. What CPT® code is reported for this EEG Monitoring?

95955-26 The physician is using an EEG to record and measure the patient's brain electrical activity while performing the thromboendarterectomy (not intracranial surgery). Look in the CPT Index for Electroencephalography/Intraoperative guiding you to code 95955. Verify code selection in the Medicine section. Modifier 26 is added to report the physician's professional component of the procedure.

A 63 year-old came into the ED with severe shortness of breath and goes into respiratory failure. He was intubated and admitted for acute respiratory failure. Chest X-ray shows he has pleural effusion. What ICD-10-CM code(s) is/are reported?

96.00, J90 According to ICD-10-CM guideline I.C.10.b.1, acute respiratory failure can be a primary diagnosis with another acute diagnosis if it is clear the respiratory failure was responsible for the patient being admitted. Look in the ICD-10-CM Alphabetic Index for Failure/respiration, respiratory/acute J96.00-. We do not have documentation supporting hypercapnia or hypoxia, so the respiratory failure is unspecified which is code J96.00. Then, in the Alphabetic Index, look for Effusion/chest which directs you to see Effusion, pleura. Effusion/pleura, pleurisy, pleuritic, pleuropericardial directs you to J90. Confirm code selection in the Tabular List.

A patient needs a renal transplant. The patient has been on dialysis and is awaiting a suitable donor. A clinical psychologist meets with the patient to assess the patient's ability to comply with the requirements and drug regimen if a donor match is found. The session lasts 2 hours. What is the correct code for this service?

96156 Code 96156 describes the health behavior assessment or re-assessment.. The encounter lasted two hours, but the code is not a time-based code and should only be billed with a quantity of 1. In the CPT® Index, look for Evaluation and Management/Health Behavior/Assessment.

A patient presents with vomiting and diarrhea lasting three days. The physician determines the patient is dehydrated and orders infusion of hydration fluids to run for two hours. Code the hydration service.

96360, 96361 96360 and 96361 describe hydration infusion for two hours. Code 96360 is the first hour and 96361 is the second hour. The add-on code 96361 cannot be reported independently, but only in addition to 96360. The fluids infused are separately reported, using the appropriate code from HCPCS II. In the CPT® Index, look for Infusion/Hydration.

A patient with a long history of migraine headaches decides to try acupuncture in an attempt to reduce the symptoms. The provider uses acupuncture with electrical stimulation during a 15-minute, face-to-face encounter with the patient. What is/are the correct code(s)?

97813 97813 describes a 15-minute encounter with one-on-one patient contact using acupuncture with electrical stimulation. In the CPT® Index, look for Acupuncture/with Electrical Stimulation.

A patient with polyneuropathy in the feet undergoes osteopathic manipulation in an effort to improve tingling and numbness sensations. The provider manipulates both feet during the session. What is/are the correct code(s)?

98925 98925 describes manipulation of 1-2 body regions. Both feet were manipulated during the session. In the CPT® Index, look for Osteopathic Manipulation.

A diabetic patient who has not been successful managing his diet meets personally with a Registered Dietician for one hour to develop a diet plan. What is the correct code for this service?

98960 x 2 98960 describes face-to face education and training with one patient for 30 minutes. Report two units for one hour. In the CPT® Index, look for Special Services/Individual Education/Self-management.

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?

99000 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.

A physician provides medical testimony in a suspicious death case. What is the correct code for this service?

99075 Physicians may be called upon to give a medical opinion about cause of death in a court proceeding. Code 99075 is designated for medical testimony. In the CPT® Index, look for Medical Testimony.

An 11 month-old patient presented for emergency surgery to repair a severely broken arm after falling from a third story window. What qualifying circumstance code(s) may be reported in addition to the anesthesia code?

99100, 99140 In the CPT® Anesthesia Guidelines under the subheading Qualifying Circumstances each of the qualifying circumstances codes identifies a different circumstance, and more than one may be appended when applicable, unless the reported anesthesia code already contains the risk factor. In this case, 99100 is assigned for extreme age of one year or younger and 99140 is assigned for emergency conditions. Note: Qualifying Circumstances codes may also be found in CPT® Medicine Subsection Miscellaneous Services/Qualifying Circumstances for Anesthesia.

A patient sees her physician for follow-up of a repaired damaged nerve to her finger. During the visit she tells the doctor she fell and hit her little toe this morning; now it is red and swollen, and she wants to make sure it's not broken. The physician examines the toe and reassures her it is not fractured. The doctor also examines the finger which is healing well with no infection. Select the Evaluation and Management service for this visit.

99212-24 Even though the patient is in a post-operative period from surgery, the physician can bill this E/M visit and append modifier 24. The examination is unrelated to the nerve repair surgery. Modifiers 55 and 54 are only appended to surgical procedure codes not Evaluation and Management services.

An established patient is seen in clinic for allergic rhinitis. A problem focused history, an expanded problem focused exam, and a low level of medical decision making are performed. What E/M code is reported for this visit?

99213 Established patient codes require two of three key components be met to determine a level of visit. In this case, the expanded problem focused exam and low level of medical decision making support a level 3 established patient office visit 99213.

A 45 year-old established female patient is seen today at her provider's office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the provider documents a moderate complexity MDM. What CPT® code is reported for this visit?

99214 This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Detailed (HPI Extended; ROS Extended, PFSH Complete), Exam Detailed, MDM Moderate. 99214 is the level of visit supported.

A 90 year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

99235 This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate." The provider performed a comprehensive history, comprehensive exam, and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?

99239, 99304 Hospital discharge is a time-based code. The documentation states that the provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission is reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305.

A 32 year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

99242 The three Rs of consultation are documented (request, render, reply). The consultation code range is 99241-99245 and applies to new or established patients. Consultations require three key components. The documentation states the history and exam were expanded problem focused and the MDM is straightforward. These three key elements meet the requirement for 99242.

A 25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient's altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported?

99285 According to CPT® Critical Care Services guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date is reported with the appropriate E/M code." For this encounter the provider is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient's condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is high. The proper code is 99285. There is also a statement in the description of 99285 that states, "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."

The EMS brought a 31 year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?

99285 In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45 minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?

99291-25, 31500, 36510, 94610 When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). According to CPT® Critical Care Services guidelines these procedures are not included in the critical care codes. Therefore, they can be reported separately in addition to critical care services with modifier 25 appended to code 99291.

A provider makes a home care visit to a 63 year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this provider was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The provider speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported?

99348 According to CPT® E/M guidelines, Home Services codes (99341-99353) are used to report evaluation and management services provided in a private residence. This is an established patient to the provider. Established patient home care codes require two of three key components. The provider performed an expanded problem focused exam and low MDM resulting is code 99348.

A post-surgical patient is discharged from the hospital to home. The patient still has a urinary catheter needing attention for the next several days. The physician arranges for patient care through a home care agency. Code the non-physician healthcare professional's service.

99507 Patients often discharge to home when they no longer need the hospital level of care, but still need some assistance. The physician typically arranges the care with a home care agency by sending a qualified person to the patient's home. Code 99507 describes home care for maintenance of catheters. In the CPT® Index, look for Home Services/Catheter Care.

Impetigo is best described as:

A bacterial skin infection

What is the ICD-10-CM code selection for a patient with whooping cough who presents with pneumonia?

A37.91 This condition is coded with a combination code. A combination code is a single code used to describe a diagnosis with an associat-ed secondary process (manifestation) or a diagnosis with an associated complication. A secondary code is not required. In the ICD-10-CM Alphabetic Index locate Pneumonia/In (due to)/whooping cough.

What type of CPT® code is "modifier 51 exempt" even though there is no modifier 51 exempt symbol next to it?

Add-on codes Per CPT® guideline, "all add-on codes found in the CPT® code book are exempt from the multiple procedure concept."

Which gland is located on the superior surface of the kidney?

Adrenal gland

What does contralateral mean?

Affecting or originating in the opposite side. Contralateral means affecting or originating in the opposite side. This term is often used in describing thyroid surgeries.

The Global Surgical Package applies to services performed in what setting?

All of the above The services included in the global surgical package may be furnished in any setting, including hospitals, ASCs, and physicians' offices. Visits to a patient in an intensive or critical care unit are also included if made by the surgeon.

Applying the coding concept from ICD-10-CM guideline I.B.1., which of the following is the recommended method for using your ICD-10-CM code book?

Always consult the Alphabetic Index first. Refer to the Tabular List to locate the selected code Introduction ICD-10-CM - How to Use the ICD-10-CM - Steps to Correct Coding tells us to locate the main term in the Alphabetic Index, then verify the code in the Tabular List.

Which provider is NOT a mid-level provider?

Anesthesiologist Mid-level providers include physician assistants (PA) and nurse practitioners (NP). An anesthesiologist is a physician. Mid-level providers are also known as physician extenders because they extend the work of a physician.

A procedure widening a narrowed vessel or obstructed blood vessel is called a(n)

Angioplasty

" Chapter 15 Questions

Answers Rationale

" Chapter 17 Questions

Answers Rationale

Chapter 13 Questions

Answers Rationale

Chapter 16 Questions

Answers Rationale

Chapter 18 Questions

Answers Rationale

Chapter 19 Questions

Answers Rationale

" Chapter 10 Questions

Answers Rationale:

" Chapter 2 Questions

Answers Rationale:

" Chapter 8 Questions

Answers Rationale:

Chapter 11 Questions

Answers Rationale:

Where is the starting point for selective catheter placement for the vascular families in Appendix L in the CPT® code book?

Aorta Look in Appendix L of the CPT® code book. The guideline for Appendix L states the assumption is made that the starting point of catheterization is the aorta.

Which of the following is not included in the base unit value of anesthesia services?

Arterial line placement The placement of an arterial line for intraoperative monitoring is not included in the base value services listed in the Anesthesia Guidelines.

What position is the body placed in when it is in an oblique position?

At an angle, neither frontal nor lateral An oblique position is a slanted position where the patient is lying at an angle which is neither prone nor supine.

What is the correct HCPCS Level II code for parenteral nutrition solution amino acid, 3.5%?

B4168 In the HCPCS Level II Index, look for Parenteral nutrition/solution. You are directed to codes B4164-B5200. When you review the B codes, B4168 is reported.

" In ICD-10-CM, what type of burn is considered corrosion?

Burn from a chemical ICD-10-CM makes a distinction between burns and corrosions. The burn codes (T20-T25) report thermal burns that come from a heat source (e.g., a hot appliance or fire, electricity and radiation). Corrosions are burns that occur due to exposure to chemicals. Sunburns are not assigned codes from the Injury section. See ICD-10-CM guideline I.C.19.d.

What is a dime sized opening in the skull to access the brain called?

Burr hole A Burr hole is a dime sized opening in the skull, also called a keyhole craniotomy.

What temporary HCPCS Level II codes are required for use by Outpatient Prospective Payment System (OPPS) Hospitals?

C codes Outpatient PPS (C1713-C9899) Guideline explains C codes are required for Outpatient Prospective Payment System (OPPS) Hospitals to report new technology procedures, medical devices, drugs, biologicals and radiopharmaceuticals that do not have other HCPCS codes assigned. Other facilities may report C codes at their discretion.

A patient is being treated for ketoacidosis and diabetic coma due to malignant neoplasm of the pancreatic body. The patient uses insulin routinely. What ICD-10-CM codes are reported?

C25.1, E08.11, Z79.4 The patient's diabetes is due to the pancreatic cancer as an underlying condition. In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/due to underlying condition/with/ketoacidosis/with coma E08.11. In the Tabular List under category code E08 an instructional note indicates to code the underlying condition first. In the Table of Neoplasms look for Neoplasm, neoplastic/pancreas/body and select the code from the Malignant Primary column which directs the coder to C25.1. There is also coding guidance under category code E08 to use additional code for patients who routinely use insulin. Report code Z79.4 which is found in the Alphabetic Index under Long-term (current) (prophylactic) drug therapy (use of)/insulin directing you to code Z79.4. Verify code selection in the Tabular List.

" What is the correct ICD-10-CM diagnosis code for a patient with a postoperative diagnosis of a malignant pancreatic mass?

C25.9 In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/pancreas and select from the Malignant Primary column which directs you to C25.9. Verify code selection in the Tabular List. Because the mass is documented as malignant, the malignant cancer code is reported. Please refer to the notes at the beginning of the Neoplasm Table.

A patient is taken to surgery for removal of a squamous cell carcinoma of the right thigh. What is the correct diagnosis code for today's procedure?

C44.722 In the ICD-10-CM Alphabetic Index look for Carcinoma, there is a note to see also Neoplasm by site, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/skin NOS/limb NEC/lower/squamous cell carcinoma/Malignant Primary column refers you to subcategory code C44.72-. In the Tabular List the 6 th character 2 indicates the right lower limb (thigh).

" A woman has identified a lump in her right breast. After examination, the physician decides a biopsy is indicated. A specimen is sent for pathologic examination. The finding is carcinoma of the breast in the upper inner quadrant. What diagnosis is assigned for the pathologic examination?

C50.211 Always code the most specific diagnosis known. When a diagnosis of carcinoma of the breast has been confirmed, it is inappropriate to code a less specific diagnosis, no matter the reason for the original test. In the ICD-10-CM Alphabetic Index, look for Carcinoma (malignant) (see also Neoplasm, by site, malignant). Go to the Table of Neoplasms, and look for Neoplasm, neoplastic/breast/upper inner quadrant/Malignant Primary (column) C50.2-. Verification in the Tabular List indicates six characters are needed to complete the code. Report C50.211 for the upper inner quadrant of the right breast.

A 60-year-old man with prostate cancer is status post-radical prostatectomy. Prostate specific antigen (PSA) test detects high-grade disease. He is here to discuss gold fiducial marker seed placement for adjuvant radiation therapy. What is the ICD-10-CM code?

C61 Because this patient still has documented disease, Z85.46 Personal history of malignant neoplasm of prostate is incorrect. Neoplasm of unspecified behavior of other genitourinary organs, D49.59 not coded because prostate cancer is documented. Uncertain behavior of prostate neoplasm, as well as uncertain behavior of other neoplasms, should be coded only when the pathological report states uncertain. Look in the ICD-10-CM Alphabetic Index for Cancer and you are directed to see also Neoplasm, by site, malignant. In the Table of Neoplasms look for Neoplasm, neoplastic/prostate/Primary column C61. Verify code selection in the Tabular List.

Mr. McFarland visits his oncologist for prostate cancer. He is reporting more fatigue than usual. Lab tests determine the patient has anemia due to the cancer. Applying the coding concept from ICD-10-CM guideline I.C.2.c.1., what ICD-10-CM codes should be reported for the visit?

C61, D63.0 ICD-10-CM Official Coding Guidelines, Section I.C.2.c.1, states when the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for the anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia. The patient visited the oncologist for the prostate cancer and the lab tests indicate anemia due to cancer. According to the guidelines, the primary diagnosis reported for the visit, is prostate cancer. Look in the Table of Neoplasms for prostate (gland) and select the code from the Malignant Primary column C61. Then look in the Alphabetic Index for Anemia/in (due to) (with)/ neoplastic disease D63.0. Verify codes in the Tabular List.

What ICD-10-CM code is reported for carcinoma of the bladder dome?

C67.1 Neoplasm codes of the bladder, as well as other organs, are specific to site. In the ICD-10-CM Table of the Neoplasms look for Neoplasm, neoplastic/bladder (urinary)/dome and select the code from the Malignant Primary column which directs you to code C67.1. If the provider's documentation does not report the exact location of the tumor, use the unspecified diagnosis code C67.9. Verify code selection in the Tabular List.

A provider performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced right lung cancer that has metastasized to the pleura with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same provider performed a repeat thoracentesis. What ICD-10-CM codes are reported?

C78.2, C34.91, J91.0 The patient has malignant pleural effusion. Look in the ICD-10-CM Alphabetic Index for Effusion/pleura, pleurisy, pleuritic, pleuropericardial/malignant directing you to code J91.0. In the Tabular List there is a note under J91.0 to code the malignant neoplasm first, if known. In this case, it is known. According to ICD-10-CM guideline I.C.2.b when treatment is directed to the secondary cancer, the secondary cancer is reported first. The primary cancer is reported second. Treatment is due to the accumulation of fluid due to metastasis to the pleura. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/pleura, pleural (cavity) and use the code from the Malignant Secondary column which directs the coder to C78.2. The primary malignancy should also be reported. Look in the Table of Neoplasms for Neoplasm, neoplastic/lung and use the code from the Malignant Primary column which directs the coder to C34.9-. In the Tabular List, 5 th character 1 is selected for the right lung. Verify code selection in the Tabular List.

What diagnosis code is reported for secondary neoplasm of the descending colon?

C78.5 In the ICD-10-CM Table of Neoplasms look for Neoplasm/colon referring you to see also Neoplasm, intestine, large. Look for Neoplasm/intestine/large/colon/descending and use the code from the Malignant Secondary column guiding you to code C78.5. Verify code selection in the Tabular List.

What form is used to submit a provider's charge to the insurance carrier?

CMS-1500 Once documentation is translated into codes, it is then sent on a CMS-1500 form to the insurance carrier for reimbursement.

What codes are voluntarily reported to payers and provide evidence-based performance-measure data?

CPT® Category II codes Per AMA, CPT® Category II codes are a set of supplemental tracking codes used for performance measurement.

What publications does the AMA copyright and maintain?

CPT® code book and CPT® Assistant CPT® code book (all three categories) and CPT® Assistant is published, copyrighted and maintained by AMA.

What are the three categories of CPT® codes?

Categories I, II, and III Category I, Category II, Category III - The main body of the CPT® manual is comprised of the Category I CPT® Codes (00100-99607), Category II CPT® Codes (0001F-9007F), Category III CPT® Codes (0019T-0339T).

In which circumstances would an external cause code be reported?

Causes of injury or health condition. ICD-10-CM guideline I.C.20.a.1 states, an external cause code may be used with any code in the range of A00.0-T88.9, Z00-Z99, classification that is a health condition due to an external cause. Though they are most applicable to injuries, they are also valid for use with such things as infections or diseases due to an external source, and other health conditions, such as heart attack that occurs during strenuous physical activity.

Upon leaving the last portion of the small intestine, nutrients move through the large intestine in what order?

Cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus

Cytopathology is the study of:

Cells

Which layer is the middle layer of the eyeball?

Choroid The eyeball has three layers: the retina (innermost), choroid (middle), and sclera (outermost).

What does the abbreviation CKD stand for?

Chronic Kidney Disease CKD is Chronic Kidney Disease. Category N18 in the Tabular List of the ICD-10-CM codebook contains the different stages of chronic kidney disease.

According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care?

Chronic venous insufficiency According to the LCD, Chronic venous insufficiency is a systemic condition that may result in the need for routine foot care.

Referencing ICD-10-CM guideline I.B.8., when a patient presents with an acute exacerbation of a chronic condition, and no single code captures both the chronic and acute nature of the illness, how are the codes sequenced?

Code the acute condition first, followed by the chronic condition. ICD-10-CM Official Coding Guidelines, Section I.B.8 state to code the acute condition first, followed by the chronic condition.

A form of milk produced the first few days after giving birth is:

Colostrum

What type of fracture is considered traumatic?

Comminuted fracture Traumatic fractures are a result of a traumatic event, occurrence, or even extreme force (for example, motor vehicle accidents, a fall from greater than standing height or level standing height). Traumatic fractures will always be coded from Chapter 19 of the Tabular List. A comminuted fracture is a type of traumatic fracture where the bone is crushed or splintered into several pieces. In the Alphabetic Index look for Fracture, traumatic/shaft/comminuted referring you to S72.35-, which is a code found in Chapter 19. A pathological fracture is a fracture caused by a disease that led to weakness of the bone structure. Stress fractures are indexed to category M84 in chapter 13. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/spontaneous (cause unknown), which states to see Fracture, pathological. These conditions are not listed in the chapter 19 category of fracture codes; they are considered nontraumatic fractures.

Which of the following conditions results from an injury to the head? The symptoms include headache, dizziness and vomiting.

Concussion

Which is not one of the seven key components of an internal compliance plan?

Conduct training but not perform education on practice standards and procedures.

" The OIG recommends that provider practices enforce disciplinary actions through well publicized compliance guidelines to ensure actions that are ______.

Consistent and appropriate The OIG recommends that a provider practice's enforcement and disciplinary mechanisms ensure that violations of the practice's compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual.

What type of profession, other than coding, might skilled coders enter?

Consultants, educators, medical auditors

The AAPC offers over 500 local chapters across the country for the purpose of

Continuing education and networking The AAPC offers over 500 local chapters across the country. Through local chapters, AAPC members can obtain continuing education, gain leadership skills and network.

Which plane divides the body into anterior and posterior halves?

Coronal The coronal (frontal) plane cuts the body into front (anterior) and back (posterior) halves.

Which option best describes what is being done during strabismus surgery?

Corrects the muscle misalignment. Strabismus surgery is surgery on the extraocular muscles to correct the misalignment of the eyes.

Referring to the CPT® codebook in the Evocative/Suppression subsection, if a patient has congenital adrenal hypoplasia (CAH) and testing is performed to identify if the insufficiency is due to 21 hydroxylase deficiency (insufficient stimulating hormones or inability to react to those hormones), what substances are tested for and how many times must the tests be performed?

Cortisol x 2, 17 Hydroxyprogesterone x 2 In the CPT® Index, look for Evocative/Suppression Test. There is a note to See Pathology and Laboratory, Evocative/Suppression Test. Look for Pathology and Laboratory/Evocative/Suppression Test/ Stimulation Panel/ACTH directing you to codes 80400, 80402, 80406. Section guidelines state "In the code descriptors where reference is made to a particular analyte the "X 2" refers to the number of times the test for that particular analyte is performed." Code 80402 for 21 hydroxylase deficiency states in the code descriptor: Cortisol (82533 x 2) and 17 Hydroxyprogesterone (83498 x 2).

What is not a common reason Medicare may deny a procedure or service?

Covered service

The process of preserving cells or whole tissues at extremely low temperatures is known as:

Cryopreservation

In what section of the Pathology chapter of CPT® will a coder find codes for a FISH test?

Cytopathology The fluorescent in situ hybridization or FISH test is a cytopathology test. You are directed to this by looking at FISH in the CPT® Index. FISH directs you to See Fluorescent In Situ Hybridization.

A deficiency of cells in the blood is defined as:

Cytopenia

What ICD-10-CM code is reported for VIN III?

D07.1 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.

Choose the code for VIN III.

D07.1 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 di-rected 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 patient is seen in the outpatient GI lab of the hospital for rectal bleeding. A colonoscopy revealed three polyps in the transverse colon. The polyps were removed by snare technique and determined to be benign. What is the correct diagnosis code for this procedure?

D12.3 The definitive diagnosis is polyps and identified as benign. Rectal bleeding is a sign of polyps in the colon and not coded. In the ICD-10-CM Alphabetic Index, look for Polyp, polypus/colon/transverse directing you to D12.3. You can also use the Table of Neoplasms and look for Neoplasm, neoplastic/Intestine, intestinal/large/transverse; the Benign column indicates D12.3.

Using your ICD-10-CM Alphabetic Index, look for the diagnosis code for a patient with a preoperative diagnosis of abdominal pain, right lower quadrant and a postoperative diagnosis of uterine fibroids. Which of the following is the correct diagnosis code?

D25.9 The preoperative diagnosis is disregarded because a more definitive diagnosis is determined following surgery. Look in the ICD-10-CM Alphabetic Index for Fibroid/uterus D25.9. Verify code selection in the Tabular List.

A patient presents to the office with a suspicious lesion of the nose. The physician takes a biopsy of the lesion and pathology determines the lesion to be uncertain. What is the correct diagnosis code to report?

D48.5 The pathology report indicates the lesion is uncertain, which is classified in the ICD-10-CM Table of Neoplasms under Neoplasm/nose, nasal /external (skin) ( see also Neoplasm, nose, skin)/Uncertain Behavior (column) referring you to code D48.5. Verify code selection in the Tabular List.

A 45 year-old female with ovarian cancer visits her oncologist to receive an injection of Procrit®. The Procrit® has been prescribed to her for treatment of her anemia resulting from antineoplastic chemotherapy treatment. Applying the coding concept from ICD-10-CM guidelines I.C.2.c.2. What ICD-10-CM codes should be reported?

D64.81, C56.9, T45.1X5A According to ICD-10-CM guidelines 1.C.2.c.2., because the treatment is directed at the anemia associated with chemotherapy, and the treatment is only for the anemia, the anemia should be sequenced first, followed by the appropriate codes for the neoplasm and the adverse effect (T45.1X5). Look in the ICD 10-CM Alphabetic Index for Anemia/due to (in) (with)/antineoplastic chemotherapy (D64.81). According to guideline 1.C.2.c.2. the malignancy is reported secondarily followed by code T45.1X5. Look in the ICD-10-CM Table of Neoplasms for ovary and report the code from the Malignant Primary column (C56.-). In the Tabular List, C56.9 is reported because the laterality is not stated. Next, to locate T45.1X5 look in the Table of Drugs and Chemicals for Antineoplastic NEC and selecting the code from the Adverse effect column (T45.1X5). In the Tabular List, T45.1X5 requires a 7th character extender. A is selected because this is considered active treatment.

In the ICD-10-CM Alphabetic Index what is the code next to the main term called?

Default Code The Alphabetic Index utilizes the same main term/subterm indexing systems. In ICD-10-CM, the code listed next to the main term is considered the default code. The default code represents the condition most commonly associated with the main term. As with all code assignment, always verify the default code in the Tabular List to assure proper reporting. Refer to ICD-10-CM guideline I.A.18.

What are five tips for coding operative (op) reports?

Diagnosis code reporting, Start with the procedures listed, Look for key words, Highlight unfamiliar words, Read the body

The dome-shaped muscle under the lungs flattening during inspiration is the:

Diaphragm

Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures?

Disclosures to the individual who is the subject of the information.

The word "pathology" refers to the study of:

Disease The root word path means "disease". The suffix -logy is "study of".

What is the term for the first portion of the small intestine?

Duodenum The first portion of the small intestine is the duodenum, the second portion is the jejunum, and the distal portion is the ileum.

What is the correct 7th character, in ICD-10-CM, for a healing comminuted fracture of the right fibula, open, type 1?

E Look up Fracture/fibula/comminuted/. S82.45-. Verification in the Tabular List indicates correct 6th character is 1 for the right side. Correct 7th character is "E", for subsequent encounter, open fracture Type 1. See list of 7th digits under category S82. Per Chapter 19 guidelines, a fracture not indicated whether displaced or not displaced should be coded to displaced.

Patient presents to this clinic with palpitations, weight loss, bulging eyes and extreme nervousness. The tests ordered come back positive with Graves' disease. Select the ICD-10-CM code(s) to report.

E05.00 Definitive diagnosis is Graves' disease and the only code reported. The palpitations, weight loss, bulging eyes and extreme nervousness are symptoms of the Graves' disease and not reported separately. Refer to ICD-10-CM guidelines I.B.5. Look in the ICD-10-CM Alphabetic Index for Disease/Graves' (exophthalmic goiter) - see Hyperthyroidism, with goiter (diffuse). Look for Hyperthyroidism/with/goiter (diffuse) directing you to E05.00. Verify code selection in the Tabular List. There is no mention of the Graves' disease with a crisis or storm, code E05.01 is not reported.

Friends brought a young male with type 1 diabetes to the emergency department, in a comatose state. He was admitted with ketoacidosis and was resuscitated with saline hydration via insulin drip. After regaining consciousness, the patient reported that the morning of admission he was experiencing nausea and vomiting and decided not to take his insulin because he had not eaten. He was treated with intravenous hydration and insulin drip. By the following morning, his laboratory work was within normal range and he was experiencing no symptoms. What ICD-10-CM code(s) are reported?

E10.11 In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/ketoacidosis/with coma guiding you to code E10.11. Code Z79.4 Long term use of insulin is not required for a type 1 diabetic because these patients are insulin dependent. Verify code selection in the Tabular List.

The patient is a 65-year-old female with Type 2 diabetes. She is seen today by her primary care physician for extreme abdominal bloating and discomfort after eating. The patient also complains of constant heartburn. This occurrs frequently and is not relieved by anything the patient has tried. The patient recorded her blood sugar this morning as 178. Her A1C taken in the office was 8.2. The physician diagnoses gastroparesis due to the patient's diabetes. Code the ICD-10-CM diagnosis(es).

E11.43, K31.84 Gastroparesis is also called delayed gastric emptying. Gastroparesis may occur when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract. The most common cause of gastroparesis is diabetes. In this case, the physician did link the gastroparesis to the patient's diabetes so we will use a diabetic complication code. In ICD-10-CM Alphabetic Index look for Diabetes, diabetic/type 2/with gastroparesis which directs you to E11.43. Even if the provider had not linked the gastroparesis with diabetes, because it is listed under 'with' in the Alphabetic Index, there is a presumed causal relationship. In the Tabular List there is an instructional note for code K31.84 that indicates to Code first underlying disease, if known and code E11.43 is listed. There is also an Excludes2 note under category code K31 which indicates that code E11.43 can be reported with codes in category K31.

A patient with diabetic peripheral circulatory disorder is having a lower leg amputation due to gangrene. What ICD-10-CM code(s) is/are reported?

E11.52 In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 2/with/peripheral angiopathy/with gangrene which directs you to code E11.52. This is a combination code that reports both the diabetic status of the patient and the complication due to the diabetic state. Note: ICD-10-CM guideline I.C.1.C.4.a.2 indicates that if the diabetic type is not documented the coder should default to type 2. Verify code selection in the Tabular List.

" What is the correct ICD-10-CM code for a 30 year-old obese patient with a BMI of 32.5?

E66.9, Z68.32 In the ICD-10-CM Alphabetic Index, look for Obesity. You are directed to E66.9. In the Tabular List under category code E66 there is an instructional note to use additional code to identify body mass index (BMI), if known (Z68.-). Code Z68.32 represents an adult BMI of 32.0-32.9.

Local Coverage Determinations are administered by whom?

Each regional MAC Each Medicare Administrative Contractor (MAC) is responsible for interpreting national policies into regional policies.

EHR stands for:

Electronic health record EHR stands for electronic health record

A respiratory disease characterized by overexpansion and destruction of the alveoli is identified as:

Emphysema

What are the layers of the skin?

Epidermis and Dermis Two layers make up human skin: the dermis and the epidermis. Some textbooks refer to the hypodermis as a layer of skin. The hypodermis is tissue connecting the skin to the underlying tissue, which is technically not part of the skin.

What is the medical term for a congenital defect in which the urethra opens on the dorsum of the penis?

Epispadias Epispadias is a congenital defect in which the urethra opens on the dorsum of the penis. Hypospadias is a congenital defect in which the urethra opens on the underside of the penis. (epi=on, over, hypo= under, below.)

A dacryocystectomy describes:

Excision of the lacrimal sac

The meaning of the root blephar/o is:

Eyelid

The provider sees a 70 year-old patient with a documented history in the past few months of being combative and aggressive in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation on her combative and aggressive behavior. What ICD-10-CM code(s) is/are reported?

F03.91 In ICD-10-CM Alphabetic Index look for Dementia/with/aggressive behavior directing you to F03.91. Next, look for Dementia/with/combative behavior directing you to F03.91. Verify the codes in the Tabular List. Both manifestations are reported with the same code, so it is only reported once according to ICD-10-CM guideline I.B.12.

A 21 year-old male is brought into the ED by his father who states that his son is dizzy and has anxiety. The ED provider runs a drug screen test and the test comes back positive for marijuana use. The final diagnosis is documented as marijuana abuse with anxiety disorder. What ICD-10-CM code is reported?

F12.180 The diagnosis is abuse of marijuana (cannabis). Look in the ICD-10-CM Alphabetic Index look for Abuse/drug NEC/cannabis/with/anxiety disorder which directs the coder to F12.180. Verify code selection in the Tabular List.

A young female was brought to the clinic by her sister. She has had periods of severe depression for many years and is on Lithium. Her provider also manages her manic-depressive psychosis, hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for Lithium adjustment. Diagnoses are moderate manic-depressive bipolar with circular current manic state, hypothyroidism, and migraine. What ICD-10-CM codes are reported?

F31.12, E03.9, G43.909 In the ICD-10-CM Alphabetic Index look for Disorder/bipolar/current (or most recent) episode/manic/without psychotic features/moderate guiding you to code F31.12. No code assignment is necessary for depression because depression is a component of bipolar disorder. Although not psychiatric conditions, both hypothyroidism and migraine headaches are coexisting conditions under treatment and are coded. In the Alphabetic Index, look for Hypothyroidism which directs you to E03.9 and look for Migraine directing you to code G43.90-. Verify the codes in the Tabular List. When reviewing code G43.90 in the Tabular List, a 6th character of 9 is selected because there is no mention of an intractable migraine or status migrainosus.

A mother brings her son into the doctor because he has been getting in trouble in school for his behavior. He is not paying attention or following the instructions. He is constantly losing his pencil and forgetting to bring in his homework. After evaluating the child, the provider diagnoses him with attention deficit hyperactivity disorder (ADHD), predominately inattentive type, and sends the patient for a consultation with a psychiatrist to see if medication can help. Select the diagnosis code.

F90.0 The patient is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), predominately inattentive type. In the ICD 10-CM Alphabetic Index, look for Disorder (of)/attention deficit hyperactivity (adolescent) (adult) (child)/inattentive type F90.0. Verify code selection in the Tabular List.

Services provided in the home by an agency are considered

Facility services The Introduction in the CPT® code book (after the Table of Contents) includes instructions under the subheading Place of Service and Facility Reporting, which indicates services provided in the home by an agency are considered facility services.

Voluntary compliance programs also provide benefits by not only helping to prevent erroneous or ____, but also by showing that the provider practice is making additional good faith efforts to submit claims appropriately.

Fraudulent claims Voluntary compliance programs also provide benefits by not only helping to prevent erroneous or fraudulent claims, but also by showing that the provider practice is making additional good faith efforts to submit claims appropriately.

Which set of HCPCS Level II codes are considered temporary codes assigned by CMS and reviewed by AMA for inclusion in the CPT®?

G codes The G codes are temporary HCPCS Level II codes assigned by CMS. The G codes are reviewed by the AMA for possible inclusion in the CPT®. Until these codes are replaced by CPT® codes and appropriate descriptions, CMS uses the G codes to report specific services and procedures that do not otherwise have a Level I or Level II code.

A 77 year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported?

G0102 CMS has very specific guidelines on eligibility and coding of preventive services. There is no specific CPT® code for a digital rectal exam. Code 45990 is a diagnostic exam that includes a diagnostic anoscopy and rigid proctoscopy. Neither service is documented nor is it stated that the patient received an annual exam. The service provided is best represented by HCPCS code G0102. (https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html)

A 20 year-old comes into the ED with symptoms of a severe headache, vomiting, stiff neck, and fever. The ED physician suspects meningitis and performs a lumbar puncture. The ED physician reviews the results and the patient is admitted to the hospital for meningitis which is suspected to be bacterial. Which ICD-10-CM code(s) is/are reported by the ED physician?

G03.9 The symptoms for this scenario (headache, vomiting, stiff neck, and fever) are associated with meningitis (definitive diagnosis). ICD-10-CM guideline I.B.4 states signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes. Per ICD-10-CM guidelines IV.D and II.H do not code a diagnosis documented as probable, suspected, questionable, rule out, or working diagnosis. Look in the Alphabetic Index for Meningitis G03.9. Verify code selection in the Tabular List.

What diagnosis code(s) is/are reported for behavioral disturbances in a patient with early onset Alzheimer's?

G30.0, F02.81 In the Alphabetic Index, look for Disease/Alzheimer's/Early Onset/with behavioral disturbance guiding you to codes G30.0 [ F02.81]. A code in brackets is reported as an additional diagnosis. There is an instructional note in the Tabular List under category code G30 that states, use additional code to identify manifestation. You see dementia with behavioral disturbance listed as an additional code. When you go to code F02.81 in the Tabular List there is an instructional note under category F02 to code first Alzheimer's (G30.-).

What is the ICD-10-CM code for classical migraine?

G43.109 Look in the ICD-10-CM Alphabetic Index for Migraine/classical and you are directed to see migraine with aura. Migraine/with aura directs you to G43.109. Verify code selection in the Tabular List.

Using the ICD-10-CM codebook, locate the diagnosis codes for the following condition: Chronic non-intractable common migraine headache with status migrainosus

G43.701 Determine the main term which is headache. In the ICD-10-CM Alphabetic Index, look for Headache/migraine (type) (see also Migraine). In the same index look for Migraine (idiopathic)/without aura/chronic/not intractable/with status migrainosus directs you to code G43.701. Review the code in the Tabular List to verify the code accuracy.

What ICD-10-CM code is used for hemiplegia affecting the left dominant side?

G81.92 In the ICD-10-CM Alphabetic Index, look for Hemiplegia directing you to G81.9-. In the Tabular List a 5 th character is required to complete the code. The 5 th character of 2 indicates it affects the left dominant side.

What is the term that describes the removal of a portion or all of the stomach?

Gastrectomy The prefix gastr- refers to the stomach and the suffix -ectomy indicates removal of.

What is the full description for CPT® code 43622?

Gastrectomy, total; with formation of intestinal pouch, any type The full descriptor of 43622 includes the common portion before the semi-colon of code 43620, followed by the description next to 43620 (with formation of intestinal pouch, any type).

What are the three classifications of anesthesia?

General, Regional and Monitored Anesthesia Care An epidural is a type of regional anesthesia. Moderate or conscious sedation is typically provided by the same physician performing the service sedation supports and requires the presence of an independent observer to monitor the patient.

The endocrine system is comprised of:

Glands The endocrine system is comprised of glands, located throughout the body, that produce various hormones.

What type of print indicates new additions and revisions in the CPT® code book each year?

Green print New additions and revisions in the CPT® code book each year appear in green print.

In ICD-10-CM, what classification system is used to report open fracture classifications?

Gustilo classification for open fractures Open fracture designations are based on the Gustilo open fracture classification. 7 th characters are added to indicate the type of encounter. This classification is grouped into three major category types to indicate the mechanism of the injury, soft tissue damage and the degree of skeletal involvement. One of the main categories, Type III, is further subdivided into IIIA, IIIB, and IIIC to report levels of extensive damage.

Topical antibiotics were prescribed today for Jack Jones, who presented with pink eye in both eyes. His four children are all being treated for the same condition by their pediatrician. What is the correct diagnosis code?

H10.023 Pink eye is a highly infectious form of mucopurulent conjunctivitis. This infection typically is accompanied by very bloodshot eyes and a heavy discharge. In the ICD-10-CM Alphabetic Index, look for Pink/eye - see Conjunctivitis, acute, mucopurulent. Look for Conjunctivitis/acute/mucopurulent H10.02-. In the Tabular List, the codes contain laterality and documentation indicates both eyes (bilateral) are affected.

A patient is having phacoemulsification of an age-related nuclear cataract of the left eye. What ICD-10-CM code is reported?

H25.12 Look in the ICD-10-CM Alphabetic Index for Cataract/age-related and you are directed to see Cataract, senile. Cataract/senile/nuclear (sclerosis) directs you to H25.1-. A 5th character 2 is selected for the left eye.

What ICD-10-CM code(s) is/are reported for bilateral cataracts?

H26.9 In the ICD-10-CM Alphabetic Index look for Cataract and you are directed to the default code H26.9. Modifiers are not appended to diagnosis codes. There is no documentation to support that the cataracts are congenital. Even though the cataract is in both eyes, it is only necessary to report the ICD-10-CM code once per ICD-10-CM guideline I.B.12.

The patient has a significant visual impairment (category 2) due to astigmatism in the left eye. It is corrected with glasses. The right eye has normal vision. What ICD-10-CM code(s) is/are reported?

H52.202, H54.52A2 Look in the ICD-10-CM Alphabetic Index for Impaired, impairment (function)/vision NEC referring you to H54.7. In the Tabular List category H54 has a note to see the definition of visual impairment categories. Category 2 is considered low vision. Looking through the codes, low vision in the left eye is reported with H54.52-. A2 is assigned as 6th and 7th character to identify Category 2. Or, you can look in the Alphabetic Index for Low/vision/one eye/left (normal vision on right) referring you to H54.52. It is important to read the instructional notes in the Tabular List that are associated with categories before selecting your code. Category H54 also has a note to code first any cause of the blindness. In this case, the low vision is due to the astigmatism. Look in the Alphabetic Index for Astigmatism referring you to H52.20-. In the Tabular List, H52.202 is reported for the left eye.

What ICD-10-CM code is reported for bilateral chronic otitis media with effusion?

H65.493 Look in the ICD-10-CM Alphabetic Index for Otitis/media /chronic/with effusion (nonpurulent) which states see Otitis, media, nonsuppurative, chronic. Look for Otitis/media/nonsuppurative/chronic which directs you to H65.49-. A 6 th character of 3 specifies the condition is bilateral.

A patient sees her provider for spontaneous episodes of vertigo lasting 30 minutes each, fluctuating hearing loss, and tinnitus. The provider performs a hearing test and confirms hearing loss in the right ear. The provider documents the patient has Meniere's disease in the right ear. What ICD-10-CM code(s) is (are) reported?

H81.01 Look in the ICD-10-CM Alphabetic Index for Meniere's disease, syndrome or vertigo H81.0-. The 5th character 1 indicates the right ear. The vertigo, hearing loss, and tinnitus are all symptoms of Meniere's disease and are not reported separately. The vertigo (R42), loss of hearing (H91.91) and the tinnitus (H93.11) are signs/symptoms for the Meniere's disease and not separately reported (refer to ICD-10-CM Guideline Section I.B.5).

A 35 year-old woman is experiencing dizziness with nausea and vomiting. The provider documents auditory vertigo of both ears, possible Meniere's disease. What ICD-10-CM code(s) is/are reported?

H81.313 In the ICD-10-CM Alphabetic Index look for Vertigo/auditory telling you to see Vertigo, aural. Vertigo/aural which guides you to code H81.31-. In the Tabular List 6 th character 3 is selected because the condition is bilateral. The Meniere's disease is a possible diagnosis and is not reported. Per ICD-10-CM guideline I.B.5 signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes. Dizziness, nausea and vomiting are symptoms of the vertigo and are not reported separately. Verify code selection in the Tabular List.

Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?

HITECH The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as a part of the American Recovery and Reinvestment Act of 2009 (ARRA) to promote the adoption and meaningful use of health information technology. Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information.

" HIPAA stands for

Health Insurance Portability and Accountability Act Health Insurance Portability and Accountability Act (HIPAA)

The __________ is a fist-sized, cone-shaped muscle sitting between the lungs and behind the sternum.

Heart The heart is a fist-sized, cone-shaped muscle sitting between the lungs and behind the sternum.

Which statement is TRUE regarding codes for hypertension and heart disease in ICD-10-CM?

Hypertension and heart disease have an assumed causal relationship. ICD-10-CM Coding Guidelines I.C.9.a states a causal relationship is presumed between hypertension and heart involvement. Only if the documentation specifically states they are unrelated, are they to be coded separately. ICD-10-CM guideline I.C.9.a.1 indicates two codes are required to report hypertension and heart failure.

Which layer is NOT considered part of the skin?

Hypodermis

A procedure requiring the physician to cut down to the superficial fascia is documented as cutting down into the:

Hypodermis The hypodermis (subcutaneous) serves to protect the underlying structures, prevent loss of body heat and anchor skin to the underlying musculature. Fibrous connective tissue referred to as superficial fascia is included in this layer.

" A patient with hypertensive cardiovascular disease is admitted by his primary care provider. What is/are the correct ICD-10-CM code(s) for this encounter?

I11.9 In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/cardiovascular/disease (arteriosclerotic) (sclerotic) directs you to see Hypertension, heart. Look for Hypertension/heart (disease) (conditions in I51.4-I51.9 due to hypertension) referring you to I11.9. ICD-10-CM guideline, I.C.9.a.1., states code I11- is used when a causal relationship is stated or implied. Tabular List confirms code I11.9 is correct as heart failure is not documented.

A patient is seen for his hypertension with stage 5 CKD and myocardial disease. The conditions are stable and he is told to continue with his medications. The myocardial disease is unrelated to the hypertension. What ICD-10-CM codes are reported?

I12.0, N18.5, I51.5 ICD-10-CM guideline I.C.9.a.2 indicates that ICD-10-CM presumes a causal relationship between chronic kidney disease (CKD) and hypertension. Look in the ICD-10-CM Alphabetic Index for Hypertension/kidney/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) referring you to I12.0. Instructional note under I12.0 indicates to use additional code to identify the stage of the CKD. Code N18.5 is reported for stage 5 CKD. ICD-10-CM guideline, I.C.9.a.1 indicates if the documentation does not have a causal relationship between the hypertension and heart disease the conditions are coded separately. Look in the Alphabetic Index for Disease/myocardium, myocardial referring you to I51.5. Verify code selection in the Tabular List.

A 54 year-old male goes to his primary care provider with dizziness. On physical exam his blood pressure is 200/130. After a complete work-up, including laboratory tests, the provider makes a diagnosis of end stage renal disease and hypertension. What are the appropriate diagnosis codes for this encounter?

I12.0, N18.6 ICD-10-CM guideline I.C.9.a.2 indicates to assign codes from category I12 when conditions classified to category N18 are present with hypertension. A causal relationship is assumed between hypertension and chronic kidney disease. Guideline I.C.14.a.1 tells us to code N18.6 when the provider has documented end stage renal disease. In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/with kidney involvement and you are directed to see Hypertension, kidney. Hypertension/kidney/with/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) referring you to I12.0. In the Tabular List there is an instructional note to use an additional code to identify the stage of the chronic kidney disease (N18.5, N18.6). In this case the patient has end stage renal disease, reporting code N18.6. This is found in the Alphabetic Index by looking for Disease, diseased/renal/with/end stage (failure) referring you to N18.6. Verify code selection in the Tabular List.

Patient is diagnosed as having chronic renal failure with hypertension. He is end stage receiving dialysis. What ICD-10-CM codes are reported?

I12.0, N18.6, Z99.2 According to the ICD-10-CM guideline I.C.9.a.2., a relationship is assumed between hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for Hypertension, hypertensive/ kidney/with/stage 5 chronic kidney disease (CKD) or end stage renal disease (ESRD) referring you to I12.0. Verify in the Tabular List. An instructional note indicates to use additional code to identify the stage of chronic kidney disease (N18.5, N18.6). Code N18.6 is reported for the end stage renal failure. There is an instructional note to use additional code to identify dialysis status (Z99.2).

What ICD-10-CM codes are reported for uncontrolled hypertension with stage 3 chronic kidney disease?

I12.9, N18.3 Per ICD-10-CM guideline I.C.9.a.2 assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classified to category N18, Chronic kidney disease are present. In the ICD-10-CM Alphabetic Index look for Hypertension/kidney/with/stage 1 through stage 4 chronic kidney disease which directs you to code I12.9. In the Tabular List, there is a note to use an additional code to identify the stage of chronic kidney disease (N18.1-N18.4 or N18.9). Look in the Alphabetic Index for Disease, diseased/kidney/chronic/stage 3 (moderate) directing you to code N18.3. Verify code selection in the Tabular List.

A patient undergoes heart surgery for angina decubitus and coronary artery disease (CAD). What ICD-10-CM code is reported?

I25.118 In the ICD-10-CM Alphabetic Index look for Disease/coronary (artery) which states see Disease/heart/ischemic/atherosclerotic (of) with angina pectoris which directs you to see Arteriosclerosis, coronary (artery). Look for Arteriosclerosis/coronary (artery)/native vessel/with/angina/specified type NEC which directs you to I25.118. Verify code selection in the Tabular List.

The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported?

I50.22, I10 ICD-10-CM guideline I.C.9.a.1 indicates when the documentation specifically states the two conditions are unrelated between hypertension and heart disease, they are coded separately. In this case, there is no causal relationship coded. Look in the ICD-10-CM Alphabetic Index for Failure/heart/systolic (congestive)/chronic (congestive) directing you to I50.22. Then, look for Hypertension which directs you to I10. Verify code selection in the Tabular List.

A patient is diagnosed with acute on chronic diastolic congestive heart failure (CHF). Report the ICD-10-CM code(s).

I50.33 There is a combination code for acute on chronic diastolic congestive heart failure. Look in the Index to Diseases and Injuries for Failure/heart/diastolic (congestive)/acute/and (on) chronic (congestive) referring you to I50.33. Always verify your codes in the Tabular List.

A patient suffered postoperative left heart failure following repair of an abdominal aortic aneurysm. What ICD-10-CM code(s) is/are reported?

I97.131, I50.1 In the ICD-10-CM Alphabetic Index look for Complication(s) (from) (of)/postprocedural/heart failure/following other surgery or Failure, failed/heart/postprocedural directing you to code I97.131. Verify the code selection in the Tabular List. There is a note under subcategory I97.13 to use additional code to identify the heart failure (I50.-). The patient is in left heart failure. In the Alphabetic Index look for Failure, failed/heart/left (ventricular) which instructs you to see Failure, ventricular, left. In the Alphabetic Index look for Failure, failed/ventricular/left which guides you to code I50.1. Verify the code selection in the Tabular List. You do not code the abdominal aortic aneurysm because the patient no longer has that condition.

According to ICD-10-CM guideline I.B.1 use both ____ and ____ when locating and assigning a diagnosis code.

ICD-10-CM Alphabetic Index and Tabular List According to the ICD-10-CM guideline 1.B.1 both the Alphabetical Index and Tabular List are used to locate and assign a code. Reliance on only the Alphabetic Index or the Tabular List will lead to errors and less specificity in reporting codes.

The Table of Drugs in the HCPCS Level II book indicates various medication routes of administration. What abbreviation represents the route where a drug is introduced into the subdural space of the spinal cord?

IT In the HCPCS Level II code book, there is an appendix that lists the abbreviations and acronyms and their meanings. IT stands for Intrathecal. IT is the route where a drug is introduced into the subdural space of the spinal cord.

What does the 7 th character A indicate in Chapter 19?

Initial encounter According to ICD-10-CM guideline I.C.19.a, the 7 th character A represents the initial encounter for each encounter where active treatment is received for the condition.

What is the difference between outpatient and inpatient coding?

Inpatient coders use ICD-10-CM and ICD-10-PCS.

___________ fixation with pins, screws, plates, or wires is placed directly on or in the bone to immobilize a fractured bone and to maintain alignment while it heals.

Internal Some fractures are treated with either internal or external fixation to maintain the alignment of the bone and immobilize it while it heals, or to reinforce the bone permanently. Internal fixation can be performed with pins, screws, plates or wires placed directly in or on the bone to immobilize it.

What does ICD-10-CM stand for?

International Classification of Diseases 10th Revision, Clinical Modification Per the Introduction page of the ICD-10-CM codebook, the abbreviation stands for International Classification of Diseases 10 th Revision, Clinical Modification.

What does IOL stand for?

Intraocular lens IOL stands for intraocular lens.

Restriction of blood supply, commonly due to factors in the blood vessel, that can result in damage or dysfunction of tissue is known as:

Ischemia

What is the function of the gall bladder?

It conveys and stores bile. The gall bladder is a sac-shaped organ located under the liver. It stores bile that is produced by the liver.

When is it appropriate to use history of malignancy from category Z85?

It has been excised, no evidence of any existing primary malignancy, and there is no further treatment directed to the site. ICD-10-CM guideline 1.C.2.m indicates that when a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85 Personal history of malignant neoplasm is used to indicate the former site of the malignancy.

Which of the following is NOT true of the thoracic diaphragm?

It is a frequent site of a Spigelian (lateral ventral) hernia

What is the ICD-10-CM code for strep throat?

J02.0 Look in the ICD-10-CM Alphabetic Index for Streptococcus, streptococcal and you are directed to see also condition. Look in the Alphabetic Index for Sore/throat/streptococcal (ulcerative) J02.0. Verify code selection in the Tabular List.

A 10 month-old comes into the pediatrician's office for a harsh, bark-like cough. She is diagnosed with croup. The mother also wants the pediatrician to look at a rash that has developed on her leg. The pediatrician prescribes over the counter medication of acetaminophen for the croup and hydrocortisone cream for the rash on the leg. She is to follow up in five days or return earlier if the conditions worsen. What ICD-10-CM code(s) should be reported for this visit?

J05.0, R21 Signs and symptoms that are associated with a disease process should not be reported, refer to ICD-10-CM guideline I.B.5. ICD-10-CM code R05 is not reported because cough is a symptom of croup. Codes for signs and symptoms that are not routinely associated with a definitive diagnosis should be reported, according to ICD-10-CM guidelines 1.B.4 and I.B.5. The rash is reported because it is not related or associated with croup. Look for Croup in the ICD-10-CM Alphabetic Index referring you to code J05.0. Look for Rash in the Alphabetic Index referring you to code R21. Verify both codes in the Tabular List.

What is the diagnosis code(s) for a patient with bronchitis and the flu?

J11.1 Look in the ICD-10-CM Alphabetic Index for Bronchitis/with/influenza, flu or grippe which states to see Influenza, with, respiratory manifestations NEC. Look for Influenza/with/respiratory manifestations NEC J11.1. Verify code selection in the Tabular List.

Pneumonia due to adenovirus. What ICD-10-CM code is reported?

J12.0 In the ICD-10-CM Alphabetic Index look for Pneumonia/adenoviral and you are directed to code J12.0. Verification in the Tabular List confirms code selection.

What diagnosis code(s) is/are reported for pneumonia due to SARS?

J12.81 ICD-10-CM guideline I.B.9 indicates that a combination code is a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation). Multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis. In the ICD-10-CM Alphabetic Index look for Syndrome/severe acute respiratory (SARS) guiding you to code J12.81. You can also look for Pneumonia/SARS-associated coronavirus J12.81. Verify code selection in the Tabular List.

Provide the correct ICD-10-CM code(s) for acute RSV bronchiolitis.

J21.0 RSV is the acronym for respiratory syncytial virus. In the ICD-10-CM Alphabetic Index look for Bronchiolitis. Acute is a nonessential modifier. Bronchiolitis (acute) (infective) (subacute)/due to/respiratory syncytial virus refers you to J21.0. Verification in the Tabular List confirms code selection.

A patient presents to the physician with persistent stuffiness and facial pain. The physician documents a diagnosis of nasal polyps. What ICD-10-CM code is reported?

J33.9 Look in the ICD-10-CM Alphabetic Index for Polyp, polypus/nasal, J33.9.This is the correct code for an unspecified nasal polyp.

A final diagnosis for a patient in the ER is COPD with acute bronchitis due to echovirus. How is this diagnosis coded?

J44.0, J20.7 Look in the ICD-10-CM Alphabetic Index for Disease, diseased/pulmonary/chronic obstructive/with/acute bronchitis directing you to J44.0. In the Tabular List an instructional note is given for code J44.0 to use additional code to identify the infection. Look for Bronchitis/acute or subacute/due to/virus/echovirus directing you to code J20.7.

A 65 year-old female patient returns to her primary care provider for follow up of an upper respiratory infection diagnosed the previous week. Her condition has not improved and her cough has increased. She has a long history of smoking. She currently smokes one pack a day and is dependent on the cigarettes. She uses a bronchodilator for her COPD. The provider changes her antibiotics to treat her acute bronchitis with COPD. What ICD-10-CM codes are reported for this visit?

J44.0, J20.9, F17.210 In the ICD-10-CM Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive/with/acute bronchitis J44.0. In the Tabular List, there is an instructional note to code also to identify the infection. For this example, the infection is reported with a code from category code J20 Acute Bronchitis. Because there is no indication of the infectious agent for the acute bronchitis, an unspecified code is used. Look for Bronchitis/acute or subacute (with bronchospasm or obstruction) J20.9. In the Tabular List category J44 has a note to code also the type of asthma which is not applicable to this case, so it is not coded. J44 also has a note to report an additional code for use of or exposure to smoke. The patient is currently still smoking and is dependent on cigarettes. Look for Dependence (on)/nicotine/cigarettes F17.210. Verify code selection in the Tabular List.

What is the ICD-10-CM code for a child with an acute exacerbation of hay fever asthma?

J45.901 Look in the ICD-10-CM Alphabetic Index for Asthma/with/Hay Fever which points to see Asthma, allergic extrinsic. Locate Asthma/allergic extrinsic/with/exacerbation (acute) referring you to J45.901. In ICD-10-CM asthma codes are specific to severity - mild, moderate, severe as well as intermittent or persistent. In this case the indexing leads to an unspecified code.

What ICD-10-CM code is reported for spontaneous pneumothorax?

J93.83 In the ICD-10-CM Alphabetic Index look for Pneumothorax/spontaneous NOS referring you to code J93.83. Verify code selection in the Tabular List.

Using your ICD-10-CM codebook look for the diagnosis code for a patient with a preoperative diagnosis of abdominal pain, right lower quadrant and a postoperative diagnosis of acute appendicitis with peritoneal abscess. What ICD-10-CM code is reported?

K35.33 The preoperative diagnosis of abdominal pain in the right lower quadrant is not reported because there is definitive diagnosis listed post-operatively. The postoperative diagnosis specifies acute appendicitis with peritoneal abscess. Look in the ICD-10-CM Alphabetic Index for Abscess/peritoneum, peritoneal (perforated)/with appendicitis or Appendicitis/acute/with/peritoneal abscess which directs you to K35.33. Verify code selection in the Tabular List.

A 22 year-old is in an outpatient facility for an inguinal hernia repair. Just before surgery, the surgeon discovers the patient is positive for MRSA and the surgery is canceled. Which ICD-10-CM code(s) should be reported for the outpatient service?

K40.90, A49.02, Z53.09 ICD-10-CM guidelines for outpatient services IV.A.1 states to report the reason for surgery as the first listed diagnosis even if the surgery is canceled due to a contraindication. Look in the ICD-10-CM Alphabetic Index for Hernia/inguinal referring you to code K40.90. Next, look for MRSA (Methicillin resistant Staphylococcus aureus)/infection referring you to code A49.02. Lastly, look for Canceled procedure (surgical)/because of/contraindication referring you to code Z53.09. Verify code selection in the Tabular List.

In the ED, a 50 year-old male complains of severe bloating and stomach cramps, some nausea, vomiting, and diarrhea for the past four months. In the last three weeks, he has had pain in middle right side of his back which radiates around his rib cage as well as stomach gurgling with massive pain. After examination, the provider determines he has irritable bowel syndrome with diarrhea. What diagnosis code(s) is/are reported?

K58.0 Look in the ICD-10-CM Alphabetic Index for Syndrome/irritable/bowel/with diarrhea which directs you to K58.0. Refer to ICD-10-CM guidelines I.B.4 (Signs and Symptoms) and I.B.15 (Syndrome). Verification in the Tabular List confirms code selection.

A patient with a large prolapsed hemorrhoid arrives at the Emergency Department. After multiple attempts, the provider is unable to reduce it. The physician applies granulated sugar to the hemorrhoid and is then able to reduce the hemorrhoid. What is the correct diagnosis code?

K64.8 Hemorrhoids are dilated or enlarged varicose veins which occur in and around the anus and rectum. The condition can be complicated by thrombosis, strangulation, prolapse, and ulceration. To find hemorrhoids in the ICD-10-CM Alphabetic Index, locate Hemorrhoids/Prolapsed directing you to K64.8. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for internal hemorrhoids?

K64.8 Look in the ICD-10-CM Alphabetic Index for Hemorrhoids (bleeding) (without mention of degree)/internal (without mention of degree) which refers you to K64.8. Verification in the Tabular List confirms code selection.

A patient presents with abdominal pain. The physician performs an abdominal ultrasound and discovers the patient has gallstones and inflammation of the gallbladder. Select the diagnosis code(s).

K80.10 The patient is diagnosed with gallstones (cholelithiasis) and gallbladder inflammation (cholecystitis). In the ICD-10-CM Alphabetic Index, look for Cholecystitis/with calculus, stones in/gallbladder; you are referred to - see Calculus gallbladder, with cholecystitis. Look for Calculus/gallbladder/with cholecystitis which directs you to K80.10. Because code K80.10 is a combination code for both cholelithiasis and cholecystitis only one code is reported, not each separately (Refer to ICD-10-CM guideline I.B.9). Verify code selection in Tabular List.

A patient is admitted for an outpatient cholecystectomy for gall stones. During recovery, the patient developed severe postoperative pain. The patient was admitted to observation to monitor the pain. Applying the coding concept from ICD-10-CM guideline IV.A.2., what ICD-10-CM code(s) are reported for the observation?

K80.20, G89.18 According to the ICD-10-CM Guidelines, Section IV.A.2, when a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the primary diagnosis, and the complications as secondary diagnosis. Look for main term Gallstone in the Index to Diseases and Injuries and you are referred to see also Calculus, gallbladder. Look for Calculus/gallbladder, which refers you to K80.20. For the postoperative pain, look for Pain(s)/postoperative NOS and you are referred to G89.18. Verify codes in the Tabular List.

A 37 year-old male is diagnosed with cholelithiasis, choledocholithiasis and acute and chronic cholecystitis. What ICD-10-CM code(s) is/are reported?

K80.66 A combination code is reported for all three diagnoses. ICD-10-CM guideline I.B.9 states you assign only the combination code when that code fully identifies the diagnostic conditions involved. In the Alphabetic Index look for Cholelithiasis and you are directed to see Calculus, gallbladder. Look for Choledocholithiasis and you are directed to see Calculus, bile duct. Look for Calculus/gallbladder and bile duct/with/cholecystitis/acute/with/chronic cholecystitis K80.66. Verify the code in the Tabular List.

What is the ICD-10-CM code for hives?

L50.9 Look in the ICD-10-CM Alphabetic Index for Hives and you are directed to see Urticaria. Urticaria directs you to L50.9. Verify code selection in the Tabular List.

A 25-year-old man complains he has premature hair loss. The provider suspects it is due to stress, but is uncertain. List the ICD-10-CM code(s) for the hair loss.

L64.8 Alopecia is hair loss. You can find the correct code by looking for Loss (of)/hair, which directs you to see Alopecia. Look for Alopecia in the ICD-10-CM Alphabetic Index. Alopecia/premature L64.8. Verify in the Tabular List. L65.0 Telogen effluvium is hair loss due to stress, but the provider only suspects it is due to stress so it is not coded.

A patient presents to the physician to discuss her acne and ask the physician about a suspicious lesion of the left ear. The patient and physician discuss further treatment of the acne and agree to take a biopsy of the lesion of the ear. Billing was sent prior to receiving the pathology report. What ICD-10-CM code(s) is/are reported?

L70.9, D49.2 The patient is presenting with acne, additionally the patient has a suspicious lesion of the left ear which requires a biopsy. In the ICD-10-CM Alphabetic Index look for Acne referring you to L70.9. The ear lesion is noted as suspicious, and a biopsy was taken to determine whether it is benign or malignant. Because this is submitted to the carrier prior to receiving the pathology report, it is necessary to report unspecified for the lesion. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/ear (external)/Unspecified Behavior column referring you to code D49.2. Verify all codes in the Tabular List.

A patient is diagnosed with pressure ulcers on each heel. Each heel displays bone involvement with evidence of necrosis and is identified as stage 4. Select the diagnosis code(s).

L89.614, L89.624 Codes for pressure ulcers are determined by site, stage, and laterality. In this case, the patient has pressure ulcers on each heel, stage 4. Look in the ICD-10-CM Alphabetic Index for Ulcer/pressure/stage 4/heel L89.6-. In the Tabular List, a 5th character is required for laterality and 6th character is required for the stage. Report L89.614 for the right and L89.624 for the left. The stage is documented as stage 4.

What is the ICD-10-CM code for keloid scar on the foot?

L91.0 Look in the ICD-10-CM Alphabetic Index for Scar/keloid L91.0. The location does not affect code selection. Verify code selection in the Tabular List.

What information does ICD-10-CM add to many of the codes for eye disorders or injuries?

Laterality (eye affected). ICD-10-CM lists many of the codes for eye disorders or injuries based on which eye was affected (laterality - left, right, bilateral or unspecified).

What is the term for removal of part of the lymph system?

Lymphadenectomy The suffix "ectomy" means removal, so lymphadenectomy is the correct answer

What is the ICD-10-CM code for bilateral hip pain?

M25.551, M25.552 In the Index to Diseases and Injuries, look for Pain(s)/ joint/hip. You are directed to subcategory code M25.55. In the Tabular List, a sixth character is assigned to indicate laterality. Because there is no code choice for bilateral, M25.551 is reported for the right hip pain and M25.552 is reported for the left hip pain.

A patient returns to the provider for an injection to relieve low back pain from a car accident. What ICD-10-CM code(s) is/are reported?

M54.5 Per ICD-10-CM guideline I.C.6.b.1, if the pain is not specified as acute or chronic, do not assign codes from category G89, except for post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome. Look in the ICD-10-CM Alphabetic Index for Pain/low back which directs the coder to M54.5. Verify code selection in the Tabular List.

A patient has foot surgery for a right calcaneal spur. Chronic myocardial ischemia was listed on the pre-anesthesia assessment. What ICD-10-CM code(s) is/are reported?

M77.31, I25.9 In the ICD-10-CM Alphabetic Index look for Spur, bone/calcaneal which directs you to M77.3-. Next, in the Alphabetic Index under Ischemia, ischemic/heart (chronic or with a stated duration of over 4 weeks) which directs you to I25.9. In the Tabular List confirm the code selection. Code M77.3- indicates that a 5 th character is needed to define the laterality of the foot. Calcaneal spur in the right foot report M77.31, for the foot surgery. The chronic myocardial ischemia code I25.9 denotes the anesthesia risk and is also reported.

A patient with age-related osteoporosis suffers a pathologic fracture to her right hip. She is being seen for this new fracture today. Select the diagnosis code(s).

M80.051A A combination code is reported for the pathological fracture and osteoporosis. In the ICD-10-CM Alphabetic Index, look for Osteoporosis/age related/with current pathological fracture/ilium M80.05-. In the Tabular List, this section includes osteoporosis with current pathological fracture and the subcategory code is reported for age-related osteoporosis with current pathological fracture of hip. A 6th character is required. Complete the code with 6th character 1 for right femur and 7th character A for initial encounter.

Which of the following does NOT contribute to refraction in the eye?

Macula

What three components are used to configure relative value units?

Malpractice insurance costs, physician work, practice expense RVUs are configured utilizing physician work, practice expense and malpractice insurance costs.

What anatomical cavity or compartment contains all of the thoracic viscera except the lungs?

Mediastinum The mediastinum extends from the sternum to the vertebral column and contains all the thoracic viscera, except the lungs.

What type of health insurance provides coverage for low-income families?

Medicaid Medicaid is a health insurance assistance program for some low-income people (especially children and pregnant women) sponsored by federal and state governments.

What does MAC stands for?

Medicare Administrative Contractor Medicare Administrative Contractor (MAC)

Which part of the brain controls blood pressure, heart rate and respiration?

Medulla

What is an example of a long bone?

Metacarpals Long bones are named for their shape, not their size. Metacarpals are long bones in the fingers.

What is a mid-level provider?

Mid-level providers include physician assistants (PA) and nurse practitioners (NP).

What are three types of codes printed in the HCPCS Level II codebook?

Miscellaneous codes, Permanent National codes, Temporary National codes Three types of HCPCS codes printed in the HCPCS Level II codebook consist of: Permanent National Codes, Miscellaneous Codes/not otherwise classified, Temporary National Codes. This can be verified by reviewing the HCPCS Coding Procedures in the front of the HCPCS Level II codebook.

What modifier is used to report the termination of a surgery following induction of anesthesia due to extenuating circumstances or those that threaten the well-being of the patient?

Modifier 53 Modifier 53 is used to indicate the physician has elected to terminate a surgical or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient. CPT® modifiers are found on the inside front cover and in Appendix A of the CPT® code book.

A 55 year-old female with right hydronephrosis presents for a cystourethroscopy with a retrograde pyelogram. What is the correct diagnosis code?

N13.30 The indication for the surgery is hydronephrosis. In the ICD-10-CM Alphabetic Index, look for the main term Hydronephrosis. There is no indication of causal organism, or that it is a congenital condition. The default code is N13.30. A review of this code in the Tabular List confirms this is the correct diagnosis.

Preoperative diagnosis: Hematuria. Postoperative diagnosis: Right renal calculi and bladder calculus. What ICD-10-CM code(s) is/are reported for this service?

N20.0, N21.0 The preoperative diagnosis indicates the reason for the surgery. The postoperative diagnosis indicates what was found during the surgery. Hematuria is a symptom of renal calculi and bladder calculus, and not coded separately. Refer to ICD-10-CM guideline 1.B.4 or I.B.18. Look in the ICD-10-CM Alphabetic Index for Calculus, calculi, calculous/kidney which directs you to code N20.0 and Calculus, calculi, calculous /bladder which directs you to code N21.0. Verify the code selections in the Tabular List.

Mr. James is an established patient with calculus in diverticulum of bladder. What is the ICD-10-CM code?

N21.0 Looking in the ICD-10-CM Alphabetic Index in this example is critical in selecting the correct code. If you look for the main term Bladder in the Alphabetic Index it indicates to see condition. If you look for the main term Diverticulum, diverticula/bladder it directs you to code N32.3 which is diverticulum of bladder. There is a stone in the diverticulum of bladder. If you look for Calculus, calculi, calculous/bladder (diverticulum) it directs you to the code N21.0 which is the correct code. Verify code selection in the Tabular List.

What diagnosis code(s) should be reported for acute and chronic cystitis?

N30.00, N30.20 ICD-10-CM guideline.I.B.8 states when the same condition is described as both acute and chronic and separate subentries exist, code both and sequence the acute code first.

What is the ICD-10-CM code for UTI?

N39.0 UTI stands for urinary tract infection. Look in the ICD-10-CM Alphabetic Index for Infection/urinary (tract) N39.0. Verify code selection in the Tabular List. There is an instructional note use additional code to identify organism. There is no information of the infectious agent and no additional code is reported.

What ICD-10-CM code is reported for male stress incontinence?

N39.3 Look in the ICD-10-CM Alphabetic Index for Incontinence/stress (female) (male) which directs you to N39.3. The terms male and female are enclosed in parenthesis making them nonessential modifiers for code selection. Verify code selection in the Tabular List.

Mary visited her family physician for a lump in the upper outer quadrant of her left breast. The physician ordered a mammogram to rule out breast cancer. The radiologist did not find any abnormal findings. What diagnosis is reported for the professional portion of the mammography?

N63.21 When a test is ordered for a sign or symptom, and the outcome of the test is a normal result with no confirmed diagnosis, the coder reports the sign or symptom that prompted the physician to order the test. Because the test was ordered for a lump in the breast, but the outcome is normal, the lump in the breast, N63 is reported as the diagnosis. In the ICD-10-CM Alphabetic Index, look for Lump/breast/left/upper puter quadrant which directs you to N63.21. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for an incomplete uterine prolapse?

N81.2 In the ICD-10-CM Alphabetic Index look for Prolapse/uterus/incomplete directing you to code N81.2. Looking in the Tabular List confirms this code selection.

A 45 year-old mother of three children is having surgery to correct an anterior vaginal wall prolapse with an incomplete uterine prolapse. What ICD-10-CM code is reported?

N81.2 In the ICD-10-CM Alphabetic Index, look for Prolapse/vagina (anterior) (wall)/with prolapse of uterus/incomplete, guiding you to code N81.2. Verify code selection in the Tabular List.

A patient is in outpatient surgery for a laparoscopic oophorectomy for a right ovarian cyst. After admission, the anesthesiologist discovered the patient had an upper respiratory infection and the surgery was cancelled. Applying the coding concept from ICD-10-CM guideline IV.A.1., which ICD-10-CM code(s) are reported?

N83.201, J06.9, Z53.09 ICD-10-CM coding guidelines Section IV.A.1.states to report the reason for surgery as the first listed diagnosis even if the surgery is cancelled due to a contraindication. Look in the Index to Diseases and Injuries for Cyst/ovary, ovarian (twisted) and you are referred N83.201. In the Tabular List, 6th character 1 is reported for the right side. For the respiratory infection, look for Infection/respiratory (tract)/upper (acute) NOS and you are referred to J06.9. Then, look for Canceled procedure/because of/contraindication which refers you to Z53.09. Verify codes in the Tabular List.

A 40 year-old presents with vaginal bleeding for several weeks unrelated to her menstrual cycle. The gynecologist orders an ultrasound to obtain more information for a diagnosis. What diagnosis code is appropriate for this encounter?

N93.9 The bleeding is unrelated to the patient's 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.

A 6 year-old patient is seen in the office for acute otitis media, coded as H66.90. This is an example of a ____ code.

NOS H66.90 is Not Otherwise Specified. ICD-10-CM guideline I.A.9.b codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. The inclusion terms under H66.9 include NOS in the description.

A PCP transfers a patient to a cardiologist for management of the patient's congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?

New patient office visit The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient since the cardiologist accepted the patient and is taking over the care of a specific problem.

A patient was seen in the provider's office and diagnosed with influenza with pneumonia. The provider selected J18.9. Refer to the Tabular List to verify code J18.9. Is it correct to report code J18.9? Why?

No, there is a combination code J11.00 includes influenza with pneumonia. D-10-CM guideline I.B.9, states "Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetical Index so directs."

Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He acted as a co-surgeon working with an orthopedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. From what category or subcategory of evaluation and management services would Dr. Hedrick's follow up visit be reported?

Non-billable The follow-up visit from the neurosurgeon the day following surgery is bundled in the surgical procedure and is not billable. The visit is within the global period of the procedure.

A 67-year-old patient is undergoing anesthesia for a re-operation after a coronary bypass two months ago. Which of the following qualifying circumstances may be reported separately?

None of the above Qualifying circumstances may not be separately reported if the anesthesia code already takes difficulty into consideration.

Patient presents with no menses and positive pregnancy test, but an ultrasound reveals no uterine contents. An embryo has implanted on the left ovary and this is treated with laparoscopic oophorectomy. What ICD-10-CM code is reported for this procedure?

O00.202 For the diagnosis, look in the ICD-10-CM Alphabetic Index for Pregnancy/ovarian directing you to O00.20-a 6th character is required to identify laterality. 2 is assigned for the left ovary. In the Tabular List, there is an instructional note to use an additional code from category O08 to identify any associated complication. No complication is documented. Verify code selection in the Tabular List.

The patient has a left ovarian pregnancy without intrauterine pregnancy. What ICD-10-CM codes are reported?

O00.202, Z3A.00 In the ICD-10-CM Alphabetic Index, look for Pregnancy/ovarian guiding you to code O00.20. In the Tabular List, the 6th character 2 is selected to specify the left ovary. ICD-10-CM guideline I.C.15.b.1 states to not assign codes from category Z34 with Chapter 15 codes. At the beginning of Chapter 15 there is a note to use an additional code from Category Z3A Weeks of gestation, to identify the weeks of gestation for codes O00-O9A. In this case the weeks of gestation is not documented. In the Alphabetic Index look for Pregnancy/weeks of gestation/not specified which directs you to Z3A.00. Verify code selection in the Tabular List.

A patient had a spontaneous complete abortion three days ago. She returns to the ED and is bleeding. After the ED provider examines her, she still has retained products of conception (POC). What ICD-10-CM code is reported for this encounter?

O03.1 ICD-10-CM guideline I.C.15.q.2 indicates when a patient has retained products of conception following a spontaneous abortion, report a code from category O03 Spontaneous abortion even when the patient has been discharged with a diagnosis of complete abortion previously. This is an incomplete abortion because there are retained products of conception. Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous)/complicated by/hemorrhage (delayed) (excessive) directing you to O03.1. Verify code selection 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?

O10.03 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.

A patient presents in her 15 th week of pregnancy with cramping, cervix dilated to 2 cm and bulging amniotic sac. The physician confirms a threatened abortion and decides to manage the patient expectantly with monitoring. What is the ICD-10-CM code?

O20.0, Z3A.15 In the ICD-10-CM Alphabetic Index look for Abortion/threatened (spontaneous) O20.0. Chapter notes indicate to code the weeks of gestation. In the Alphabetic Index look for Pregnancy/weeks of gestation/15 weeks referring you to Z3A.15. Verify codes in the Tabular List.

What ICD-10-CM codes are reported on the maternal record for a delivery of triplets that are all liveborn at 32 weeks of pregnancy?

O30.103, Z37.51, Z3A.32 Look in the ICD-10-CM Alphabetic Index for Pregnancy/triplet O30.10-. In the Tabular List, additional characters are required to indicate the number of placenta and the number of amniotic sacs. Because you do not have that documentation, 0 for unspecified is reported as the 5 th character. The 6 th character 3 is reported to indicate the 3 rd trimester (trimesters are listed at the beginning of Chapter 15 in the ICD-10-CM codebook). The complete code is O30.103. Next, look in the Alphabetic Index for Outcome of Delivery/multiple births/all liveborn/triplets Z37.51. The last code indicates the weeks of gestation. Documentation indicates she delivered at her 32 nd week. Look in the Alphabetic Index for Pregnancy/weeks of gestation/32 weeks Z3A.32. Verify code selection in the Tabular List.

At 39 weeks gestation, a 26 year-old woman is admitted for precipitous labor and vaginally delivers a healthy baby girl. What ICD-10-CM codes are reported on the maternal record?

O62.3, Z37.0, Z3A.39 The labor is precipitous. In the ICD-10-CM Alphabetic Index, look for Delivery (childbirth) (labor)/complicated/by/precipitate labor directing you to O62.3. ICD-10-CM guideline I.C.15.n.1 states that code O80 is reported for a full-term normal delivery of a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is not to be reported with any other pregnancy complication code from chapter 15. In this case, O62.3 is reported for the complication and the normal delivery code (O80) is not reported. The outcome of delivery is also reported. Look in the Alphabetic Index for Outcome of delivery/single/liveborn directing you to Z37.0. Code Z38.00 is only to be used on the newborn's record, not the maternal record. At the beginning of chapter 15, there is a note to use an additional code to report the weeks of gestation. The patient is 39 weeks gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation/39 weeks directing you to Z3A.39. Verify the code selection in the Tabular List.

" A patient was admitted three weeks following a normal vaginal delivery with a postpartum breast abscess. What ICD-10-CM code is reported?

O91.12 In the ICD-10-CM Alphabetic Index look for Abscess/breast (acute) (chronic) (nonpuerperal)/puerperal, postpartum, gestational which guides you to see Mastitis, obstetric, purulent. Look for Mastitis (acute) (diffuse) (nonpuerperal) (subacute)/obstetric/purulent/associated with/puerperium guiding you to code O91.12. In the Tabular List, the description under O91.12 includes puerperal mammary abscess. The puerperium is the period of six weeks or 42 days following childbirth.

A pregnant female, at 21 weeks, is diagnosed with iron-deficiency anemia and is sent to the clinic for a transfusion. Select the diagnosis code(s).

O99.012, D50.9, Z3A.21 Codes O99.012, Z3A.21 are both assigned. ICD-10-CM guideline 1.C.15.b.3 indicates, "in episodes where no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter". Look in the Alphabetic Index for Pregnancy/complicated by/anemia O99.01-.Verification in the Tabular List indicates the code is completed with a 6th character based on trimester. Choose O99.012 for second trimester. There is an instructional note under category code O99 that indicates to use an additional code to identify the specific condition. Code D50.9 is reported for iron deficiency anemia. Use additional code for number of weeks. Look for Pregnancy/weeks of gestation/21 weeks Z3A.21.

What document assists provider offices with the development of Compliance Manuals?

OIG Compliance Program Guidance The OIG has offered compliance program guidance to form the basis of a voluntary compliance program for physician offices. Although this was released in October 2000, it is still considered as active compliance guidance today.

What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?

OIG Work Plan Twice a year, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead. Within the Work Plan, potential problem areas with claims submissions are listed and will be targeted with special scrutiny.

Which anatomic position has the patient lying at an angle instead of lying flat or directly on their side?

Oblique The oblique position is a slanted position where the patient is lying at an angle that is neither prone nor supine.

" Which option is TRUE regarding reporting codes for cytomegaloviral pneumonitis in ICD-10-CM?

One code is used to report both the pneumonia and the cytomegaloviral disease. ICD-10-CM Tabular List does not have the instructional note to code first underlying disease that is seen for codes listed in ICD-10-CM for category code B25. Both conditions are reported with one code in ICD-10-CM.

Under HIPAA, what would be a policy requirement for "minimum necessary"?

Only individuals whose job requires it may have access to protected health information. It is the responsibility of a covered entity to develop and implement policies, best suited to its particular circumstances to meet HIPAA requirements. As a policy requirement, only those individuals whose job requires it may have access to protected health information.

Which of the following physical status modifiers best describes a normal health patient who is undergoing anesthesia?

P1 A normal healthy patient is reported with physical status modifier P1. No additional value is recognized.

An 18 day-old infant develops bradycardia. What ICD-10-CM code is reported?

P29.12 Per ICD-10-CM guideline I.C.16 the perinatal period is defined as before birth through the 28 th day following birth. In the ICD-10-CM Alphabetic Index, look for Bradycardia/neonatal, guiding you to code P29.12. Verify code selection in the Tabular List.

What physical status modifier best describes a patient who has a severe systemic disease that is a constant threat to life?

P4 Review the Anesthesia Guidelines in the CPT® codebook to determine that the Physical Status modifier P4 is the correct choice. Note: Medicare does not recognize physical status modifiers for additional payment.

Assign the code for feeding problems in newborn.

P92.9 In the ICD-10-CM Alphabetic Index, look for Feeding/problem/newborn. You are referred to P92.9. Verify the code in the Tabular List.

Who would NOT be considered a covered entity under HIPAA?

Patients Covered entities in relation to HIPAA include Health Care Providers, Health Plans, and Health Care Clearinghouses. The patient is not considered a covered entity although it is the patient's data that is protected.

According to the OIG, internal monitoring and auditing should be performed by what means?

Periodic audits. A key component of an effective compliance program includes internal monitoring and auditing through the performance of periodic audits. This ongoing evaluation includes not only whether the provider practice's standards and procedures are in fact current and accurate, but also whether the compliance program is working, (for example, whether individuals are properly carrying out their responsibilities and claims are submitted appropriately).

What type of cell is housed by the lymphatic system to help the body's defense system?

Phagocytes Lymphoid organs scattered throughout the body house phagocytic cells and lymphocytes, which are essential to the body's defense system.

What type of provider goes through approximately 26 ½ months of education and is licensed to practice medicine with the oversight of a physician?

Physician Assistant (PA) Physician Assistants are licensed to practice medicine with physician supervision. A PA program takes approximately 26 ½ months to complete.

What three components contribute to the calculation of Relative Value Units?

Physician work, Practice expense, Malpractice insurance Per the Centers for Medicare & Medicaid Services (CMS), Relative value units (RVUs) capture the following three components of patient care: Physician work RVU, Practice Expense RVU, and Malpractice RVUs.

" A virus is identified by observing growth patterns on cultured media. What is this type of identification is called?

Presumptive Presumptive identification identifies microorganisms like viruses by observing growth patterns and other characteristics.

A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive check-up and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam?

Preventive medicine, established patient The mother "takes her 2-year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.

The path of the X-ray beam is known as?

Projection The projection is the path the X-ray beam takes through the body.

What is PHI?

Protected health information Protected health information under the Health Information Portability and Accountability Act (HIPAA) is any information, whether oral or recorded, in any form or medium that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse relating to the past, present or future physical or mental health or condition of an individual, the provision of health services to that individual or payment around those services. Only health information at the individual level is covered; health information of groups is not.

What is exophthalmos?

Protrusion of the eyeballs. Exophthalmos is a protruding eyeball anteriorly out of the orbit (eye socket). When there is an increase in the volume of the tissue behind the eyes, the eyes will appear to bulge out of the face.

The minimum necessary rule is based on sound current practice that protected health information should NOT be used or disclosed when it is not necessary to satisfy a particular purpose or carry out a function. What does this mean?

Providers should develop safeguards to prevent unauthorized access to protected health information. The minimum necessary standard requires covered entities to evaluate their practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information. Only those individuals whose job requires it may have access to PHI. Only the minimum protected information required to do the job should be shared.

Which valves are the semilunar valves?

Pulmonary and Aortic The tricuspid and mitral valves are the atrioventricular valves. The pulmonary and aortic valves are the semilunar valves because of their shape.

A 4 year-old male is brought to the hospital by his mother. Today he is going to have surgery to repair his Cheiloschisis. Assign the correct code for his condition.

Q36.9 Look in the ICD-10-CM Alphabetic Index for Cheiloschisis referring you to see Cleft, lip. Look for Cleft/lip, you are directed to Q36.9. Verification in the Tabular List reports Cleft lip NOS under code Q36.9.

What modifier must always be applied to Medicare claims for tests performed in a site with a CLIA Waived certificate?

QW Medicare requires that the QW modifier be applied for all claims for payment of test performed in a site with a CLIA waived certificate. If the location does not have a certificate, the service should not be billed and it should not be performed. Modifier QW is found in the HCPCS Level II codebook.

An anesthesiologist is medically supervising six cases. What modifier is reported for the CRNA's medically directed service?

QX In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA service under medical direction is coded with modifier QX. Reporting modifier QZ indicates the anesthesia was performed by non-medically directed CRNA and results in overpayment for the anesthesia service provided. The other two modifier selections are only reported for physician services. Modifier QX is assigned because there is no way the CRNA knows medical direction changed to medical supervision.

A CRNA is personally performing a case with medical direction from an anesthesiologist. What modifier is appropriately reported for the CRNA services?

QX In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA with medical direction from an anesthesiologist is appropriately reported with modifier QX. Any time the CRNA is working with medical direction, the anesthesia procedure is reported with QX. The anesthesiologist reports QY if only directing one CRNA and QK if directing 2 to 4 CRNAs.

What modifier is used for medically-directed CRNA services?

QX In the HCPCS Level II codebook look for where the modifiers are listed and refer to modifier QX. QX is the correct modifier for CRNA services when medically directed by a physician.

A CRNA is personally performing a case, without medical direction from an anesthesiologist. Which modifier reports the CRNA services?

QZ A CRNA without medical direction is reported with QZ modifier.

" A test determining the presence or absence of a substance is considered what type of test?

Qualitative A qualitative test determines the presence or absence of the substance.

" If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)?

Quality Quality describes a problem's characteristics. Sharp, stabbing or dull refer to the characteristics of pain.

What is the diagnosis code for an elevated blood pressure reading?

R03.0 Elevated blood pressure is a nonspecific finding with no formal diagnosis of hypertension. This is considered an incidental finding. Hypertension should not be coded unless it is documented specifically by the physician. Look in the ICD-10-CM Alphabetic Index for Elevated, elevation/blood pressure/reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension.

The patient was hit in the nose by the ball playing basketball on the varsity team last evening at the gym and woke up with severe epistaxis. The family physician controlled the nasal hemorrhage with cauterization and afterwards packed the nose with nasal packs. What are the correct diagnosis codes?

R04.0, W21.05XA, Y92.39, Y93.67, Y99.8 The epistaxis is caused from an injury; it is not hereditary. This is found by looking in the ICD-10-CM Alphabetic Index for Epistaxis (multiple) and using the default code R04.0. Four external cause codes are required in this case. The first code indicates how the injury occurred (hit with a ball). Look in the External Cause of Injuries Index for Struck (accidentally) by/ball (hit) (thrown)/basketball W21.05-. Add a placeholder X for the 6th character and an A for the 7th character to indicate initial encounter, W21.05XA. The next code reports where the accident occurred. Look for Place of occurrence/Gymnasium, Y92.39. Next, code the activity he was involved in at the time. Look for Activity/basketball Y93.67. The last external cause code is a status code. Look for Status of external cause/student activity, Y99.8.

A patient visits his primary care physician for complaints of nausea and vomiting. Which option would be appropriate reporting for a diagnosis of nausea and vomiting? Apply the coding concept from ICD-10-CM guideline I.B.9.

R11.2 The ICD-10-CM Official Guidelines, Section I.B.9 give instructions to code both conditions together when a combination code applies. Look in the Index to Diseases and Injuries for Nausea/with vomiting. R11.2 combines the nausea and vomiting conditions.

What is the ICD-10-CM code for heartburn?

R12 Look in the ICD-10-CM Alphabetic Index for Heartburn and you are directed to R12. Verify code selection in the Tabular List

A patient is seen in the nursing home for dizziness and a healed stage II pressure ulcer is also noted. What ICD-10-CM code(s) is/are reported?

R42 Dizziness is found in the ICD-10-CM Alphabetic Index by looking for Dizziness and verified in the Tabular List as R42. The pressure ulcer is stated as healed and would not be coded according to ICD-10-CM guideline I.C.12.a.4, "No code is assigned if the documentation states that the pressure ulcer is completely healed."

A lab test reveals an excessive level of alcohol in the blood. What ICD-10-CM code is reported?

R78.0 Look in the ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/in blood (of substance not normally found in blood)/alcohol (excessive level) which refers to R78.0. Verification in Tabular List confirms R78.0 is for finding of alcohol in blood.

" A surgeon performed a cataract extraction with an intraocular lens implant on the right eye of a Medicare patient. What modifier(s) would be reported?

RT Modifiers RT and LT are used to identify procedures performed on paired organs such eyes, ears, breasts (excluding skin) or on sides of the body.

A covered entity may obtain consent from an individual to use or disclose protected health information to carry out all of the following EXCEPT what?

Research A covered entity may obtain consent of the individual to use or disclose protected health information to carry out treatment, payment or healthcare operations.

How are multiple moderate lacerations of the spleen, initial encounter coded in ICD-10-CM?

S36.032A Look in the ICD-10-CM Alphabetic Index for Laceration/spleen/moderate which directs the coder to S36.031. However, in the Tabular List code S36.032 has inclusion terms that includes multiple moderate lacerations of spleen. Code S36.032 requires a 7 th character of A, D, or S.

What is the code for a traumatic fracture of the fifth metacarpal shaft on the right hand with delayed healing?

S62.326G In ICD-10-CM Alphabetic Index look for Fracture/traumatic/metacarpal/fifth/shaft (displaced) directing you to S62.32-. In the Tabular List subcategory S62.32 requires a 6th character for laterality and a 7th character for type of encounter. S62.326G is the correct code. ICD-10-CM Guidelines I.19.c states "A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced".

What is the ICD-10-CM code for a bruised left knee, initial encounter?

S80.02XA In the Index to Diseases and Injuries, look for the main term Bruise. You are directed to see also Contusion. Look for the main term Contusion, locate the site, subterm, knee and you are referred to S80.0-. Review in Tabular List. There is a fifth character symbol in front of subcategory code S80.0 to indicate the laterality of the contusion. The contusion is on the left knee, reporting so far S80.02. There is a symbol for 7th, X, extension character, indicating you need to report two more characters to complete this code. Because you only have so far five characters, S80.02, you need to report an "X" as a dummy placeholder for your sixth character and then an "A" to indicate initial encounter for your seventh character. There is an instructional note under category code S80 that indicates which letters can only be used as the 7th character. Correct code choice is S80.02XA.

A 7 year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the puncture wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What ICD-10-CM codes are reported?

S81.852A, Z20.3, Z23, W54.0XXA The child had puncture wounds to her left leg from a dog bite. Look in the ICD-10-CM Alphabetic Index for Bite(s) (animal) (human)/leg (lower) S81.85-. In the Tabular List, 6 th character 2 is reported for the left leg and 7 th character A is applied for the initial encounter. She did not have rabies but was exposed to it because the dog was known to have rabies. This exposure to rabies is reported. Look in the Alphabetic Index for Exposure (to)/rabies directing you to Z20.3. She received a rabies vaccination. Look in the Alphabetic Index for Immunization/encounter for directing you to Z23. Next, the circumstances for the injury are reported. The only thing we know is that it is a dog bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/dog directing you to W54.0-. In the Tabular List the 7 th character A is applied for the initial encounter. Placeholder X is used for the 5 th and 6 th characters to keep the 7 th character in the 7 th position. Verify code selection in the Tabular List.

Which of the following is the correct diagnosis code to report a tibial closed fracture, proximal end, of the left leg, initial encounter?

S82.102A This is a closed fracture. Look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/tibia/proximal end and you are directed to see Fracture, tibia, upper end. Fracture, traumatic/tibia/upper end directs you to code S82.10-. In the Tabular List, 6th character 2 is reported for the left leg and 7th character A is selected for a closed fracture, initial encounter.

What is the ICD-10-CM code for sprained left ankle, initial encounter?

S93.402A Look in the ICD-10-CM Alphabetic Index for Sprain/ankle which directs the coder to S93.40-. In the Tabular List, 6 th character 2 is selected for the left ankle. This code also indicates a 7 th character is required. A is selected for the initial encounter.

What is the term for the divider between the heart chamber walls?

Septum The heart is divided into right and left sides by a septum which is a muscular wall.

When coding multiple burns, which is correct?

Sequence first the code reflecting the highest degree of burn. ICD-10-CM Official Coding Guidelines Section I.C.19.d.1. Sequencing of burn and related condition codes, "Sequence first the code that reflects the highest degree of burn when more than one burn is present."

Applying the coding concept from ICD-10-CM guideline I.C.9.a.5, how do you code hypertensive retinopathy?

Sequencing is based on the reason for the encounter. ICD-10-CM Official Coding Guidelines, Section I.C.9.a.5, state Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15 to identify the hypertension. Sequencing is based on the reason for the encounter.

What do the services in the Reproductive Medicine Procedures section of the Pathology and Laboratory chapter of CPT® report?

Services related to in vitro fertilization These codes describe services related to in vitro fertilization.

Which organ is not considered part of the urinary system?

Spleen The organs making up the urinary system consist of the kidneys, ureters, bladder, and urethra. The spleen is part of the body's lymphatic system.

How is Streptococcal A Meningitis reported in ICD-10-CM?

Streptococcal meningitis is reported first; Streptococcal, group A, as the cause of diseases classified elsewhere is reported second. Look in the ICD-10-CM Alphabetic Index for Meningitis/streptococcal (acute) directing the coder to G00.2. In the Tabular List, G00.2 has a note to use an additional code to further identify the organism. The organism is Streptococcus A. In the Alphabetic Index, look for Streptococcus, streptococcal/group/A, as cause of disease classified elsewhere directing the coder to B95.0. Verify all codes in the Tabular List.

The muscles that help control movement of the body, maintain posture, and help produce heat are of what type?

Striated or skeletal Striated or skeletal muscles are often attached to bones, and help move the body. They are considered voluntary muscles—meaning we have control over their movement.

Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent?

Subjective, Objective, Assessment, Plan

valuation and management services are often provided in a standard format such as SOAP notes. What does the acronym SOAP stand for?

Subjective, Objective, Assessment, Plan S-Subjective, O-Objective, A-Assessment, P-Plan

Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes have three main 7 th character extenders (with the exception of fractures). What does 7 th character D indicate?

Subsequent encounter Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, And Certain Other Consequences of External Causes have a 7 th character requirement for each applicable code. For most codes, there are three main 7 th character values (with the exception of fractures) in this section: A, initial encounter; D, subsequent; and S, sequela.

In the ICD-10-CM Alphabetic Index next to Hypertension, what do the terms in parentheses indicate?

Supplementary words that can be present or absent with the diagnosis hypertension and does not affect the code to which it is assigned. ICD-10-CM guideline I.A.7 states parentheses are used to enclose supplementary words that may be present or absent in the statement of disease or procedure, without affecting the code number to which it assigned.

Based on word parts, what is the definition of a salpingo-oophorectomy?

Surgical removal of an ovary and tube. The root salpingo- means oviduct or tube. The root oophor- means ovary. The suffix -ectomy means excision or surgical removal of. The pairing of salpingo- with oophor- tells you the procedure was performed on the female reproductive organs and not the auditory system

How would compartment syndrome of the lower extremity caused by an auto accident be listed in the ICD-10-CM Alphabetic Index?

Syndrome/compartment/lower extremity Compartment syndrome is listed under Syndrome in ICD-10-CM. Traumatic is considered the default unless specifically stated as nontraumatic. An auto accident would be considered a traumatic injury.

What type of joint is most common in the human body?

Synovial Most joints in the body are synovial joints. All joints in the extremities are synovial joints. Synovial joints allow for smooth motion within the joint.

A 3 year-old is brought to the burn unit after pulling a pot of hot soup off the stove and spilling it on herself. She sustained 18% second degree burns on her legs and 20% third degree burns on her chest and arms. Total body surface area burned is 38%. What ICD-10-CM codes are reported for the burns (do not include external cause codes for the accident)?

T21.31XA, T22.391A, T22.392A, T24.291A, T24.292A, T31.32 ICD-10-CM guideline I.C.19.d.1 states to sequence first the code that reflects the highest degree of burn when more than one burn is present. In this case, the burns on her chest and arms are third degree and are reported first. In the ICD-10-CM Alphabetic Index look for Burn/chest wall/third degree, referring you to subcategory T21.31. Because the question indicates arms and legs (plural) we will code multiple sites of the right and left upper and lower limbs. In the Alphabetic Index look for Burn/upper limb/multiple sites/left/third degree directing you to subcategory T22.392-, and Burn/upper limb/multiple sites/right/third degree directing you to T22.391-. Next look for Burn/lower/limb/multiple sites/left/second degree directing you to subcategory T24.292-. Look for Burn/lower/limb/multiple sites/right/second degree directing you to subcategory T24.291- The Tabular List indicates a 7th character is needed for all of these codes; a placeholder X is required for T21.31. The 7th character A is reported for the initial encounter. Refer to ICD-10-CM guideline I.C.19.d.6 for instructions on assigning a code from category T31 to report the extent of body surface involved. The 4th character represents the total body surface area (TBSA) (all degrees) that was burned. The 5th character represents the percentage of third degree burns to the body. In the scenario, 38% is documented as the TBSA making 3 the appropriate 4th character; 20% is third degree burns, making 2 the 5th character. In the Alphabetic Index look for Burn/extent (percentage of body surface)/30-39 percent/with 20-29 percent third degree burns directing you to code T31.32 The external cause codes would also be reported for the accident. Verify code selection in the Tabular List.

A patient visits the ED for ringing in the ears, nausea, vomiting and drowsiness. During the history taking, the provider learns the patient has been taking 2 aspirins every hour for the last three days. After examination and performing blood tests the provider diagnoses the patient with aspirin poisoning. What ICD-10-CM codes are reported?

T39.011A, H93.13, R11.2, R40.0 Over the counter medication taken in an improper dosage is considered a poisoning. ICD-10-CM guideline I.C.19.e.5.b states "When coding a poisoning or reaction to the improper use of a medication (for example: overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50." This was an accident (taken incorrectly). In the ICD10-CM Table of Drugs and Chemicals, look for Aspirin/Poisoning, Accidental (unintentional) column directing you to T39.011. In the Tabular List this code needs a 7 th character. The seventh character chosen is A. The first code to assign is the poisoning, T39.011A. The codes for the manifestations are assigned next and are found in the ICD-10-CM Alphabetic Index by looking for Tinnitus (ringing in the ear) H93.1-, 5 th character 3 for both ears; Nausea/with vomiting (R11.2); and Drowsiness (R40.0). Verify code selection in the Tabular List.

A patient was prescribed an anti-depressant. She forgot she had taken her pills for the day and took another pill by accident. She is now complaining of dizziness and excessive sweating. Select the diagnosis codes in the correct sequence.

T43.201A, R42, R61 The patient took the correct medication but accidently did not take it as prescribed. This is considered poisoning. The first code to report is the poisoning code for type of medicine, followed by the symptoms. Look in the Table of Drugs and Chemicals for antidepressant. The first code reported is the code from the Poisoning, Accidental (unintentional) column T43.201. Verification in the Tabular List indicates the need for a 7th character choosing A for initial encounter, T43.201A. The manifestation or condition codes are reported next. Look in the Alphabetic Index for Dizziness R42 and Sweating, excessive R61. Verify codes in the Tabular List.

A 70-year-old patient has toxic myelitis due to inhaling vapors of carbon tetrachloride from using a fire extinguisher. The appropriate codes to report are:

T53.0X1A, G92 Toxic myelitis is in the ICD-10-CM Alphabetic Index under Myelitis/toxic, directing you to code G92. Under G92 in the Tabular List, there is an instructional note to code first, if applicable, (T51-T65) to identify toxic agent. In the Table of Drugs and Chemicals, look for Carbon/tetrachloride (vapor) NEC/Poisoning Accidental (unintentional) column guiding you to code T53.0X1-. Verification in the Tabular List indicates to add a 7th character; A is reported for the initial encounter. Code G92 is reported as a secondary code. Verify code selection in the Tabular List.

A patient was treated in the emergency department for a nasal fracture. Bleeding was controlled, a splint applied, and the patient sent home. He returned to the ED several hours later with new bleeding from both nares due to the fracture. The ED provider had to repack the nose and insert new splints to stabilize the fracture. What ICD-10-CM code(s) is/are reported for the second ED visit?

T79.2XXA, S02.2XXA The patient is seen for the second time in the ED for continued care of a nasal fracture. Look in the ICD-10-CM Alphabetic Index for Hemorrhage, hemorrhagic/traumatic/recurring or secondary (following initial hemorrhage at time of injury) which guides you to T79.2-. Next, look for Fracture, traumatic/nasal (bone(s)) which guides you to code S02.2. Per ICD-10-CM guideline I.C.19.a, 7th character A for initial encounter is used for each encounter when the patient is receiving active treatment. Examples are of active treatment are surgical treatment, emergency department encounter, and evaluation and continued treatment by the same or different provider. Because the patient is seen for the second time in the ED for continued care of the fracture, 7th character A is used for each code. Placeholder X is needed for the 5th and 6th characters. Verify code selection in the Tabular List.

What ICD-10-CM codes are reported for postoperative pulmonary edema due to fluid overload from an infusion?

T80.89XA, J81.1, Y63.0 In the ICD-10-CM Alphabetic Index look for Complication/infusion (procedure)/specified type NEC directing you to T80.89. In the Tabular List this subcategory code requires seven characters. T80.89XA is the correct code choice. Next look for Edema/lung directing you to J81.1. Because the edema is due to the fluid overload that is associated with an infusion given during the patient's medical care look in the ICD-10-CM External Cause of Injuries Index for Misadventure(s) to patient(s) during surgical or medical care/excessive amount of blood or other fluid during transfusion or infusion directing you to Y63.0.

Ten days following a surgical below the knee amputation, the patient sees her provider. The provider notes that the amputation stump is not healing and is infected. What ICD-10-CM code(s) is/are reported?

T87.40 In the ICD-10-CM Alphabetic Index look for Complication (s) (from) (of)/amputation stump (surgical) (late) NEC/infection or inflammation/lower limb guiding you to subcategory T87.4-. The Tabular List shows that a 5 th character is needed to complete the code. The documentation does not state which side has the amputation which makes 0 the correct 5 th character. Code S88.119D is not reported because the encounter is not for a patient with a traumatic amputation. Verify code selection in the Tabular List.

This type of connective tissue attaches a muscle to a bone:

Tendon Tendons attach muscles to bone, and ligaments attach bones to other bones.

A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?

The acute tonsillitis is reported first; the chronic tonsillitis is reported second. Coding acute and chronic conditions in ICD-10-CM follows the coding guidelines I.B.8. If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute or (subacute) code first.

What information is needed in order to accurately code hypertension retinopathy in ICD-10-CM?

The affected eye(s). Hypertensive retinopathy for ICD-10-CM needs a 6th character that specifies the laterality of the retinopathy. Look in the ICD-10-CM Alphabetic Index for Retinopathy/hypertensive which directs you to H35.03.

When it is documented that the patient is both using tobacco and has a dependence on tobacco, how is this reported in ICD-10-CM?

The dependence on tobacco is the only code reported based on the hierarchy in the ICD-10-CM guidelines. In ICD-10-CM guideline I.C.5.b.2, there are codes for use, abuse, and dependence. Only one code is assigned to identify the pattern of use. This is based on the following hierarchy, listed in order of priority: dependence, abuse, use. If the documentation shows both use and dependence, only dependence is reported.

Which statement is TRUE for reporting burn codes?

The highest degree of burn is reported as the primary code. ICD-10-CM guideline I.C.19.d.1 instructs you to sequence first the code that reflects the highest degree of burn when more than one burn is present. Sunburns are not classified under the traumatic burn codes (T20-T25); they have their own set of codes under category code L55. First degree burns are superficial burns through only the epidermis.

To code for the operating microscope, what verbiage are you looking for in the medical record?

The operating microscope was sterilely draped and brought into the surgical field. A loupe is a single vision magnifying glass most often identified with jewelers or watchmakers. An operating microscope is a binocular microscope used to see and repair small intricate parts of the body, such as nerves and blood vessels. It is not an instrument that can be sterilized so it must be sterilely draped for use in the operating room

The term pneumomediastinum describes what condition?

The presence of air in the mediastinum

What is the sequencing order when coding a sequela (late effect)?

The residual condition is coded first, and the code(s) for the cause of the late effect are coded as secondary. Per ICD -10-CM guideline 1.B.10 coding of sequela (late effects) generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first and the late effect code is sequenced second. Exceptions to this guideline are those instances where the code for the late effect is followed by a manifestation code in the Tabular List and title or the late effect code has been expanded to include the manifestation.

Most of the codes in ICD-10-CM Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue have site and laterality designations. According to ICD-10-CM guidelines what is considered the site?

The site may be the bone, joint or muscle involved. According to ICD-10-CM guideline I.C.13.a., the site may be the bone, joint or muscle involved.

What will the scope of a compliance program depend on?

The size and resources of the provider's practice. The scope of a compliance program will depend on the size and resources of the provider practice.

" What occurs in myringotomy?

The tympanic membrane is incised. Myring/a is a root word identifying the tympanic membrane and -otomy is a suffix indicating an incision.

How many layers of tissue does an artery have?

Three An artery has three layers: an outer layer of tissue, a muscular middle and an inner layer of epithelial cells.

Which of the following is a BENEFIT of electronic transactions?

Timely submission of claims Electronic claims benefit the provider office by allowing timely submissions to the insurance carrier and proof of transmission of the claims.

If a diabetic patient uses insulin, and the type of diabetes is not documented, what type of diabetes would be coded according to ICD-10-CM guidelines?

Type 2 Some patients with type 2 diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do require insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the diabetes is reported as type 2. Refer to ICD-10-CM guidelines I.C.4.a.3.

Which statement describes a medically necessary service?

Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition. Medical necessity is using the least radical services/procedure that allows for effective treatment of the patient's complaint or condition.

Vulvar cancer in situ can also be documented as:

VIN III 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.

When do you code acute respiratory failure as a secondary diagnosis?

When it occurs after admission. According to ICD-10-CM guideline I.C.10.b.2, respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

What is not a region of the spinal cord nerve segments?

Vertebra Vertebra is not a region of the spinal nerve segments because it is the bony segment surrrounding the spinal cord. The lumbar region has five segments forming five pairs of lumbar nerves. The cervical region has seven segments forming eight pairs of cervical nerves. The coccygeal region has three segments forming one pair of coccygeal nerves.

Name an example of when a problem caused by diabetes is NOT sequenced after the code for diabetes. Refer to ICD-10-CM guideline I.C.4.a.5.a.

When a patient's insulin pump malfunctions. The ICD-10-CM Official Coding Guidelines, Section I.C.4.a.5.a states to use a code from category T85.6 as the primary diagnosis for an underdose of insulin, due to insulin pump malfunction. The second code would be T38.3x6-, for the underdosing of insulin, followed by the appropriate diabetes mellitus code based on documentation.

In which option below is it appropriate to append HCPCS Level II modifiers to CPT® procedure codes?

When specificity is required for eyelids, fingers, toes, and coronary arteries HCPCS Level II Modifiers are required to add specificity to CPT® procedure codes performed on eyelids, fingers, toes, and coronary arteries.

ICD-10-CM guideline I.C.6.b.1.a., when should a code from category G89 be reported as a first-listed diagnosis?

When the pain control or pain management is the purpose of the encounter According to ICD-10-CM Official Coding Guidelines, Section I.C.6.a.1.(a), when pain control or pain management is the reason for the admission/encounter, a diagnosis from G89 can be reported as the primary diagnosis.

What information is required to accurately code osteoarthritis in ICD-10-CM?

Whether the osteoarthritis is primary, secondary, post-traumatic, the site and laterality. To accurately code osteoarthritis in ICD-10-CM, the documentation needs to include whether the arthritis is primary, secondary, post-traumatic, the site and laterality (right/left).

How does the lymphatic system work to ensure lymph fluid travels one way to the heart?

With a system of one-way valves The lymphatic system operates without a pump by using a series of valves to ensure the fluid travels in one direction to the heart.

An indirect endoscopic procedure of the larynx means the larynx is viewed:

With mirrors Indirect endoscope of the larynx is performed by viewing the larynx with the use of mirrors. A direct laryngoscopy is the use of an endoscope to look directly at the larynx.

" 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?

Yes, because the doctor did the work, even though the outcome was unsuccessful. Report this procedure with code 59412 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.

Mr. Davis has his yearly preventive medicine exam. The physician orders a chest X-ray as part of the preventive exam. What diagnosis is reported for the chest X-ray?

Z00.00 For encounters for routine radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z00.00. Because there were no signs or symptoms for the chest X-ray, and it was routinely performed as part of a preventive medicine exam, ICD-10-CM Z00.00 is reported. In the ICD-10-CM Alphabetic Index, look for Examination/annual (adult) or Examination/radiological (as part of a general medical examination) Z00.00. In the Tabular List, the note under subcategory code Z00.0 indicates the code is for an, "Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations."

What ICD-10-CM code is reported for a routine chest X-ray?

Z00.00 Look in the ICD-10-CM Alphabetic Index for Encounter/X-ray of chest (as part of general medical examination) which refers you to Z00.00. There is no mention of abnormal findings making Z00.00 the correct code choice. Verify code selection in the Tabular List.

A patient visits her family provider for her annual wellness exam. The provider notices a suspicious skin lesion on her arm and refers her to a dermatologist. Applying the coding concept from ICD-10-CM guideline IV.P, which ICD-10-CM code(s) is/are reported?

Z00.01, L98.9 ICD-10-CM coding guidelines, section IV.P. requires the coder to report first the general medical exam diagnosis and then the abnormal finding. Look in the ICD-10-CM Alphabetic Index for Examination (for) (following) (general) (of) (routine)/annual (adult) (periodic) (physical)/with abnormal findings Z00.01. In the Tabular List, there is a note to also report the code to identify the abnormal finding. Look in the ICD-10-CM Alphabetic Index for Lesion/Skin L98.9. Verify code selection in the Tabular List.

A 17 year-old female has a bone marrow biopsy for examination as a potential volunteer stem cell donor for her mother who has acute monocytic leukemia (AML). What diagnosis code(s) is/are used for the typing of the stem cell specimens?

Z00.5 Only the donor code is used. The bone marrow specimen is being examined to identify a potential donor. The diagnosis of the potential recipient is not coded. In the ICD-10-CM Alphabetic Index look for Donor/potential/examination of you are directed to Z00.5.

A patient is seen in the ED for having unprotected sexual intercourse a few months prior. She recently found out that the individual she was with has HIV. She is only being tested for HIV. What ICD-10-CM code(s) is/are reported?

Z11.4 Per ICD-10-CM guideline I.C.1.a.2.h, if a patient is being seen to determine her HIV status use code Z11.4. In the ICD-10-CM Alphabetic Index look for Screening/disease/human immunodeficiency virus (HIV) Z11.4. Verify in the Tabular List.

Patient is in the facility today for a screening colonoscopy. During the procedure, a polyp is found and removed with a hot biopsy technique. How would this be reported?

Z12.11, K63.5 ICD-10-CM guideline I.C.21.c.5 indicates, "A screening code may be a first listed code if the reason for the visit is specifically the screening exam...Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis." For this question, the screening code is reported first. Look in the ICD-10-CM Alphabetic Index for Screening/colonoscopy which directs you to Z12.11. Then, look for Polyp, polypus/colon which directs you to K63.5 as the secondary diagnosis. Verify both code selections in the Tabular List.

The patient's dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and sister both have history of breast cancer. What are the correct diagnosis codes?

Z12.39, R92.2, Z80.3 Code the special screening as a reason for the encounter, along with a code to report the patient's breast density, which provides medical necessity for a more extensive test. Dense breast tissue occurs in many premenopausal women, and can interfere with reading a mammogram and may mask abnormalities in the image. Look in the ICD-10-CM Alphabetic Index for Screening/neoplasm (malignant) (of)/breast Z12.39. For the breast density, look in the Alphabetic Index for Dense/breasts R92.2. This code provides medical necessity of an ultrasound. To report the family history of breast cancer, look in the Alphabetic Index for History/family (of)/malignant neoplasm (of)/breast Z80.3, which may provide medical necessity information for the screening exam in a young patient. Verify all codes in the Tabular List.

Mr. Smith presents to the office for a screening test to detect sickle cell disorder. What ICD-10-CM code(s) is/are reported?

Z13.0 This is considered a screening. Per ICD-10-CM guideline I.C.21.c.5, "Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease." In the ICD-10-CM Alphabetic Index look for Screening (for)/sickle-cell disease or trait, guiding you to code Z13.0. Verify this is the correct code in the Tabular List. The patient does not have a known sickle cell disorder so a code from D57 is not reported; results from the screening test will determine if the patient has sickle cell disorder.

A patient has been exposed to rabies. He has no signs or symptoms of infection. A test is performed to check for rabies in his blood. What code describes the necessity for the test?

Z20.3 The codes in category Z20 are for exposure/contact to a disease without signs or symptoms of infection. Look in the ICD-10-CM Alphabetic Index for Exposure (to)/rabies Z20.3.

A young man is bitten by a dog found to have rabies. Although he shows no symptoms of rabies, testing is done to see if he has the infection. The tests come back negative. What diagnosis code is used to establish the medical necessity for the service?

Z20.3 When there is known exposure without symptoms, use the Z code for exposure to communicable diseases. In the ICD-10-CM Alphabetic Index, look for Exposure (to)/rabies. You are directed to Z20.3. Verify code in the Tabular List.

What ICD-10-CM category is used to report the weeks of gestation of pregnancy?

Z3A 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 male patient is here for his chemotherapy for metastatic carcinoma of the liver secondary to cancer of the right areola. What ICD-10-CM codes are reported?

Z51.11, C78.7, C50.021 ICD-10-CM guideline I.C.2.e.2 states that if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign code Z51.0 Encounter for antineoplastic radiation therapy, or Z51.11 Encounter for antineoplastic chemotherapy, or Z51.12 Encounter for antineoplastic immunotherapy as the first listed or principal diagnosis. In the ICD-10-CM Alphabetic Index look for Encounter (with health service) (for)/chemotherapy for neoplasm guiding you to code Z51.11. Next, look in the Alphabetic Index for Metastasis, metastatic/cancer/from specified site and you are directed to see Neoplasm, malignant, by site. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/liver and select the code from the Malignant Secondary column, guiding you to code C78.7. Next look for Neoplasm, neoplastic/areola and select the code from the Malignant Primary column or Neoplasm, neoplastic/breast/areola and select the code from the Malignant Primary column, guiding you to subcategory code C50.0-. In the Tabular List, the 5 th character is reported for the sex of the patient. In this case the patient is a male resulting in a 5 th character of 2. The 6 th character is for laterality; 1 is for right. The complete code is C50.021 for primary cancer of the right male areola. When assigning breast cancer codes make sure to select for the correct sex of the patient. The secondary cancer is listed first because the chemotherapy is directed to the secondary site per ICD-10-CM guideline I.C.2.b. Verify code selection in the Tabular List.

Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still symptomatic and is diagnosed with ischemic heart disease. What is (are) the correct ICD-10-CM code(s) for this condition?

Z51.89, I25.9 Because it is past four weeks since the myocardial infarction and the patient is still symptomatic, ICD-10-CM guideline, I.C.9.e.1, indicates that the appropriate aftercare code is assigned rather than a code from category I21. Look in the ICD-10-CM Alphabetic Index for Aftercare directing you to Z51.89. Verify code selection in the Tabular List. The instructional note under category Z51 indicates to code also condition requiring care. Look in the Alphabetic Index for Disease/heart/ischemic (chronic or with a stated duration of over 4 weeks) directing you to I25.9. Verify in the Tabular List.

A confirmed HIV positive patient who presents to the clinic for a medication refill for a condition not related to his HIV. What ICD-10-CM codes are reported?

Z76.0, Z21 Per ICD-10-CM guideline I.C.1.a.2.d, Z21 Asymptomatic human immunodeficiency virus (HIV) infection, is to be applied when the patient without any documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive, or similar terminology. In the ICD-10-CM Alphabetic Index look for HIV/positive, seropositive guiding you to code Z21. The code can also be found by looking in the Alphabetic Index for Human/immunodeficiency virus (HIV) disease/asymptomatic status. For medication refill look in the Alphabetic Index for Issue of/repeat prescription (appliance) (glasses) (medicinal substance, medicament, medicine) Z76.0. Because the main reason for the visit is for a medication refill unrelated to his HIV, the HIV code is not sequenced first. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for a personal history of malignant neoplasm of the breast?

Z85.3 Look in ICD-10-CM Alphabetic Index for History/personal/malignant neoplasm (of)/breast which refers you to Z85.3. Verification in the Tabular List confirms Z85.3 is for personal history of malignant neoplasm of breast.

What does "in vivo" mean?

in the living body In vivo means "in the living body" and is used to describe studies to analyze blood components, percutaneously obtained, in the body.

A patient has a fine needle aspiration with the specimen sent to cytopathology for examination. Once the specimen is reviewed, it is found to be inadequate to perform the test. A new specimen must be obtained which is then examined and a diagnosis is confirmed. What modifier is appropriate to indicate that two specimens were examined?

no modifier The first test cannot be billed if there is not a sufficient specimen to perform the examination.

" What modifier is appropriate for a separately billable antenatal service during the global OB package period?

o modifier is needed 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."

When a patient has a condition that is both acute and chronic and there are separate entries for both, how is it reported?

ode both sequencing the acute first According to the ICD-10-CM guideline 1.B.8 if the same condition is described as both acute (subacute) and chronic and separate entries exist in the ICD-10-CM Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) first.

The suffix -ology means

the study of -ology means the study of.

How many lobes make up the right lung?

three