AAPC Chapter 20: Medicine
A 35-year-old patient plans to travel to a country with a high incidence of yellow fever. The patient receives the yellow fever immunization. Select the appropriate procedure codes for this service.
90717, 90471 Rationale: Code for both the vaccine and the administration. Codes 90717 and 90471 describe the yellow fever vaccine and the immunization administration for 1 vaccine. In the CPT® Index look for Vaccines and Toxoids/Yellow Fever and Administration/Immunization One Vaccine/Toxoid.
A therapist in a residential care facility works with a nonverbal autistic child, age 4. In this session the therapist uses drawing paper and washable markers. The therapist sat with the child and began to draw on a sheet of paper. She gave paper and markers to the child and encouraged the child to draw. The psychotherapy session lasted 30 minutes.
90832, 90785, F84.0 Rationale: Psychotherapy session with was performed lasting 30 minutes. In the CPT® Index look for Psychotherapy/Individual Patient/Family Member refers you to 90832-90834, 90836-90838. Review of the codes identify code 90832 is the correct code to report. Art therapy is frequently used when working with children who are unable to verbalize well or not at all. It may give insight to thought processes through the expressions captured in the artwork. Art therapy is considered individual psychotherapy. In the CPT® Index look up Psychotherapy/Interactive Complexity you are directed to code range 90785. Code selection is based on time and whether a medical evaluation and management was performed. Code 90785 is an add-on code and for this case is reported with 90832 per instructions at the beginning of this section. Time is not a factor with 90785. The child is currently autistic and does not communicate verbally. In the ICD-10-CM Alphabetic Index look for Autism, autistic (childhood) (infantile) which directs you to F84.0. Since an autism spectrum is not defined, the correct diagnosis code is F84.0. Verification in the Tabular List confirms code selection.
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 Rationale: In the CPT® Index look for Electroconvulsive Therapy and you are directed 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.
CASE 2 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?
90875; J45.909
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 Rationale: The psychiatrist has prepared a report about her psychiatric status, history and current progress for 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 patient with long-time stress urinary incontinence undergoes biofeedback training for improvement of urine leakage. Which CPT® code accurately reports the service?
90911 Rationale: Code 90911 describes biofeedback training for the urethral sphincter. In the CPT® Index, look for Biofeedback Training/Anorectal.
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 Rationale: 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.
CASE 3 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?
91035; K21.9
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 Rationale: 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 Rationale: PTCA stands for percutaneous transluminal coronary angioplasty. In the CPT® Index look for PTCA and you are directed to see Percutaneous Transluminal Angioplasty. Under Percutaneous Transluminal Angioplasty/Artery/Coronary you are directed to code range 92920-92921. 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 55 year-old male has had several episodes of tightness in the chest. His provider ordered a PTCA (percutaneous transluminal coronary angioplasty) of the left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel. It was determined a stent would be required to keep the artery open. The stent was inserted during the procedure.
92928-LD, I25.10 Rationale: PTCA is a percutaneous transluminal coronary angioplasty. In the CPT® Index look for Transcatheter/Placement/Intravascular Stents directing you to 92928-92929. This is also found by looking at Stent/Placement/Transcatheter/Intracoronary. In this case, the angioplasty was followed by stent placement in the LD. Only one procedure can be performed in each of the coronary vessels (LC, LD, and RC). The hierarchy beginning with the lowest is angioplasty, stent, atherectomy, atherectomy & stent placement. Only the stent placement (92928) is reported. Modifier LD indicates the left anterior descending coronary artery. In ICD-10-CM Alphabetic Index look for Atherosclerosis/coronary/artery which directs you to I25.10. Verification in the Tabular List confirms code selection.
A patient was brought to the emergency department in cardiac arrest. The physician immediately initiated CPR. What CPT® code is reported for CPR?
92950 Rationale: 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 Rationale: In the CPT® Index look for EKG and you are directed to see Electrocardiography. For Electrocardiography/Evaluation you are directed to 0178T-0180T, 93000, 93010, 93660. 93660 involves a tilt table evaluation. The remaining codes are 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.
CASE 5 Pre-procedure Diagnosis: Aortic insufficiency; hypertension Post-procedure Diagnosis: Borderline Left Ventricular Hypertrophy, Mild Aortic Insufficiency, (Post-procedure diagnosis used for coding.) Left ventricular Ejection Fraction 80% (Indicates severity.) Procedure: 2D with M-mode Echocardiogram (2D echo, M-Mode.) with pulsed continuous wave with spectral display (Spectral Doppler.) and Doppler color flow mapping (Doppler Color Flow.) 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?
93306; I51.7, I35.1
A post-MI (myocardial infarction) patient has been receiving cardiac rehabilitation. At this session the provider evaluates the patient, determines he shows satisfactory progress and may increase his normal daily activities. Continuous EKG is not used at this session. What CPT® code is reported?
93797 Rationale: In the CPT® Index look for Rehabilitation/Cardiac, and you are directed to code range 93797-93798. Code 93797 describes the provider services for cardiac rehabilitation when continuous EKG monitoring is not utilized at the encounter.
CASE 6 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?
93970; I83.11, I83.12, I83.813
CASE 10 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?
93979-26; I71.4
A dialysis patient undergoes duplex scan of his hemodialysis access site to determine the pattern and blood flow in his arteries and veins. Select the appropriate CPT® code for reporting this service.
93990 Rationale: Code 93990 describes a scan of hemodialysis access and includes arterial inflow, body of access and venous outflow. In the CPT® Index, look for Hemodialysis/Duplex Scan of Access.
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 Rationale: In the CPT® Index look for Allergy Tests/Skin Tests/Allergen Extract and you are directed to codes 95004, 95024, 95027. 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.
CASE 4 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?
95808; G47.33
CASE 7 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, EOG, submental and anterior tibialis EMG, respiratory effort, nasal and oral airflow, EKG, continuous pulse oximetry. 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 What are the CPT® and ICD-10-CM codes reported?
95810; G47.30
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 Rationale: In the CPT® Index look for WADA Activation Test and you are directed to code 95958. You can also see Electroencephalography/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 and you are directed 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 which directs you to Z94.4. Verification of the codes in the Tabular List confirms code selections.
CASE 8 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 Procedure: Vagal Nerve Stimulator 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?
95970; G40.909, Z96.89
A qualified genetics counselor is working with a child who has been diagnosed with fragile X syndrome. After extensive research about the condition, she meets with the parents to discuss the features of the disease and the child's prognosis. The session lasted 45 minutes. What CPT® and ICD-10-CM codes are reported?
96040, Q99.2 Rationale: In the CPT® Index look for Medical Genetics which directs you to 96040. The genetics counseling session is reported as face-to-face time per 30 minutes. Report 1 unit for the first 30 minutes. Since the remaining time is 15 minutes, it is not reported separately per the Medical Genetics and Genetic Counseling Services guidelines. Fragile X syndrome is a congenital chromosomal anomaly that may include mental retardation. In the ICD-10-CM Alphabetic Index look for Syndrome/fragile X. The condition is reported with code Q99.2. Verification in the Tabular List confirms code selection.
A 4-year-old has not reached the expected developmental milestones for her age group. She was referred by her pediatrician for extensive developmental testing. The psychologist initiated multiple function studies, using standardized instruments and reported the results to the child's pediatrician. Code the psychologist's service.
96111 Rationale: Code 96111 describes extensive testing for developmental assessment, including interpretation and report. In the CPT® Index, look for Developmental Testing.
A cancer patient will receive chemotherapy by intrathecal delivery. A spinal puncture is necessary to accommodate the catheter. What is the correct code for this service?
96450 Rationale: Code 96450 describes intrathecal delivery of chemotherapy agents. The code includes the spinal puncture. The drugs are separately coded using HCPCS II codes. Spinal catheter placement is included in the technique. In the CPT® Index, look for Spine Chemotherapy/Administration.
CASE 9 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?
96573, J7308; L57.0
A patient who has psoriasis vulgaris on his back has not responded to topical applications. He is treated with laser therapy on a total area of 260 sq. cm.
96921, L40.0 Rationale: In the CPT® Index look for Psoriasis/Treatment, you are directed to code range 96910-96922. 96910-96913 are for photochemotherapy. 96920-96922 are for laser treatment and code selection is based on the size of the area treated. 260 sq. cm is reported with 96921. In the ICD-10-CM Alphabetic Index, look for Psoriasis/vulgaris referring you to L40.0. Verification in the Tabular List confirms code selection.
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 Rationale: Code 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 presents with a complaint of continuing left shoulder pain after falling from her patio onto a wooden step. No fracture was identified at the time of the fall. After assessing the patient, the chiropractor manipulates the shoulder region. What is/are the correct code(s)?
98943 Rationale: Code 98943 describes extraspinal manipulation, one or more regions. In the CPT® Index, look for Manipulation/Chiropractic.
A patient calls her physician to discuss the refill of a current prescription. She speaks with the registered nurse who discusses the patient's current status and advises that the prescription to be called into her pharmacy. The call lasts 12 minutes. What is the correct code for this service?
98967 Rationale: Code 98967 describes a telephone discussion with a nonphysician qualified healthcare professional for 11-20 minutes. The discussion did not lead to an appointment within the next 24 hours or the soonest available appointment and was not related to an E/M service within the previous seven days. In the CPT® Index, look for Telephone/Evaluation and Management/Nonphysician.
A physician agrees to meet a patient at the office on Sunday afternoon to assess a repeat problem. Special equipment in the physician office is needed to evaluate the condition. Normal office hours are Monday-Friday. What is the correct code for this service?
99050 Rationale: Code 99050 describes services provided on holidays & weekends that are outside of normal business hours. In the CPT® Index, look for After Hours Medical Services.
A 5 year-old fell on broken glass and required suturing of a laceration. Due to the age and combative behavior of the patient, the provider utilized moderate sedation while repairing the laceration. The provider gave the child 50 mg of Ketamine IM. A nurse monitored the patient during the procedure which took 30 minutes. What CPT® code is reported for moderate sedation?
99152, 99153 Rationale: Moderate sedation is often used for pediatric patients in situations not normally requiring sedation. In this case, the provider administered sedation with a nurse assisting in monitoring the patient. In the CPT® Index look for Sedation/Moderate/with Independent Observation and you are directed to code range 99151-99153. Code selection is based on age of the patient and the length of time. Code 99152 describes an encounter using moderate sedation, and the physician or other qualified health care professional rendering the diagnostic or therapeutic service also manages the sedation. This code is specific for the age of the patient and up to 15 minutes of time. Add-on 99153 is for each additional 15 minutes of intraservice time.
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 Rationale: 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 6th character 2 indicates the left leg. 7th 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 6th character and A is assigned for initial encounter for the 7th 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 Rationale: 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 symptoms. The diagnosis is dizziness (R42). In the ICD-10-CM Alphabetic Index look for Dizziness. Verification in the Tabular List confirms code selection.
CASE 1 10-Year-old established patient (The patient is established.) presents today for well child check (Patient presents for a preventive exam.) 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. (Urinalysis lab test performed in the office) Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety. Assessment: Well Child Check, ADHD, Wart, Frequent Urination (Preventive exam and problems treated.) Refill Concerta 18mg PO q AM Wart cleansed with alcohol. Histofreeze x 25 seconds (Wart is destroyed.) was performed to destroy the wart. Varicella Vaccine #2 (Vaccination is administered.) administered without any complications. What are the CPT® and ICD-10-CM Codes?
99393-25, 17110, 90471, 90716, 81002; Z00.121, F90.9, B07.9, R35.0, Z23
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 Rationale: 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.
A patient with chronic respiratory failure is visited at home by a certified respiratory therapist to manage his home oxygen therapy. What CPT® and ICD-10-CM codes are reported?
99503, J96.10 Rationale: In the CPT® Index look for Home Services/Respiratory Therapy and you are directed to 99503. In the ICD-10-CM Alphabetic Index, look for Failure, failed/respiration, respiratory/chronic and you are directed to J96.10. Verification in the Tabular List confirms code selection.
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 Rationale: 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.
What ICD-10-CM code(s) is/are reported for a diabetic foot ulcer on the right foot?
E11.621, L97.519 Rationale: ICD-10-CM guideline I.C.4.a.2. instructs you to use the default code E11- for type 2 diabetes when the type is not indicated. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/with/foot ulcer which directs you to E11.621. In the Tabular List there is a note to use an additional code to identify the site of the ulcer (L97.4-, L97.5-). Look in the Alphabetic Index for Ulcer/lower limb/foot specified NEC/right which directs the coder to L97.519. The severity of the ulcer is not documented in this scenario. Verification in the Tabular List confirms E11.621 is for type 2 diabetes mellitus with foot ulcer and L97.519 is for non-pressure chronic ulcer of other part of right foot with unspecified severity.
What ICD-10-CM code is reported for a fear of spiders?
F40.210 Rationale: Look in the ICD-10-CM Alphabetic Index for Fear of which states see Phobia. Phobia, phobic/animal/spiders directs you to F40.210. This can also be found in the Alphabetic Index by looking for Arachnophobia F40.210. Verify code selection in the Tabular List.
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 Rationale: In the ICD-10-CM Alphabetic Index look for Hypertension, hypertensive/cardiovascular/disease (arteriosclerotic) (sclerotic) which states to see Hypertension, heart. Look for Hypertension/heart (disease) (conditions in I51.4-I51.9 due to hypertension) directing 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.
What ICD-10-CM code is reported for an anaphylactic reaction to peanuts, initial encounter?
T78.01XA Rationale: In the ICD-10-CM Alphabetic Index look for Anaphylactic/shock or reaction which states see Shock, anaphylactic. Look for Shock/anaphylactic/due to food (nonpoisonous)/peanuts which directs you to T78.01. In the Tabular List, a 7th character is required. Placeholder X is used for the 6th character. The initial encounter is specified with 7th character A for the initial encounter.
A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid. What HCPCS Level II and ICD-10-CM codes are reported?
V5261, Z46.1, H90.3 Rationale: In the HCPCS Level II Index look for Hearing aid/Binaural/Digital/BTE referring you to V5261. The purpose of the visit is the fitting of the hearing aid. Look in the ICD-10-CM Alphabetic Index for Fitting (and adjustment) (of)/hearing aid directing you to Z46.1. The condition necessitating the hearing aid is bilateral sensory hearing loss. In the Alphabetic Index, look for Deafness/sensorineural/bilateral which directs you to H90.3. Verification in the Tabular List confirms code selection.
What ICD-10-CM code is reported when a flu vaccine is administered?
Z23 Rationale: In the ICD-10-CM Alphabetic Index look for Vaccination (prophylactic)/encounter for Z23. Verification in the Tabular List confirms Z23 is for an encounter for immunization. This code is nonspecific as to the type of vaccination that is given. The type of vaccination given (i.e. influenza, MMR, DPT) will be specified by procedure/HCPCS codes.
