CHAPTER 9 AAPC

A 3-year-old girl is playing with a marble and sticks it in her nose. Her mother is unable to dislodge the marble so she takes her to the physician's office. The physician removes the marble with hemostats. What CPT® and ICD-10-CM codes are reported?

30300, T17.1XXA

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:Rationale: 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

This 25-year-old male presents with a deviated nasal septum. The patient undergoes a nasal septum repair and submucous resection. Cartilage from the bony septum was detached and the nasoseptum was realigned and removed in a piecemeal fashion. Thereafter, 4-0 chronic was used to approximate mucous membranes. Next, submucous resection of the turbinates was handled in the usual fashion by removing the anterior third of the bony turbinate and lateral mucosa followed by bipolar cauterization. What CPT® codes should be reported?

30520, 30140-51:Rationale: Septum repair is a septoplasty. In the CPT® Index, Septoplasty directs you to 30520. Under the code, there is a parenthetical statement to use 30140 for submucous resection of the turbinates. Modifier 51 is used to indicate multiple procedures.

A patient underwent bilateral nasal/sinus diagnostic endoscopy. Finding the airway obstructed the physician 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:Rationale: 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.

14-year-old boy presents at the Emergency Department experiencing an uncontrolled epistaxis. Through the nares, the ED physician packs his entire nose via an anterior approach with extensive packing of medicated gauze. In approximately 15 minutes the nosebleed stops. What CPT® and ICD-10-CM codes are reported? a. 30903-50, R04.0 c. 30901, I78.0 b. 30901-50, R04.0 d. 30905, R04.0

30903-50, R04.0:Rationale: Epistaxis is the term for nasal hemorrhage. In the CPT® Index look for Packing/Nasal Hemorrhage which directs you to code range 30901-30906. 30903 represents anterior packing for an uncontrolled or extensive nasal hemorrhage. Modifier 50 indicates this was done in both nares (bilaterally). In the ICD-10-CM Alphabetic Index look for Epistaxis referring you to code R04.0. Verification in the Tabular List confirms code selection.

A 43-year-old female is seen in the emergency room with severe epistaxis. She said this is a common occurrence for her during the cold dry months of winter and this is why she is here for the third time this week. Extensive bilateral posterior cautery and packing is again required to control the hemorrhage. What CPT® code is reported for the procedure? (Note: Do not code the E/M)

30906-50:Rationale: Epistaxis is the term for nasal hemorrhage. In the CPT® Index, look up Packing, Nasal Hemorrhage and you are directed to code range 30901-30906. Code selection is determined by whether the procedure is posterior or anterior. This is posterior and is subsequent making the correct code 30906. Modifier 50 indicates this was done bilaterally.

A patient with a diagnosis of chronic sphenoidal sinusitis undergoes a bilateral sinusotomy. While the physician 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 should be reported?

31051-50, J32.3, J33.8:Rationale: 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 is seen in the endoscopy suite for a diagnostic maxillary sinusotomy. During the sinusotomy, the physician observes some diseased tissue which needs to be removed. The physician decides to perform a maxillary antrostomy with tissue removal. Bleeding is controlled. The patient tolerated the procedure well. What CPT® code(s) should be reported?

31267:Rationale: According to the CPT® guidelines for coding of endoscopies, a surgical sinus endoscopy includes a sinusotomy and diagnostic endoscopy. In the CPT® Index, look up Sinus/Sinuses/ Maxillary/Antrostomy and you are directed to code range 31256-31267. We see code 31267 represents a surgical maxillary antrostomy with maxillary tissue removal.

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:Rationale: 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.

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:Rationale: 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.

The pulmonologist in a multispecialty group refers a patient to the otolaryngologist in the same group, same tax ID, 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

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 physician performs an emergency transtracheal tracheostomy. What CPT® and ICD-10-CM codes are reported?

31603, T17.290A:Rationale: 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. 7th character A, initial encounter, is the correct choice because this is an emergency department encounter.

The surgeon makes an incision in the neck near the cricothyroid membrane for an emergency tracheostomy for a patient who arrives in the emergency room with tracheal crushing injuries suffered in a car accident in which the patient was riding as the passenger.

31605, S17.0XXA, V49.9XXA:Rationale: The correct CPT® code for an emergency cricothyroid tracheostomy is code 31605. Look in the CPT® Index for Tracheostomy/Emergency which directs you to 31603-31605. Look in the ICD-10-CM Alphabetic Index for Crush/trachea referring you to S17.0-. Verification in the Tabular List indicates to complete the code with seven characters. The placeholder X is required for the 5th and 6th characters and a 7th character A for initial encounter are assigned. The documentation tells us this was a motor vehicle accident and the patient was the passenger in the vehicle. Look in the External Cause of Injuries Index for Accident/transport/car occupant refers you to V49.9-. In the Tabular List it indicates seven characters the placeholder X is required for the 5th and 6th characters and a 7th character A for initial encounter are assigned.

A 20-year-old patient is seen for 5 transbronchial lung biopsies of 2 separate lobes. One biopsy is taken in one lobe and 4 biopsies in another lobe. What CPT® code(s) is/are reported?

31628, 31632:Rationale: Transbronchial biopsies are performed via a bronchoscopy. In the CPT® Index look for Bronchoscopy/Biopsy and we are directed to codes 31625-31629, 31632, 31633. Code 31628 represents a transbronchial biopsy of one lobe. A parenthetical statement under this code indicates to use code 31632 for any additional transbronchial biopsies on additional lobes. Code 31632 is reported once even when multiple biopsies are taken in a lobe.

An ICU diabetic patient who has been in a coma for weeks as the result of a head injury becomes conscious and begins to improve. The physician performs a tracheostomy closure and since the scar tissue is minimal, the plastic surgeon is not needed. What CPT® and ICD-10-CM codes are reported for this procedure?

31820, Z43.0, S06.9X9D, E11.9:Rationale: In the CPT® Index look for Tracheostomy/Surgical Closure/without Plastic Repair. This directs you to code 31820. In the ICD-10-CM Alphabetic Index look for Attention (to)/tracheostomy which directs you to Z43.0. It is reported as a primary code because the closure of the tracheostomy is the reason for the procedure performed. Diabetic coma (E11.641) is not reported because the coma resulted from a head injury not diabetes. Coma would not be reported because it is resolved and the patient no longer has it. In the Alphabetic Index look for Injury/head directing you to S09.90-. Verification in the Tabular List has an Excludes 1 note that indicates head injury with LOC is to be coded in the S06.9 series. Choose S06.9X9D for unspecified intracranial injury with LOC of unspecified duration, subsequent encounter. Diabetes found by looking for Diabetes/type 2 which directs the coder to E11.9. Verification in the Tabular List confirms code selection.

55-year-old female smoker presents with cough, hemoptysis, slurred speech, and weight loss. Chest X-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. Under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. What CPT® and ICD-10-CM codes are reported?

32405-RT, 77002-26, C34.11:Rationale: In the CPT® Index look for Biopsy/Lung/Needle. This directs you to code 32405. Code 77002 is the appropriate code for the fluoroscopic guidance as indicated by the parenthetical statement under code 32405 and by reviewing the code descriptor for 77002. Modifier 26 is appended to report the professional component. RT modifier is to indicate the right lung was where the biopsy was performed. We have a diagnosis of small cell carcinoma of the right lung which is code C34.11. In the ICD-10-CM Alphabetic Index look for Carcinoma which states see also Neoplasm, malignant, by site. Look in the Table of Neoplasms for Neoplasm, neoplastic/lung/upper lobe and select from the Malignant Primary column directing you to C34.1-. Verification in the Tabular List requires a 5th character to indicate laterality. Report C34.11 to indicate the right lung. The signs and symptoms are not coded because we do have a definitive diagnosis (ICD-10-CM guideline I.B.4). Brain metastasis is suspected but not confirmed so it would not be reported. The chemotherapy is planned but not performed so it would not be reported either.

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

32445, 32540-51:Rationale: 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.

55-year-old patient has history of lung cancer of the right lower lobe. He is complaining of difficulty breathing and mild chest pain. Patient is scheduled for a diagnostic VATS. Under general anesthesia he was placed in left lateral decubitus position and a thoracoscope was inserted through a port site. The VATS exploration immediately revealed a mass of the left upper lobe. A biopsy was performed and sent to pathology. Results from pathology revealed small cell carcinoma. Decision was made to remove the upper lobe of his left lung by performing an open procedure. The thoracoscope is withdrawn and the surgeon opens the chest cavity and rib spreaders are inserted to separate the ribs to gain access to the lung. The upper lobe of the left lung is identified, isolated and removed. The instruments are removed and the chest incision is closed in layers. What CPT® codes are reported?

32480-58, 32608-51:Rationale: The patient presented for a diagnostic VATS and a biopsy was performed. Look in the CPT® Index for Thoracoscopy/Diagnostic/with Biopsy 32604, 32606, 32607-32609. Code 32608 reports thoracoscopy with diagnostic biopsy of a lung mass. The biopsy was positive for cancer which prompted the surgeon to perform a thoracotomy to remove the upper lobe of the left lung. Look in the CPT® Index for Lung/Excision/Lobe 32480-32482. Code 32480 describes the removal of a single lobe. Report modifier 58 with 32480 to show the lobectomy was performed by a thoracotomy as a staged procedure. Some payers may require modifier 59 on 32480. Check with your payer.

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:Rationale: A segment of the lung is removed. In the CPT® Index look for Removal/Lung/Single Segment. This directs 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 which directs 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 directs you to code F17.210. Verification in the Tabular List confirms code selection.

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 4th and 5th intercostal space on the left side. There is a very bad infection at the insertion site. The physician removes this chest tube and inserts another chest tube between the 5th and 6th 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 Rationale: 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 6th character and A, initial encounter, for the 7th 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 5th 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.)

A patient presents to the emergency department (ED) with a sucking chest wound. The ED physician on duty performs an immediate tube thoracostomy in order to restore normal breathing to the patient before rushing him to surgery for another physician to address other injuries. What CPT® codes is reported by the ED physician?

32551:Rationale: In the CPT® Index look for Thoracostomy/Tube which directs you code 32551. The ED provider would not be performing the surgery for other injuries so we would not bundle the tube insertion into any of those procedures.

A patient with recurrent pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos-free talc was introduced into the pleural space via the catheter. What CPT® and ICD-10-CM codes are reported?

32560, J93.81:Rationale: Chemopleurodesis is represented by codes 32560-32562. In the CPT® Index look for Pleurodesis/Instillation of Agent. Code 32560 is appropriate for the described actions taken to instill the talc used to treat recurrent pneumothorax. Look in the ICD-10-CM Alphabetic Index for Pneumothorax NOS/chronic which directs you to code J93.81. Verification in the Tabular List confirms code selection

This 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?

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

The provider performs a diagnostic thoracoscopy followed by the thoracoscopic excision of a pericardial cyst. What CPT® code(s) is/are reported?

32661 In the CPT® Index look for Thoracoscopy/Surgical/with Excision Pericardial Cyst, Tumor and/or Mass and you are directed to 32661.

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

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

A patient with AML (Acute Myelogenous Leukemia) has just learned his sister is an HLA (Human Leukocyte Antigen) match for him. Stem cells taken from the donor (the patient's sister) will be transplanted into the patient to help with his treatment. What CPT® code is used to report the harvesting of the stem cells from the donor (his sister)?

38205:Rationale: In the CPT® Index look for Stem Cell/Harvesting. This directs you to code range 38205, 38206. Code selection is based on whether it is allogenic (from a donor) or autologous (from the patient). This is allogenic making 38205 the correct code choice.

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:Rationale: In the CPT® Index, look under 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 the 51 modifier is to indicate multiple procedures performed at same session.

A surgeon performed a transthoracic median sternotomy for exploration of the space around the lung sacs and for drainage of fluid, caused by pneumonia. What is/are the appropriate code(s) for this scenario?

39010:Rationale: In the CPT® Index look for Mediastinum/Exploration which directs us to codes 39000-39010, 60505. Code selection is made based on the approach used. In this case, it is a transthoracic approach making 39010 the correct code. Drainage of fluid is already included in the code and is not separately reportable

A patient is seen in the OR for removal of a hepatic adenoma, which has invaded the diaphragm. The resection of the diaphragm portion of the mass was repaired with primary sutures. What CPT® code is reported for the diaphragmatic mass resection

39560: Rationale: In the CPT® Index, look up Resection/Diaphragm, which directs you to code range 39560-39561. Code selection depends on the type of repair. The repair is with primary sutures which is considered a simple repair making 39560 the correct code choice.

A returning two-year-old child is seen in the pediatrician's office with stridor and a "bark" like cough. The pediatrician examines the child quickly and determines the child has stridulous croup. The child is given a nebulizer breathing treatment in the office to improve PO2 levels. Medication used is breathable Epinephrine. What CPT® and ICD-10-CM codes are reported?

94640, J38.5