coding CPT/ICD

The National Correct Coding Initiative (NCCI) has resulted in the use of edits in:

Medicare Part B claims processing software in order to ensure that outpatient claims were submitted correctly, Medicare Part B claims processing software was developed and is required (Kuehn 2014, 378).

A patient has a diabetic ulcer of the right foot. How should this patient's record be coded?

E11.621 Type 2 diabetes mellitus with foot ulcer L97.419 Non-pressure chronic ulcer of right heel and midfoot with unspecified severity When assigning codes for diabetes and its associated conditions, the code(s) from the diabetes category must be sequenced before the codes for the associated conditions (HHS 2014, Section I, C, 4., 32).

Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS procedure code for this surgery.

0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach Surgery is the only treatment for diaphramatic hernias. ICD-10-PCS code 0BQR4ZZ, is used for laparoscopic repair of diaphragmatic hernia.

Assign the correct code for an open total cholecystectomy with exploration of common bile duct and removal of common bile duct stone.

0FT40ZZ, Resection gallbladder, open approach and 0FC90ZZ, Removal, common bile duct stone, open The common bile duct exploration is not assigned separately since the calculus was removed. The root operations for these two procedures are "resection" for the total cholecystectomy and "extirpation" for the removal of the common bile duct calculus.

A laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code?

0FT44ZZ Resection of gallbladder, percutaneous endoscopic approach The gallbladder is a specified body part in ICD-10-PCS, therefore, the correct root operation is Resection. Since it is specified as a laparoscopic cholecystectomy, the approach is percutaneous endoscopic (Leon-Chisen 2013, 250, 251).

A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent a percutaneous intradiscal electrothermal annuloplasty (IDET) in the radiology suite. What ICD-10-PCS code should be used?

0S523ZZ, Destruction, lumbar vertebral disc, percutaneous IDET is done with thermal energy (heat) directed into the outer disc wall (annulus) and inner disc contents (nucleus) via a heating coil, decreasing the pressure inside the disc.

Assign the code for dilation and curettage for retained products of conception abortion at 11 weeks' gestation.

10D17ZZ Extraction of products of conception, retained, via natural or artificial opening The procedure code assigned is associated with the diagnosis of missed abortion. The diagnosis of missed abortion denotes that the patient has retained products of conception that in other circumstances may have resulted in a miscarriage (Leon-Chisen 2013, 352).

Removal of two (2) skin tags on chest (0.3 cm and 0.5 cm). What is the correct CPT code(s) assignment?

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions The documentation needed to properly code removal of skin tags includes diagnosis of skin tags and the number of skin tags removed. These details are provided in the scenario given, therefore, the correct code assignment is 11200, Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions (Smith 2015, 61).

A patient underwent an excision of a malignant lesion of the chest that measured 1.0 cm and there was a 0.2 cm margin on both sides. Based on the 2015 CPT codes, which code would be used for the procedure?

1602, Excision malignant lesion of trunk; excised diameter 1.1 cm to 2.0 cm 11602: Excision malignant lesion of trunk; excised diameter 1.1 cm to 2.0 cm. The size of the lesion plus the margins are included in coding the excision. Excised diameter: 1.0 cm + 0.2 cm + 0.2 cm = 1.4 cm (Smith 2015, 60-63).

Assign the code(s) for endoscopic sinusotomy with bilateral anterior ethmoidectomy.

31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) -50 Bilateral procedure code for the anterior ethmoidectomy is assigned and to denote the bilateral procedure, a modifier of -50 is added (CPT Assistant Winter 1993, 23; Jan. 1997, 4; Sept. 1997, 10; Oct. 1997, 5; Dec. 2001, 6; May 2003, 5). The sinusotomy is not coded separately, as it is a diagnostic procedure.

In outpatient surgery, a patient undergoes a direct laryngoscopy with operating microscope. What code should be assigned?

31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope The code 31526 is assigned because the patient had a laryngoscopy with an operating microscope. The use of a microscope and whether or not the laryngoscopy was direct are two key issues that must be considered when assigning the CPT code. Codes 31515-31571 are used to identify a direct laryngoscopy. It is inappropriate to use code 69990, Use of operating microscope, in addition to any laryngoscopy code identified as being done with an operating microscope (AMA 2013, 160; Smith 2015, 94-95).

Assign the code(s) for bronchoscopy with bilateral transbronchial biopsy.

31628 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe 31629 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) 31632 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), each In contrast to question 28, the code description for the transbronchial biopsy includes the specification that the biopsy is in a single lobe. An additional CPT code is needed (as opposed to a modifier) to denote the bilateral aspect of the biopsy. CPT code 31632 is an "add-on" code, which means it is coded in addition to the primary procedure code (AMA 2014, 171-172; CPT Assistant 2005; May 2008, 15; Feb. 2010, 6; April 2010, 5).

Assign the correct CPT code for a 50-year-old female patient admitted to outpatient surgery department for laparoscopic surgical repair of a recurrent, incarcerated incisional hernia with mesh insertion.

49657 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated Codes 49650-49659 describe procedures related to laparoscopic hernia repairs. Note that 49657 was a new code in 2009 to specifically describe laparoscopic surgical repair of recurrent incisional hernia, incarcerated (including mesh insertion) (Smith 2015, 123-125).

Assign the code(s) for diagnostic left and right cardiac catheterization, left and right coronary arteriogram with low osmolar contrast and fluoroscopic guidance.

4A023N8 Measurement of cardiac sampling and pressure, bilateral, percutaneous approach B2111ZZ Fluoroscopy of Multiple Coronary Arteries using Low Osmolar Contrast There is a combination code for a left and right cardiac catheterization (4A023N8). Both the diagnostic cardiac catheterization and the cardiac angiography procedures are assigned (Leon-Chisen 2013, 413-414).

Patient with renal tumors received percutaneous cryotherapy ablation of three tumors on the right kidney in the same operative episode at Memorial Hospital. Assign a CPT code for this procedure.

50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of the bladder. The patient's presenting symptom is hematuria. What is the correct code assignment for this procedure?

52204 Cystourethroscopy with biopsy(s) CPT code 52204 is reported only once, irrespective of how many biopsy specimens are obtained and how the specimens are sent for pathologic examination (CPT Assistant August 2009, 19(8):6). Modifier 22 is not appropriate because it is not approved for hospital outpatient use (AMA 2014, front cover).

Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9 cm, 6.0 cm) are undertaken. The appropriate CPT code(s) would be:

52240 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of large bladder tumor(s) Codes (52234-52240) should only be reported once, regardless of the number of tumors removed. Only one of the three codes may be reported per session. Select the code based on the largest tumor. Code 52240 is used when one or more of the tumors are larger than 5.0 cm (CPT Assistant August 2009, 19(8):6).

Assign the code(s) for bilateral epidural lumbar injection of steroids:

62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)

Assign the code(s) for bilateral epidural lumbar injection of steroids:

62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Modifier -50 would not be used as this modifier pertains to paired organs only (CPT Assistant Feb. 2000, 4; Nov. 2008, 11; Oct. 2009, 12).

The patient was monitored under general anesthesia for keratoplasty including excision of diseased cornea. A controlled depth-setting blade was used to cut partially into the recipient's cornea in a manner to allow the lamellar graft to fit. Which CPT code should be assigned?

65710 Keratoplasty (corneal transplant); anterior lamellar Codes 65710-65757 are used to describe keratoplasty or corneal transplants. This case does not mention penetrating but anterior lamellar keratoplasty. Therefore, the correct code assignment is 65710, Keratoplasty (corneal transplant), anterior lamellar (CPT Changes Insider's View 2009).

Physician performed a myringotomy under general anesthesia for insertion of bilateral ventilating tubes on a 4-year-old male. This is due to chronic otitis media. What is the correct CPT code assignment and what modifier should be appended (if applicable) to this procedure code?

69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia -50 Bilateral procedure A myringotomy for insertion of ventilating tubes is a tympanostomy, which is described by codes 69433-69436. Code 69436, Tympanostomy (requiring insertion of ventilating tube), general anesthesia describes the procedure performed. In addition, this procedure was performed bilaterally, therefore, modifier -50 is added (Smith 2015, 154).

A virtual screening colonoscopy would be coded as:

74263 Computed tomographic (CT) colonography, screening including image postprocessing CT colonography uses CT scanning to obtain an interior view of the colon (the large intestine) that is otherwise only seen with a more invasive procedure where an endoscope is inserted into the rectum (Kuehn 2014, 159). Note: Code 0066T has been deleted and the coder is instructed to use 74263. Computed tomographic (CT) colonography, screening, including image post-processing (AMA CPT Professional Edition 2014, 403).

In outpatient surgery, a PTCA is completed with insertion of a drug-eluting stent in the left circumflex artery and a non-drug-eluting stent inserted into the left anterior descending artery of this 56-year-old female. Assign the correct CPT code(s) for this procedure.

92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch -LC Left circumflex coronary artery +92921 each additional branch of a major coronary artery (List separately in additional to code for primary procedure.) -LC Left circumflex coronary artery CPT codes 92920-LC and 92921-LD would be reported for transcatheter stenting (Smith 2015, 221-222).

When a Medicare patient receives an injection of IM penicillin G benzathine, 100,000 units only, what is the appropriate code assignment?

96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular The codes are differentiated according to the route of administration. For Medicare cases, a Level II HCPCS code (J series) is reported with the identification of the specific substance or drug; for non-Medicare cases, code 99070 may be reported. In this case, use both 96372 and J0561 (Smith 2015, 231-232). Note: HCPCS codes are used in the multiple choice questions but are not assigned when coding the cases on the CCS exam. Refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book.

Assign the code(s) for chemotherapy for 3 hours' infusion.

96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug +96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) Three codes are needed to capture the initial hour and the two additional hours. Modifier -51 would not be used in this case because modifiers are not used with add-on codes (96415) (CPT Assistant Nov. 2005, 1; Jan. 2007, 3; May 2007, 3; Sept. 2007, 3; Dec. 2007, 15; Feb. 2009, 17).

A patient has nausea and vomiting with abdominal pain due to acute cholecystitis. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. The correct diagnosis code(s) are:

Acute cholecystitis Nausea, vomiting, and abdominal pain are symptoms of acute cholecystitis. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification (HHS 2014, Section I, B, 5, 13).

During an outpatient visit the attending physician did not define a problem at the conclusion of an emergency department (ED) visit. The coder should:

Assign a code for the chief complaint as the reason for the visit Assign a code for the chief complaint as the reason for the visit in the absence of a diagnosis or defined problem, the chief compliant should be coded as the reason for the visit (HHS 2014, Section IV.G., 104).

If a patient is admitted with pneumococcal pneumonia and severe pneumococcal sepsis, the coder should:

Assign a code for the sepsis, pneumonia, and severe sepsis A patient with pneumococcal sepsis and pneumococcal pneumonia also has severe sepsis. Careful review of the ICD-10-CM Official Guidelines for Coding and Reporting provides information related to the coding and sequencing of sepsis, severe sepsis, and localized infection, such as pneumonia (HHS 2014, Section I.C.1.d.4., 22).

If a patient has undergone an outpatient echocardiogram and the cardiologist concludes in the report that the patient has mitral regurgitation the coder should:

Assign a diagnostic code for mitral regurgitation Assign a diagnostic code for mitral regurgitation. If the diagnostic test has been interpreted by a physician the coder can assign a diagnosis (HHS 2014, Section IV.K., 104-105).

A patient with human immunodeficiency virus (HIV) with methicillin susceptible pneumonia due to staphylococcus aureus was discharged from the acute-care setting. How should this be coded?

B20 Human immunodeficiency virus [HIV] disease J15.211 Pneumonia due to methicillin susceptible Staphylococcus aureus This is a confirmed AIDS case; therefore, the AIDS is sequenced as principal diagnosis, followed by the additional diagnosis code for the MSSA pneumonia (HHS 2014, Section I, C, 1, a, 1-2., 17-18).

Assign the correct code for a total open cholecystectomy with intraoperative cholangiogram. The cholangiogram was done with plain radiography with low osmolar contrast.

BF031ZZ, Intraoperative cholangiogram, Plain Radiography of Gallbladder and Bile Ducts using Low Osmolar Contrast and 0FT40ZZ, Resection, gallbladder, open approach Intraoperative cholangiogram is a significant procedure and should be coded based on the UHDDS definition (Schraffenberger 2013, 53).

Wide excision of 0.65-cm malignant melanoma (margins included) from right forearm. The diagnosis and procedure codes reported are:

C43.61 Malignant melanoma of right upper limb, including shoulder 11601 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm The melanoma is coded to the site of the lesion and the procedure code is determined based on the size of the lesion as well as the margins excised (Leon-Chisen 2013, chapter 29; CPT Assistant Fall 1995, 3; May 1996, 11; Nov. 2002, 5; Feb. 2010, 3).

A patient has squamous cell carcinoma of the knee. What code should be assigned for this diagnosis?

C44.721 Squamous cell carcinoma of skin of unspecified lower limb, including hip The ICD-10-CM Neoplasm table directs the coder to neoplasm, skin, knee, and the correct answer is C44.721 (HHS 2014, Section I.C.2., 25-26).

An inpatient is discharged with a diagnosis of "either irritable bowel or pancreatitis." Which condition would be the principal diagnosis?

Code both and sequence according to the circumstances of the admission In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first (HHS 2015, Section II.D., 98).

A Pap smear cannot be interpreted because the sample was inadequate. What type of code should be assigned?

Code for unsatisfactory cytology smear There is a specific code that should be assigned—R87.615 (Schraffenberger 2013, 366).

Which of the following is not part of a facility coding compliance plan?

Coding audits performed by payers Reviewing the results of payers' audits is valuable, but payers are an external entity. As far as a facility coding compliance plan, incorporating internal and external auditing into the coding compliance plan has proven to be the best strategy. Internal auditing enables managers to see firsthand where their units' strengths and weaknesses lie. External auditing provides an unbiased view of a department's performance. Together, internal and external audits help coding managers build effective education plans for their units (Casto and Forrestal 2013, 44).

According to the UHDDS, section III, the definition of other diagnoses is all conditions that:

Coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. The UHDDS item 11-b defines other diagnoses as "all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received or the length of stay" (HHS 2014, Section III, 100-101).

Contradictory documentation may be remedied proactively by using:

Communication tools Tools have been developed to facilitate communication to resolve differences between handwritten and dictated reports or other instances of disparate communication. Sometimes documentation in the health record or on the charge ticket needs to be corrected or verified. Many offices develop a form as a common communication tool for use between a coder and a physician. This form can be as simple or complex as the office sees fit (Kuehn 2014, 364).

A patient is admitted to the hospital with shortness of breath and congestive heart failure and subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. The correct sequencing of the diagnoses in this case would be:

Congestive heart failure and respiratory failure 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 (HHS 2014, Section I.C.10.b.2., 46).

If a diagnosis of rule-out pneumonia with cough and malaise is specified in an emergency department visit, the coder should assign a code for:

Cough and malaise Rule-out conditions are not coded in the outpatient setting and the condition qualified in that statement should not be coded as if it existed, rather the preceding signs and symptoms should be coded (HHS 2014, Section IV.D., 103).

Which of the following is not a function of the outpatient code editor (OCE)?

Determining payment-related conditions that require direct reference to ICD-10-CM codes The outpatient code editor (OCE) performs four basic functions: editing the data on the claim for accuracy, specifying the action the fiscal intermediary should take when specific edits occur, assigning APCs to the claim (for hospital outpatient services), and determining payment-related conditions that require direct reference to HCPCS codes or modifiers. Choice "d" is not one of these functions (Smith 2015, 266).

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and the:

Diameter of the lesion as well as the margins excised as described in the operative report

In 2000, the Centers for Medicare and Medicaid Services (CMS) issued the final rule on the outpatient prospective payment system (OPPS). This program:

Divided outpatient services into fixed-payment groups This final rule established APCs by dividing outpatient services into fixed-payment groups (Smith 2015, 256-257).

A patient was admitted with end stage renal disease (ESRD) following kidney transplant. The patient also had angina and chronic obstructive pulmonary disease. The diagnoses would be sequenced as:

End-stage renal disease; status post kidney transplant; chronic obstructive pulmonary disease; angina Patients who have undergone kidney transplant may still have some form of CKD, because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication (HHS 2014, Section I, C, 14, a, 2, 51-52).

According to CPT guidelines, a colonoscopy includes:

Examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum A colonoscopy is the examination of the entire colon, from the rectum to the cecum, that may include the terminal ileum (AMA CPT Professional Edition 2014, 275).

A 55-year-old male was transferred to a nursing home for continuing care because of ventilator dependence following complications of cardiac bypass surgery. He was readmitted three weeks later due to ventilator associated pneumonia (VAP) due to pseudomonas aeruginosa. How should this be coded?

J95.851, B96.5 in this case, there is documentation of the ventilator associated pneumonia (VAP) assigned to code J95.851. An additional code to identify the organism should also be assigned. No additional codes to identify the type of pneumonia are assigned (HHS 2014, Section I.C.10.d.1., 47-48).

A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct?

H25.041 Posterior subcapsular polar age-related cataract, right eye E11.9 Type 2 diabetes mellitus without complications I10 Essential hypertension N17.9 Acute kidney failure, unspecified The patient has posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus (with no designated causal relationship to the cataracts), hypertension, acute renal failure. The hypertension is not related to the renal failure as it is acute and not chronic. Because of this, a combination code for hypertension and chronic renal failure is not coded (HHS 2014, Section I.B.9, 14).

Gastrointestinal bleeding manifests as:

Hematemesis which indicates acute upper gastrointestinal hemorrhage Gastrointestinal bleeding manifests itself in several ways. These are hematemesis, melena, occult bleeding, hematochezia (Leon-Chisen 2013, 244).

female patient with hematochezia presents to the hospital outpatient surgery department for a colonoscopy but the procedure was not performed due to elevated blood pressure. What is the first-listed diagnosis for this encounter?

Hematochezia When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter) even if the surgery is not performed due to a contraindication (HHS 2014, Section IV, A, 1., 103).

A patient takes Coumadin as prescribed, and correctly administered. However, the patient develops hematuria secondary to the Coumadin use. The correct coding assignment for this case would be:

Hematuria, adverse reaction to Coumadin An adverse reaction can occur when a drug was correctly prescribed and administered. In the case of an adverse reaction, the manifestation is coded first (Hematuria) followed by an T code for the medication (Coumadin) (HHS 2014, Section I.C.19.e.5.a. 71-72).

Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension.

I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified Heart conditions are assigned a combination code when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those patients with heart failure (HHS 2014, Section I, C, 9, a,1., 41).

A 77-year-old patient has hypertensive heart disease with congestive heart failure and stage 5 renal disease. What codes would be assigned?

I13.2, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease Code both the hypertensive heart disease and stage 5 kidney disease as well as a code for the congestive heart failure and the chronic kidney disease, stage 5 (HHS 2014, Section I.C.9.a.3, 41-42; HHS 2014, Section I.C.14.a.1, 51).

A patient is admitted with acute respiratory failure, hypertension, and congestive heart failure. The patient was intubated upon admission to the hospital. What are the correct diagnosis codes and sequencing?

J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia I10 Essential hypertension I50.9 Heart failure, unspecified The patient was admitted and treated for the respiratory failure. The other conditions present are also coded (Leon-Chisen 2013, 233-234; HHS 2014, Section I.C.10.b.1, 46).

A patient was admitted to the emergency department with chest pain, and was diagnosed with aborted myocardial infarction with acute myocardial ischemia. There was no prior cardiac surgery. The cardiac enzymes were normal. The appropriate coding of the diagnosis for this case is:

I24.0, Acute coronary thrombosis not resulting in myocardial infarction Patients with acute ischemic heart disease or acute myocardial ischemia does not always indicate an infarction. It is often possible to prevent infarction by means of surgery or the use of thrombolytic agents if the patient is treated promptly. Using the main term, ischemia, then the subterms of myocardium and acute, the alphabetic index reflects that I24.0 is the correct code for an acute myocardial ischemia without myocardial infarction (Leon-Chisen 2013, 390-391).

A patient is admitted for chest pain. The patient was stabilized and discharged. In a subsequent admission, the patient was admitted as an outpatient for a left heart catheterization, coronary arteriography using two catheters and left ventricular angiography. The patient was found to have arteriosclerotic heart disease. The patient has no history of cardiac surgery. The appropriate sequencing of ICD-10-CM and CPT codes for the outpatient catheterization would be:

I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris 93458 with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed Code I25.10 is assigned to show coronary artery disease in a native coronary artery and is used when a patient has coronary artery disease and no history of coronary bypass graft (CABG) surgery (Schraffenberger 2013, 202-203). Code 93458 includes intraprocedural injection(s) for left ventricular/left atrial angiography, imaging supervision, and interpretation when performed (AMA CPT Professional Edition 2014, Cardiac Catheterization Guidelines, 557).

A patient is admitted with hypotension due to dobutamine taken and prescribed correctly. How should this be coded?

I95.2, Hypotension due to drugs T44.5X5A, Adverse effects of dobutamine This is an adverse effect of a drug as the dopamine was prescribed correctly and the patient took it correctly. Hypotension, should be assigned to describe the condition related to the adverse effect. A "T" code should be assigned to indicate that it is an adverse effect of the drug (HHS 2014, Section I, C, 19, e, 5, a. 71-72).

With regard to the implementation of ICD-10-CM, all of the following are correct except:

ICD-10-CM and ICD-10-PCS will be fully implemented beginning October 1, 2016 Full compliance is expected for claims received for encounters and discharges occurring on or after 10/1/2015 (Leon-Chisen 2013, 6).

Inpatient procedures are coded with:

ICD-10-PCS

The use of the outpatient code editor (OCE) is designed to:

Identify incomplete or incorrect claims The code editor software reviews many data elements and compares them to what data specifications are required in order to weed out incomplete or incorrect claims (Smith 2015, 256-257).

A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded in the order of sequence.

Infectious gastroenteritis, chronic obstructive pulmonary disease, angina The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline II.A, 98 for additional information on coding of symptoms, signs, and ill-defined conditions.

A patient is admitted with an acute exacerbation of COPD with stage 5 hypertensive kidney disease. What is the correct diagnostic code assignment?

J44.1 Chronic obstructive pulmonary disease with exacerbation I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease N18.5 Chronic kidney disease, stage 5 Acute exacerbation of COPD is coded as J44.1. The hypertension is present with the chronic renal disease. Because of this, a combination code for hypertension and chronic renal disease is coded. In addition, the stage of the kidney disease is also coded (HHS 2014, Section I.B.9, 14).

Acute peptic ulcer with perforation and hemorrhage and resulting blood loss anemia. What codes should be assigned?

K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation D50.0 Iron deficiency anemia secondary to blood loss (chronic) The patient has an acute peptic ulcer with perforation and hemorrhage. The patient has chronic blood loss anemia due to the hemorrhage. Blood-loss anemia not otherwise specified is coded to D50.0. Combination codes are provided for gastric, gastrojejunal, and duodenal ulcers that indicate whether there is associated bleeding, associated perforation, or both (Leon-Chisen 2013, 193, 244).

What diagnoses and procedures should be reported for recurrent left inguinal hernia with laparoscopic repair?

K40.91 Unilateral inguinal hernia, without mention of obstruction or gangrene, recurrent 49651 Laparoscopy, surgical; repair recurrent inguinal hernia

A 45-year-old female with chronic ulcerative enterocolitis and steroid induced osteoporosis due to long-term steroid therapy. What codes should be assigned?

K51.00 Ulcerative pancolitis without complications M81.8 Other osteoporosis without current pathological fracture T38.0X5A Adverse effects of glucocorticoids and synthetic analogues, initial encounter Z79.52 Long term (current) use of systemic steroids The ulcerative colitis and osteoporosis should be coded as well as the adverse effect and long term use of the steroid (HHS 2014, Section I.C.19.e.5.(a), 71).

What diagnoses and procedures should be reported for colonoscopy with cauterization of diverticular bleeding?

K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding 45382 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma, coagulator) The bleeding is included in the code for diverticulosis and therefore a second code is not warranted (CPT Assistant 4th Quarter 1990, 20-24).

A patient is treated for esophageal varices with hemorrhage due to cirrhosis. The diagnostic codes that would be assigned are:

K74.60 Unspecified cirrhosis of liver I85.11 Secondary esophageal varices without bleeding The patient has cirrhosis of the liver with resulting bleeding esophageal varices. Cirrhosis of liver is sequenced first followed by the code for the bleeding esophageal varices (HHS 2014, Section I.A.13, 10).

Itching due to drug reaction to an antihistamine. What codes should be assigned?

L29.9 Prutitus, unspecified T45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounter When the drug was taken as prescribed, code the reaction plus the appropriate T code to represent the adverse effect (HHS 2014, Section I, C, 19, e,5,a., 71).

During an ambulatory surgery visit for excision of a malignant melanoma of the right forearm, the attending surgeon listed history of benign breast cyst, history of hypertension currently on Tenormin, and a current hammer toe. Which conditions are to be coded?

Malignant melanoma of forearm, hypertension Assign codes for malignant melanoma of forearm, hypertension. Code chronic conditions if they affect the patient's treatment. The hypertension was being treated with a current medication and for this reason the hypertension is coded (HHS 2014, Section IV.A.1 and Section IV.J, 102-104).

The UHDDS definition of principal diagnosis does not apply to the coding of outpatient encounters because:

No after study element is involved as continued evaluation cannot occur The principal diagnosis requires that the condition after study, which occasioned the patient's admission to the hospital, be assigned as the principal diagnosis. In the outpatient setting, no after study element is involved as continued evaluation cannot occur (Leon-Chisen 2013, 38; HHS 2014, Section IV, 102).

A bronchoscopy with biopsy of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure codes?

No modifiers should be reported. Because the lungs are paired organs, it may seem as though modifier -50 would be appropriate. However, a modifier would not be assigned because the bronchus is not a paired organ, and the bronchus is the location of the procedure, not the lungs. Similarly, it might seem as though modifier -LT would be assigned, but again, this would not be assigned as the bronchus is not a paired organ. In order to assign the correct modifier, it is important to note that paired organs include ears, eyes, nostrils, kidneys, lungs, ovaries, and such (CPT Assistant May 2003).

During an inpatient hospitalization, a chest x-ray done to evaluate a chronic cough revealed an asymptomatic compression fracture of a lumbar vertebrae. No further evaluation was undertaken. The coder should:

Not assign a code for this condition Do not assign a code for this condition because this is a frequent condition in the elderly, is asymptomatic, and there is no documentation of treating the condition so it should not be coded (HHS 2014, Section III, B, 101).

A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis?

O48.1 Prolonged pregnancy When an admission involves delivery, the principal diagnosis should identify the main circumstance or complication of the delivery. The code for normal delivery cannot be used because there is a complication of pregnancy because the pregnancy is prolonged (HHS 2014, Section I.C.15.b.4. 54).

Normal twin delivery at 30 weeks. Both babies were delivered vaginally and were liveborn. What conditions should have codes assigned?

O60.14X0 Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified O30.003 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester Z3A.30 30 weeks gestation of pregnancy Z37.2 Twins, both liveborn Codes must reflect the twin gestation as well as preterm labor and delivery. Additionally a code from O30- must be coded with multiple gestations (Leon-Chisen 2013, 323, 327).

A patient had a normal pregnancy and delivery at 39 weeks gestation with loose nuchal cord around neck. Delivery was accompanied by an episiotomy with repair with birth of liveborn male infant. Delivery room record states "no evidence of fetal problem." What diagnosis and procedure codes should be assigned?

O69.81X0 Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified Z3A.39 39 weeks gestation of pregnancy Z37.0 Single live birth 10E0XZZ Delivery of products of conception, external approach 0W8NXZZ Division of female perineum, external approach The physician may word the delivery as "normal" but the coder cannot use O80 unless the patient meets the criteria for using it. The patient has a nuchal cord around the baby's neck which precludes the use of O80 (HHS 2014, Section I.C.15.n,58).

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder would assign:

One CPT code, adding the lengths of the lacerations together When multiple wounds are repaired with the same closure type (for example, simple), lengths of the wounds in the same classification and from all anatomical sites that are grouped together into the same code descriptor should be added together (Smith 2015, 67).

f a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD-10-PCS codes?

Open biopsy and definitive surgery The open biopsy is performed prior to the definitive surgery so that the pathologist can perform a frozen section of the tissue to determine malignancy. Approaches, suturing, and closure are not coded separately. Exploratory surgery is not coded when definitive surgery is performed (Leon-Chisen 2013, 92).

When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases?

Refractory asthma and severe, intractable wheezing Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230).

The root operation of resection applies to which of the following?

Removal of the entire body part and removal of an entire lobe of the liver The root operation, Resection, is defined as cutting out or off, without replacement, all of a body part. Removal of the lobe of the liver is also considered a resection because each lobe of the liver has a separate body part character in ICD-10-PCS (Leon-Chisen 2013, 93).

Coding professionals need to have surgical references in order to discriminate between:

Reportable and nonreportable procedures Surgical procedure names can be similar and it is important to have reference books in which to look up procedures in order to determine reportable and nonreportable procedures (Smith 2015, 36).

Determining medical necessity for outpatient services includes all the following except:

Requiring new HCPCS codes be developed to replace codes in the CPT code book Several tools and references are used to support the reimbursement process including the fee schedule and the current National Correct Coding Initiatives edits. Other valuable resources are Medicare's Carrier Manual, Medicare's National Coverage Determinations Manual, and local coverage determinations (LCDs) (Kuehn 2014, 318-322).

A patient is admitted to the hospital due to a fracture of the right hip and is scheduled for an open reduction with internal fixation. The patient developed cardiac arrhythmia which results in an inability to do the planned surgery. Assign a code for the principal diagnosis.

Right hip fracture The condition after study that occasioned the admission should be sequenced first even if the plan of treatment was not carried out due to unforeseen circumstances (HHS 2014, Section II.F, 98).

A patient is seen for evaluation of a right orbital roof fracture. How should this be coded?

S02.91XA Unspecified fracture of skull, initial encounter for closed fracture Alphabetic Index for fracture, traumatic; orbit, orbital; roof guides the coder to S02.19 (Leon-Chisen 2013, 481-486).

A patient was admitted after a fall down the steps. The patient was unconscious for approximately 45 minutes and was admitted to the emergency department (ED) within 3 hours of the fall. A CT scan was performed within an hour of admission to the ED. A cerebral contusion was diagnosed by the ED physician based on the findings in the CT scan. What conditions should be reported on the Uniform Billing form 04 (UB-04)?

S06.332A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter W10.9XXA Fall (on) (from) unspecified stairs and steps, initial encounter The code for the injury to the brain also includes the time of unconsciousness. The external cause code is provided here as part of the review; however, no external cause codes codes are used on the exam except those for poisonings and adverse effects of drugs (Leon-Chisen 2013, 485-486). (Based on inpatient exam instructions, do not assign External Causes of Morbidity V01-Y99 codes. Also, see the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book.)

A patient was treated in the emergency department with lacerations of the neck and underwent a repair of two (2) wounds of the neck (2.0 cm and 1.4 cm) with layered closure. What are the diagnosis (excluding external cause codes) and procedure codes assigned?

S11.91XA Laceration without foreign body of unspecified part of neck, initial encounter 12042 Repair, intermediate, wounds of neck, hands, feet, and/or external genitalia; 2.6 cm to 7.5 cm In order to determine the correct procedure code, the lengths of the wounds repaired with the same closure are added together (AMA 2014, 75, Surgery/Integumentary Section directions). [Note: Since this is an emergency department visit, CPT codes are assigned, rather than ICD-10-PCS codes.]

A 12-year-old boy was seen in an ambulatory surgical center for pain in his right arm. The x-ray showed fracture of ulna. Patient underwent closed reduction of fracture right proximal ulna. What diagnostic and procedure codes should be assigned?

S52.001A Unspecified fracture of upper end of right ulna, initial encounter for closed fracture 24675 Closed treatment of ulnar fracture, proximal end (e.g., olecranon or coronoid process(es); with manipulation The patient has a fracture of the right proximal ulna and closed reduction is necessary. In the ICD-10-CM codebook, under Fracture, ulna, proximal, the coder is referred to Fracture, ulna, upper end. The term "manipulation" is used to indicate reduction in CPT (AMA 2014, 98). [Note: Since this is an ambulatory surgery center case, CPT codes are assigned, rather than ICD-10-PCS codes.]

Name the types of pacemaker devices that each have a unique ICD-10-PCS code.

Single chamber rate responsive, and dual chamber The three types of pacemakers are single chamber, single chamber rate responsive, and dual chamber. A single chamber uses a single lead; a dual chamber requires two leads, one in the atrium and one in the ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418).

When coding "arthrocentesis," the code assignment is determined by:

Size of the joint The size of the joint is a key determination because arthrocentesis codes are based on whether the joint is small, intermediate, or major (AMA 2014, 101).

A patient was seen for first- and second-degree burns of the upper thigh. How should this be coded?

T24.219A Burn of second degree of unspecified thigh, initial encounter Both burns are at the same body part; therefore, only the highest degree burn should be coded (HHS 2014, Section I.C.19.d.2., 69).

Suicide attempt with overdose of Percocet. How should this be coded?

T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter An intentional drug overdose is coded as poisoning (HHS 2014, Section I, C, 19, e, 5, b, ii, 72).

A 75-year-old female was admitted for acute myocardial infarction and underwent a diagnostic cardiac catheterization. Following the catheterization, the patient developed a thrombophlebitis documented as due to the catheter in the common femoral artery. The thrombophlebitis would be coded as:

T81.718A, Complication of other artery following a procedure, not elsewhere classified, initial encounter Thrombophlebitis occurred in the artery where the catheterization was performed and the cause of the thrombophlebitis is documented as due to the catheterization. Thrombophlebitis resulting from a procedure is listed as T81.72. When the tabular is reviewed, this code relates to a vein. The exercise states that the artery is the location of the thrombophlebitis. Therefore a code from the T81.718 category is used (HHS 2014, Section I, B 16, 16).

A patient is admitted to the hospital for pain due to displacement of pacemaker electrode. The patient also has hypothyroidism due to partial thyroidectomy seven years ago and a breast cyst. The pacemaker electrode was relocated and synthroid was given during hospitalization. The diagnostic codes (excluding External Cause codes) that should be assigned are:

T82.120A Displacement of cardiac electrode, initial encounter E89.0 Postsurgical hypothyroidism Code T82.110A pertains to mechanical complications and would not be used. In this case, there is pain due to the displacement of the electrode. The breast cyst (N60.09) would not be coded because it does not meet the criteria of the UHDDS as a secondary condition; it is an incidental finding (HHS 2014, Section III, 100-101). Review the Alphabetic Index under Absence, thyroid, with hypothyroidism, which directs the coder to code E89.0.

A 65-year-old patient is admitted with pain and loosening of a left total hip prosthesis. The acetabular component has loosened and become painful. The patient was admitted for open removal and replacement of of the acetabular component of the left hip prosthesis. What is the appropriate code(s) for the admission?

T84.031A Mechanical loosening of internal left hip prosthetic joint, initial encounter 0SPB0JZ Removal of synthetic substitute from left hip joint, open approach 0SRE0JZ Replacement of left hip joint, acetabular surface with synthetic substitute, open approach

If a patient is admitted with a substance-related psychosis, what is coded?

The psychosis is coded first and the drug or alcohol dependence is coded second. The designation of the principal diagnosis depends on the circumstances of the admission. In this case the patient has psychosis and this should be sequenced first with the substance coded second (Leon-Chisen 2013, 182).

Mechanical ventilation codes require consideration of which of the following?

The start time of endotracheal tube insertion followed by mechanical ventilation Codes for mechanical ventilation indicate whether the patient was on mechanical ventilation for fewer than 96 hours or more than 96 hours. The start time for calculating the duration begins with the start time of endotracheal tube insertion as the best method, followed by mechanical ventilation or the time that a patient who is on mechanical ventilation is admitted. The time ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240).

In CPT, unlisted codes are reported only if:

There is not a HCPCS Level II code or a current CPT level III code available Before any unlisted code is assigned, the coding professional should review HCPCS Level II (national) codes to confirm that CMS has not developed a specific code for the procedure or service in question. CPT Category III codes, which are developed specifically for reporting new technology, should also be reviewed. CPT guidelines support the use of a Category III code instead of a Category I unlisted code (Smith 2015, 24-25).

An example of breast reconstruction is:

Total reconstruction Both augmentation of breast for improved appearance and reduction of breast size are considered types of reconstruction (Leon-Chisen 2013, 276).

A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct?

Two codes would be used in accordance with 2015 CPT code revisions. The endometrial biopsy (58110) is an add-on code and there are specific directions in the CPT book to use this code in conjunction with the code for the colposcopy (CPT Changes 2006— An Insider's View; CPT Assistant June 2006, 16-17).

When coding benign neoplasm of the skin, the section noted above directs the coder to:

Use category D23 for benign neoplasm of sweat glands Excludes note 1 is defined as never code here (HHS 2014, I.A.12.a, 10). D23- Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands

A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. What diagnostic codes should be used and how should they be sequenced?

Z12.11 Encounter for screening for malignant neoplasm of colon D12.6 Benign neoplasm of colon, unspecified The circumstances of the encounter are for a screening colonoscopy. Because of this the screening, colonoscopy is listed first, followed by a code for the polyps (HHS 2014, Section I.C.21.c.5, 88)

Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9 cm, 6.0 cm) are completed and a skin lesion was also removed from the left thigh. What modifier should be added to the procedure codes?

−59, Distinct procedural service The surgery is done on two distinct body systems with two distinct approaches. This warrants the use of -59 (CPT Assistant Sept. 2001).