CPC Review

____ is a term standing for enlargement of the heart.

Cardiomegaly

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

National Coverage Determinations Manual

The terms malignant, benign, in situ, and uncertain behavior are all terms used when coding what?

Neoplasms

What does the abbreviation IVF mean?

In vitro fertilization

Who is responsible for enforcing the HIPAA security rule?

The Office for Civil Rights (OCR) enforces the HIPAA Security Rule.

What is the sequencing order when coding a sequela (late effect)?

The residual condition is coded first, and the code(s) for the cause of the late effect are coded as secondary. Rationale: Per ICD -10-CM guideline 1.B.10 coding of sequela (late effects) generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first and the late effect code is sequenced second. Exceptions to this guideline are those instances where the code for the late effect is followed by a manifestation code in the Tabular List and title or the late effect code has been expanded to include the manifestation.

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

Z code

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

ABN (Advanced Beneficiary Notice)

Select the TRUE statement regarding ABNs.

ABNs may not be recognized by non-Medicare payers.

Code 00940 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified has a base value of three (3) units. The patient was admitted under emergency circumstances, qualifying circumstance code 99140, which allows two (2) extra base units. A preanesthesia assessment was performed and signed at 2:00 a.m. Anesthesia start time is reported as 2:21 am, and the surgery began at 2:28 am. The surgery finished at 3:25 am and the patient was turned over to PACU at 3:36 am, which was reported as the ending anesthesia time. Using fifteen-minute time increments and a conversion factor of $100, what is the correct anesthesia charge?

$1,000.00 Rationale: Determining the base value is the first step in calculating anesthesia charges and payment expected. Time reporting is the second step. Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In the scenario above, base units equal three (3) plus two (2) emergency qualifying circumstances units (Base 3 + QC 2 = 5 units). Five (5) time units, in fifteen minute increments, is calculated by taking the anesthesia start time (2:21) and the anesthesia end time (3:36) and determining one hour 15 minutes (75/15 = 5) of total anesthesia time. Ten units (5 + 5 = 10) are then multiplied by the $100 conversion factor (10 X $100 = $1,000.00). Note: Base Unit Values are not separately listed in the CPT®. The American Society of Anesthesiologists (ASA) determines the base units' values for anesthesia codes.

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

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

An 8 month-old has a simple Fontan procedure to repair his tricuspid atresia. During the procedure, the heart-lung machine is used. What are the correct CPT® and ICD-10-CM codes for this anesthesia service?

00561, Q22.4 Rationale: In the CPT® Index look for Anesthesia/Heart which directs you to codes 00560-00567, 00580. Refer to the numeric section to determine that the code 00561 is the correct code for a child less than 1 year of age when a pump oxygenator is used. The parenthetical note under the code states it is not to be used with the qualifying circumstance codes of 99100, 99116 and 99135. In the ICD-10-CM Alphabetic Index look for Atresia/tricuspid valve which refer you to Q22.4. Verify code selection in the Tabular List.

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

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

What is the correct anesthesia CPT® code for surgery performed on the frontal lobe of the brain?

00210 Rationale: In the CPT® Index, look for Anesthesia/Brain. Here you are directed to see codes 00210-00218, 00220-00222. Review the codes in Anesthesia section. Code 00210 represents anesthesia for intracranial (brain) procedures, not otherwise specified.

A 30 year-old patient had anesthesia for an extensive spinal procedure with instrumentation under general anesthesia. The anesthesiologist performed all required steps for medical direction while directing one CRNA. What modifier(s) and CPT® code(s) is/are reported for the anesthesiologist and CRNA services?

00670-QY and 00670-QX Rationale: In the CPT® Index look for Anesthesia/Spinal Instrumentation which directs you to code 00670. Review code in the numeric section. An anesthesiologist who is medically directing care reports their service separately from the CRNA, depending on the number of concurrent cases and the appropriate modifiers for distinction. Because there was only one case, the appropriate modifiers to report are QY for the physician and QX for the CRNA. A QZ modifier would indicate the case was performed by a non-medically directed CRNA. Refer to your HCPCS Level II codebook to verify these anesthesia modifiers.

In the hospital setting a patient undergoes transcatheter placement of an extracranial vertebral artery stent in the right vertebral artery. Which CPT® code is reported by the physician providing only the radiologic supervision and interpretation?

0075T-26 Rationale: This is a Category III code. Look in the CPT® Index for Artery/Stent Placement/Extracranial Vertebral. Code 0075T is the correct code. When you check 0075T you will see supervision and interpretation is included; therefore, modifier 26 reports the professional service.

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

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

What is the anesthesia code for a shoulder arthroscopy which became an open procedure on the shoulder joint?

01630 Rationale: In the CPT® Index, look for Anesthesia/Arthroscopic Procedures/Shoulder which directs you to code range 01622-01638. Review the codes in the numeric section to determine 01630 is the appropriate code selection because the description of the code includes open or surgical arthroscopic procedures.

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

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

The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a fragment of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, and we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it; the mass was removed. There was a granuloma capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal. He wanted me to and so I went ahead and removed the capsule with the stain and removed all the black stain. I consider this to be a complicated procedure. Hemostasis was achieved with light pressure. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene.

10121, L92.3, Z18.10, Z85.828 Rationale: In CPT® Index look for Integumentary System/Removal/Foreign Body and you are directed to codes 10120 and 10121. The surgeon indicated in the note he considered this incision and removal of foreign body to be complicated leading us to code 10121. The documentation indicates the capsule is a granuloma. In the ICD-10-CM Alphabetic Index look for Granuloma/skin/from residual foreign body referring you to L92.3. There is an instructional note given for code L92.3 to use an additional code to identify the type of retained foreign body (Z18.). Report code Z18.10. This patient has a history of basal cell carcinoma of the nose. Look in the Alphabetic Index for History/personal/malignant neoplasm/skin NEC Z85.828. Verify code selections in the Tabular List. The patient did not have a puncture wound with a foreign body; therefore, code S01.84XA is not reported.

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

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

The patient is here to see us about some skin tags on her neck and both underarms. She has had these lesions for some time; they are irritated by her clothing, itch, and at times have a burning sensation. We discussed treatment options along with risks. Informed consent was obtained and we proceeded. We removed 16 skin tags from the right axilla, 16 skin tags from the left axilla, 10 from the right side of the neck and 17 from the left side of the neck. What CPT® and ICD-10-CM codes are reported?

11200, 11201 x 5, L91.8 Rationale: In the CPT® Index look for Skin/Tags/Removal and you are directed to codes 11200, 11201. Code selection is based on the number of skin tags removed. A total of 59 skin tags were removed. Code 11200 is reported for the first 15. Add-on code 11201 is reported for each remaining 10 (or part thereof) removed. The words "part thereof" in means you do not need to have a complete total of 10 lesions to report the add-on code. The add-on code can be reported if the additional lesions are 10 and under; it is not appropriate to append modifier 51 to an add-on code. Codes 11200, 11201 x 5 are correct. In the ICD-10-CM Alphabetic Index look for Tag/skin and you are directed to L91.8. Verify code selection in the Tabular List.

Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic, prepped and draped in a sterile fashion. With the use of a scalpel the 0.3 cm lesion that included the margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this was a seborrheic keratosis. What CPT® and ICD-10-CM codes are reported?

11400, L82.1 Rationale: Seborrheic keratosis is a benign lesion. In the CPT® Index look for Skin/Excision/Lesion/Benign and you are directed to code range 11400-11446. Code selection is based on location and size. The right axilla is on the trunk underneath the arm narrowing our code selection to 11400-11406. Code 11400 is selected for the 0.3 cm lesion with margins. The simple closure is included in the excision according to the category guidelines. In the ICD-10-CM Alphabetic Index look for Keratosis/seborrheic and you are directed to L82.1. Verify in the Tabular List.

What is the correct CPT® code for the excision of a benign lesion on the scalp with an excised diameter of 2.3 cm (this includes margins)?

11423 Rationale: In the CPT® Index, look for Excision/Skin/Lesion, Benign or Skin/Excision/Lesion/Benign. You are directed to 11400-11471. Turn to these codes in the numeric section and, once reviewed, code 11423 is reported. This represents the excision of a benign lesion on the scalp, neck, hand feet or genitalia; 2.1 to 3.0 cm in diameter excised including margins.

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

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

Joe has a terrible problem with ingrown toenails. He goes to the podiatrist to have a nail permanently removed along with the nail matrix. What CPT® code is reported?

11750 Rationale: In the CPT® Index look for Removal/Nails and you are directed to two code ranges 11730-11732, 11750. Documentation states the entire nail and root (nail matrix) are removed. In the numeric section of the CPT®, removal of the nail and nail matrix is code 11750. Code 11730 reports nail removal only. There is no mention of removing a wedge of restrictive skin in the nail fold to relieve the ingrown toenail.

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

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

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

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

Patient presents to the emergency department with multiple lacerations from a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported?

13132, 12035-59, 12004-59 Rationale: Four lacerations are repaired. In the CPT® Index look for Repair/Skin/Wound for the codes for Complex, Intermediate, and Simple. The lacerations are separated first by classification (simple, intermediate, complex), then by location. There is one simple closure, which is 7.6 for the right forearm which is reported with CPT® code 12004. Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm and reported with CPT® code 12035. The last repair is a complex repair of the neck, 4.7 cm which is reported with CPT® code 13132. Subheading guidelines indicate to list the more complicated repair as the primary and the less complicated as secondary procedures using modifier 59. Report the complex repair first, followed by the intermediate and then the simple repair. Both the intermediate and the simple closures are reported with modifier 59.

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

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

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

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

While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. What CPT® code is reported?

15574 Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Category guidelines for Flaps indicate the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer.

The patient is seen for removal of fatty tissue of the posterior iliac crest, abdomen, and the medial and lateral thighs. Suction-assisted lipectomy was undertaken in the left posterior iliac crest area and was continued on the right and the lateral trochanteric and posterior aspect of the medial thighs. The medial right and left thighs were suctioned followed by the abdomen. The total amount infused was 2300 cc and the total amount removed was 2400 cc. The incisions were closed and a compression garment was applied. What CPT® codes are reported?

15877, 15879-50-51 Rationale: In the CPT® Index look for Lipectomy/Suction Assisted or Liposuction. You are referred to codes 15876-15879. Review the codes to choose the appropriate service. There were three body areas of liposuction performed. Code 15877 covers the liposuction of the posterior iliac crest and abdomen. Code 15879 covers liposuction of the thighs. Modifier 50 is appended to code 15879 to indicate the liposuction of the left and right thighs. Modifier 51 is appended to indicate more than one procedure was performed in the same surgical session.

A 50 year-old female has telangiectasias of the face on both cheeks. She is very bothered by this and presents to have them destroyed via laser. The physician lasers one cutaneous vascular lesion on each cheek; each lesion measuring 2 sq cm What CPT® code(s) is/are reported?

17106 Rationale: Telangiectasias are small dilated blood vessels, commonly referred to as spider veins, or acne rosacea, which are benign lesions. In the CPT® Index look for Destruction/Lesion/Vascular, Cutaneous and you are referred to codes 17106 - 17108. Code selection is based on size. Each lesion is 2 sq cm making the total size 4 sq cm. The correct code is 17106 for destruction of less than 10 sq cm.

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

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

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

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

Operative Report PREOPERATIVE DIAGNOSIS: Congenital left breast deformity. POSTOPERATIVE DIAGNOSIS: Congenital left breast deformity. PROCEDURE PERFORMED: Placement of left breast implant using mentor catalog #, lot #, serial #, 425 cc smooth round moderate profile implant filled with 475 cc of normal saline for breast reconstruction. INDICATIONS FOR SURGERY: The patient is a 34 year-old female who approximately 15 to 16 years ago had a left breast implant placed for breast reconstruction for her congenital deformity of the left breast. This implant ruptured and in late September 20XX I had performed a capsulectomy and exchanged her ruptured implant for a new implant. About a week after surgery, the patient developed an infection. Due to the infection, her implant had to be removed. The patient's infection has completely resolved and she is now ready to have her implant replaced. In the preoperative holding area, I marked her for the ideal position of this implant and performed a breast exam not showing a mass in either breast and no mass in axillae and we proceeded. We discussed with the patient that even though her original implant was placed in subglandular position I felt it would be beneficial to place the implant behind her pectoralis major muscle in submuscular position today. The patient agreed and we proceeded. DESCRIPTION OF PROCEDURE: The patient was given 1 g of IV Vancomycin. The patient was taken to the operating room; general anesthesia was induced and bilateral pneumatic compression stockings were worn throughout the procedure. A lower body Bair Hugger was placed. Both arms were secured to padded arm boards using Kerlix rolls. The neck, chest, axillae, and upper abdomen were prepped and draped in sterile fashion. I began by incising the central portion of her previous scar. I dissected down to the pectoralis major muscle. A submuscular plane was developed through a lateral approach and the inferior and medial origin of the muscle was partially divided using the Bovie cautery. Meticulous hemostasis was achieved using Bovie cautery. There were no signs of infection nor were there any pockets of seroma fluid or hematoma. The wound was carefully inspected. Meticulous hemostasis was achieved. Gloves were changed. The implant was opened and air was evacuated. It was placed in the submuscular pocket and the wound was temporarily closed using a skin stapler. The implant was filled to its maximum volume of 475 cc of normal saline. The patient was sat up. I adjusted the volume and ultimately felt she needed a 475 cc implant for breast symmetry with her contralateral breast. Once I was satisfied with the position of the implant, the patient was placed supine. Gloves were changed again. The fill tube was removed and I then secured the filled valves digitally and the deepest layer of breast tissue was closed using 3-0 Vicryl in running suture and the skin was closed in three layers using 4-0 Monocryl, 5-0 Monocryl, and 5-0 Prolene. The wound was dressed with Xeroform and gauze. The patient tolerated the procedure well. She was taken to recovery in good condition. What CPT® and ICD-10-CM codes are reported?

19342-LT, Q83.9 Rationale: In the CPT® Index look for Breast/Implant/Biological/Insertion and you are directed to codes 19325, 19340, 19342. This is a delayed insertion making 19342 the correct code choice. Modifier LT is appended to indicate left side. Look in the ICD-10-CM Alphabetic Index for Deformity/breast (acquired)/congenital referring you to code Q83.9. Verify code selection in the Tabular List.

In what year did HIPAA become law?

1996

A 40 year-old female in good physical health is having a laparoscopic tubal ligation. The anesthesiologist begins to prepare the patient for surgery at 08:30 am. Surgery begins at 09:00 am and ends at 10:00 am. The anesthesiologist releases the patient to recovery nurse at 1015. What is the total anesthesia time and anesthesia code?

1hr. 45 minutes, 00851 Rationale: Per Anesthesia Guidelines in the CPT® codebook under the subheading Time Reporting: Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia in the operating room (or an equivalent area) and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under postoperative supervision. In this case the start time is 08:30 am and the end time is 10:15 am equaling a total of 1 hour and 45 minutes or 105 minutes of total anesthesia time. In the CPT® Index look for Anesthesia/Tubal Ligation which directs you to code 00851. Review the code in numeric section to determine that 00851 is the correct code.

In what year was HITECH enacted as part of the American Recovery and Reinvestment Act?

2009

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

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

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

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

A 22 year-old female has a retained Kirschner wire in the left little finger. Using local anesthesia, the left upper extremity was thoroughly cleansed with Betadine. The end portion of the little finger was opened with a transverse incision through the subcutaneous tissue to the bone. The retained Kirschner wire was located within the distal phalanx. It was removed and the skin was closed with sutures. What CPT® code is reported?

20680-F4 Rationale: In the CPT® Index look for Removal/Fixation Device. You are referred to 20670-20680. Review the codes to choose the appropriate service. 20680 is the correct code because a deep incision was made all the way to the bone to locate the wire for removal. Modifier F4 is reported to indicate the left little finger.

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

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

The patient presents today for closed reduction of a nasal fracture. The depressed right nasal bone was elevated using heavy reduction forceps while the left nasal bone was pushed to the midline. This resulted in good alignment of the external nasal dorsum. What CPT® code is reported for this procedure?

21315 Rationale: In the CPT® Index look for Fracture/Nasal Bone/Closed Treatment. You are referred to 21310-21320. Review codes to choose the appropriate service. 21315 is the correct code to report a displaced nasal fracture manipulated with forceps to realign the nasal bones. Code 21310 is reported when a non-displaced fracture of the nose requires no manipulation just treatment by prescribing medication and application of ice.

This 45 year-old male presents to the operating room with a painful mass of the right upper arm. General anesthesia was induced. Soft tissue dissection was carried through the proximal aspect of the teres minor muscle. Upon further dissection a large mass was noted just distal of the IGHL (inferior glenohumeral ligament), which appeared to be benign in nature. With blunt dissection and electrocautery, the 4 cm mass was removed en bloc and sent to pathology. The wound was irrigated, and repair of the teres minor with subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. What CPT® code is reported?

23076-RT Rationale: The 4 cm mass was removed from the soft tissue of the shoulder. To access the mass, the provider had to go through the proximal aspect of the teres minor muscle. The mass was located distal to the inferior glenohumeral ligament (IGHL). Masses that are removed from joint areas as opposed to masses removed close to the skin require special knowledge and become more of an orthopedic concern due to joint involvement. Therefore, it is reported from codes within the musculoskeletal section. Code 23076 is used because dissection was carried through the proximal aspect of the teres minor. In the CPT® Index, look for Excision/Tumor/Shoulder directing you to 23071-23078.

A 66 year-old sustained a left proximal humerus fracture. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stable condition. No immediate complications. What CPT® code is reported?

23616-LT Rationale: In the CPT® Index, look for Fracture/Humerus/Open Treatment. You are referred to 23615-23616. Review the codes to choose appropriate service. 23616 is the correct code because the surgeon made an incision to expose the fracture site. The fracture repair included a prosthetic replacement (implant head) and the repair of the tuberosities. Modifier LT is appended to indicate that the procedure was performed on the left side.

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

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

A 3 year-old is brought into the ED crying. He cannot bend his left arm after his older brother twisted it. An X-ray is performed and the ED physician diagnoses is the patient has a dislocated nursemaid elbow. The ED physician reduces the elbow successfully. The patient is able to move his arm again. The patient is referred to an orthopedist for follow-up care. What CPT® and ICD-10-CM codes are reported?

24640-54-LT, S53.032A, W50.2XXA Rationale: In the CPT® Index, look for Elbow/Dislocation/Nursemaid Elbow. You are referred to 24640. Review the code for appropriate service. 24640 is the correct code to report treatment of a dislocated nursemaid's elbow with manipulation. Modifier 54 is appended to report that the ED physician performed only the surgical portion of the service. The patient is referred to an orthopedist for follow-up care. Modifier LT is appended to indicate the procedure was performed on the left side. In the ICD-10-CM Alphabetic Index, look for Nursemaid's elbow. You are referred to S53.03-. Reviewing the subcategory code in the Tabular List, the 6 th character indicates the selection is based on left or right. Documentation supports this as the left arm. A 7 th character is also required to indicate the episode of care. Because the patient is in the ED, this supports initial encounter and A is used. The complete code is S53.032A. In the ICD-10-CM External Cause of Injuries Index look for Twisted by person(s) (accidentally) referring you to W50.2. In the Tabular List this code requires a 7 th character in which the character A is used and X will be used as a placeholder for the 5 th and 6 th character positions. The place of occurrence and status is not given; therefore, it is not reported.

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

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

A 49 year-old female presented with chronic deQuervain's disease and has been unresponsive to physical therapy, bracing or cortisone injection. She has opted for more definitive treatment. After induction of anesthesia, the patient's left arm was prepared and draped in the normal sterile fashion. Local anesthetic was injected using a combination 2% lidocaine and 0.25% Marcaine. A transverse incision was made over the central area of the first dorsal compartment. The subcutaneous tissues were gently spread to protect the neural and venous structures. The retractors were placed. The fascial sheath of the first dorsal compartment was then incised and opened carefully. The underlying thumb abductor and extensor tendons were identified. The tissues were dissected and the extensor retinaculum of the first extensor compartment was incised. The fibrotic tissue was incised and the tendons gently released. The tendons were freely moving. Subcutaneous tissues were closed with a 3-0 Vicryl and the skin with 3-0 Prolene subcuticular closure. Steri-strips, Xeroform and dry sterile dressings were applied. What CPT® code is reported?

25000-LT Rationale: The report states that the extensor retinaculum of the first extensor compartment was incised. Look in the CPT® Index for Incision/Wrist/Tendon Sheath 25000-25001. Code 25000 shows deQuervain's disease in the description. Code 25001 refers to the flexor tendon sheath and this involved the extensor tendon making 25000 correct. Note this was an incision, not excision of the tendon of the extensor tendon sheath. Modifier LT is appended to indicate the procedure is performed on the left side.

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

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

A 16 year-old female was hit by a car while crossing a two-lane highway. She was taken to the hospital by ambulance. She was found to have an open wound of the left lower thigh, just above the knee and a displaced fracture of the left femoral neck. She was taken to the operating room within four hours of her injury. She was given general endotracheal anesthesia and was prepped and draped in sterile fashion. Debridement including excision of devitalized skin and muscle was performed on the lateral thigh. The area was approximately 15 sq cm. After debridement and thorough copious irrigation, the wound was closed with layer sutures and a dressing was applied and then covered with adhesive plastic. The patient was then prepped and draped for the fracture and turned on her right side. We all rescrubbed. An 8 inch incision was made over the left hip and the head of the femur was exposed. Multiple fragments from the neck and the greater tuberosity were removed. The decision was made to replace the femoral head. The femur was removed from the acetabulum and the femoral head was removed. The femoral canal was reamed and a prosthesis was placed. It was then replaced in the acetabulum with a good fit, and the capsule was closed. The wound was closed. The patient was sent to recovery in good condition.

27236-LT, 11043-59-LT Rationale: The main procedure is repair of a right femoral neck fracture. Look in the CPT® Index for Fracture/Femur/Neck/Open referring you to 27236. Modifier LT is appended to show the left side. Next look in the CPT® Index for Debridement/Skin/Subcutaneous Tissue referring you to 11042-11047. The correct code is 11043 for debridement of subcutaneous tissue including muscle for less than 20 sq cm. Do not report 11010-11012, because this was not debridement of an open fracture site. Codes 27236 and 27244 are only reported for hip arthroplasty, not for femoral neck fractures. Modifier 59 is appended to 11043 to show that this is a different site and not included in 27236.

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

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

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

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

A 14 year-old status post injury over one year ago to her left wrist presented with recurrent wrist pain. The patient was taken to the operating room and placed under general anesthesia. She was placed in wrist traction. The radiocarpal joint was entered endoscopically through sharp skin incisions and blunt dissection into the joint. There was found to be mild synovitis in the dorsal ulnar aspect of the wrist. This was debrided arthroscopically with a shaver. There was a peripheral tear of the triangular fibrocartilage. This area was shaved to promote healing. Using outside-in technique, a PDS suture was placed across the TFCC and into the capsule. There was synovitis within the midcarpal joint, but there was no articular injury. All instruments were removed and the wounds were closed with interrupted nylon sutures. What CPT® code(s) is /are reported?

29846-LT Rationale: In the CPT® Index, look for Arthroscopy/Surgical/Wrist. You are referred to 29843-29847. Code 29846 describes the arthroscopic excision and repair of triangular fibrocartilage and joint debridement. Endoscopically, arthroscopically and through the scope all mean the same thing. This is not an open surgery; it is arthroscopic. Modifier LT is appended to indicate the procedure is performed on the left side. Only one code is reported. The debridement (partial synovectomy) is included in the more intensive procedure.

This patient presented with internal derangement of the left knee. After satisfactory anesthesia was administered for the arthroscopic procedure, the left lower extremity was prepped and draped in a sterile fashion. Routine portals were made in the knee. We first looked at the medial compartment which showed a complex small tear of the posterior horn of the medial meniscus. This was debrided using a 4.0 meniscal shaver. There was an area of grade 4 chondromalacia on the proximal medial distal femur and this was all the way down to bone. There was also evidence of chondromalacia over the patellofemoral joint of grade 4. This area was drilled with a 0.45 K-wire. Multiple drill holes were placed in an attempt to get some scar tissue to form. The notch area was normal and lateral compartment normal. Following microfracture technique, the knee was irrigated, each portal was closed with 4-0 nylon and the patient was taken to recovery. What CPT® codes are reported?

29879-LT, 29881-51-LT Rationale: The procedure was a surgical arthroscopy of the knee reported with codes in the range of 29871-29889. In the CPT® Index look for Arthroscopy/Surgical/Knee directing you to 29866-29868, 29871-29889. The microfracture performed in the patellofemoral joint is reported with 29879. This code is found in the same code range as indicated above. The medial meniscectomy is reported with 29881. The microfracture procedure is more complex than the meniscectomy and it is listed first. Modifier 51 is required for the meniscectomy to indicate multiple procedures. Modifier LT is appended to indicate the procedures were performed on the left side.

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

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

This 56 year-old female presented with a degenerative posteromedial meniscal flap tear of the right knee. After appropriate preoperative evaluation, the patient was taken to the operating room where general anesthesia was instituted. The patient was placed supine on the operating table. The right lower extremity was sterilely prepped and draped for arthroscopic surgery. The leg was exsanguinated and the tourniquet inflated. The arthroscope was introduced first through the anterolateral portal with medial suprapatellar portal utilized. The lateral compartment looked fairly good. There were some minimal medial degenerative changes. In the medial compartment there was a full-thickness area of osteochondral degeneration with a flap of cartilage noted. It was possible to remove this with a bleeding bony bed with beveled edges of cartilage. The ligament itself was intact. The retropatellar area was normal with Grade I chondromalacia changes noted. The medial joint was inspected and there was a tear at the junction of the middle and posterior portions of the meniscus, a flap tear was based more anteriorly. This was shaved with a combination of small baskets and punches, and the meniscus debrided back to a smooth stable rim. There was additional synovitis in the medial aspect of the intercondylar notch and this was removed with the curved automated meniscal incisor. What CPT® code(s) should be reported?

29881 Rationale: This was a surgical arthroscopy of the knee. In the CPT® Index look for Arthroscopy/Surgical/Knee, directing you to 29866-29868, 29871-29889. The medial meniscectomy and debridement are reported with 29881. In this case the synovectomy, code 29875, is a separate procedure and bundled with 29881; it is not reported separately.

How many layers of tissue does an artery have?

3

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

32

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

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

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

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

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

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

Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass. Which CPT® codes are reported?

33426, 33405-51 Rationale: 33426 reports mitral valve valvuloplasty with a prosthetic ring, and 33405 reports an aortic valve replacement with cardiopulmonary bypass. Modifier 51 is required on the second procedure to indicate multiple procedures performed during the same setting. Look in the CPT® Index for Valvuloplasty/Mitral Valve or Mitral Valve/Repair and you are referred to 33425-33427. Look in the in the CPT® Index for Replacement/Aortic Valve. Allograft is not indicated in the question selecting 33405.

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

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

The cardiologist advances a 6 French catheter into the left renal artery via a right common femoral puncture. It is selectively catheterized and angiographic films are taken. The catheter was then removed and a diagnostic guiding type, RDC catheter was used and the left renal artery was selectively engaged. A 0.014 Supracore wire was used and the lesion was crossed. A 6.0 X 18 mm balloon expandable Racer stent was introduced. This was expanded around 8 atmospheres of pressure which is nominal. Angiography revealed excellent results with no residual stenosis. What CPT® codes are reported?

36245-LT, 37236 Rationale: The left renal artery is a first order vessel as noted in Appendix L of the CPT® codebook (36245-LT). To locate the selective catheterization, look in the CPT® Index for Artery/Abdomen/Catheterization referring you 36245-36248. 36245 is the correct code for the selective catheterization. Angiography of the left renal vessel was performed; however, there is no mention in the report of the results of the angiography. This is not a diagnostic angiography, rather it is angiography for mapping (checking out known stenosis). The stent was deployed (37236) in the left renal artery; this code also includes the radiologic supervision and interpretation. In the CPT® Index look for Angioplasty/with Intravascular Stent Placement referring you to 37215-37218, 37236-37239 or you can look for Artery/Stent Placement/Carotid. Follow-up renal angiography is bundled with the stent procedure.

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

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

A PICC with a port is placed under fluoroscopic guidance for a 45 year-old patient for chemotherapy infusion by a physician. The procedure was performed in the hospital. Report the codes for the physician.

36571, 77001-26 Rationale: Look in the CPT® Index for Central Venous Catheter Placement/Insertion/Peripheral/with Port and you are referred to 36570-36571. The age of patient is 45; therefore, report 36571. Fluoroscopic guidance for central venous access is reported with 77001 and can be found by looking in the CPT® Index for Fluoroscopy/Venous Access Device directing you to 36598, 77001. The correct code for fluoroscopy is 77001. Modifier 26 is necessary to show the professional service only.

An arterial catheterization is performed by cutdown for transfusion. What CPT® code is reported?

36625 Rationale: The answer is found in the CPT® Index by referencing Catheterization/Arterial System/Cutdown directing you to 36625.

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

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

A patient presents with a 2 cm benign lip lesion. The provider decides to remove the lesion along with a portion of the lip by performing a wedge excision. Single-layer suture repair is performed. What CPT® code(s) is/are reported for this service?

40510 Rationale: Because the physician is not only removing the lesion, but also removing part of lip, code 11422 is not reported. The lesion and a portion of the lip are removed by a transverse wedge technique. Look in the CPT® Index for Wedge Excision/Lip referring you to code 40510. The code description for code 40510 includes primary closure (suture repair) indicating an integumentary system repair code (12011) is not reported separately.

An 11 year-old patient is seen in the OR for a secondary palatoplasty for complete unilateral cleft palate. Shortly after general anesthesia is administered, the patient begins to seize. The surgeon quickly terminates the surgery in order to stabilize the patient. What CPT® and ICD-10-CM codes are reported for the surgeon?

42220-53, Q35.9, R56.9 Rationale: In the CPT® Index, look for Palatoplasty 42145, 42200-42225. An alternate path is Cleft Palate/Repair which refers you to 42200-42225. Review of the code descriptions in the main section confirms code 42220 represents a secondary repair to a cleft palate. Modifier 53 is appended because the procedure was terminated after anesthesia due to extenuating circumstances. The diagnosis of a complete unilateral cleft palate is indexed in the ICD-10-CM Alphabetic Index under Cleft/palate referring you to code Q35.9. The unspecified code is the appropriate code because the surgeon did not provide specific information for the location of the cleft. Next, look for Seizure(s) (see also Convulsions) R56.9. Both listings direct the coder to R56.9 Unspecified convulsions. Code R56.9 is reported because the patient began to seize after administering the general anesthesia. Verify all code selections in the Tabular List.

A 7 year-old female presents to the same day surgery unit for a tonsillectomy. During the surgery the physician notices the adenoids are very inflamed and must be taken out as well. The adenoids, although not planned for removal, are removed following the tonsillectomy.

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

A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon (25mm). What CPT® code(s) is/are reported?

43220 Rationale: Because the esophageal dilation using a bougie (43450) was unsuccessful, it is not reported. The esophagus was successfully dilated by performing transendoscopic balloon dilation 43220. This is the only code reported. In the CPT® Index, look for Esophagus/Dilation/Endoscopic.

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

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

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

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

A 4 year-old patient, who accidentally ingests valium found in his mother's purse, is found unconscious and rushed to the ED. The child is treated by the ED physician, who inserted a tube orally into the stomach and performed a gastric lavage, removing the stomach contents. What CPT® and ICD-10-CM codes are reported?

43753, T42.4X1A, R40.20 Rationale: Code 43753 is the correct CPT® code for gastric lavage performed for the treatment of ingested poison. Look in the CPT® Index for Gastric Lavage, Therapeutic/Intubation. The ICD-10-CM code for the poisoning is found in the Table of Drugs and Chemicals by looking for Valium/Poisoning, Accidental (unintentional) column, referring you to code T42.4X1-. In the Tabular List a 7 th character is needed to complete the code. A is reported as the 7 th character because this was the patient's initial encounter. The next code is the manifestation of ingesting the Valium, unconsciousness. Unconsciousness is found in the ICD-10-CM Alphabetic Index and directs you to see Coma R40.20. The Tabular List confirms this code is reported for unconsciousness.

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

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

A screening colonoscopy is performed on a 50 year-old patient with a family history of colon cancer. Multiple polyps were found during the procedure. Two polyps in the transverse colon were removed with hot forceps cautery. Three polyps in the ascending colon were removed via snare. Portions of all polyp tissues were sent to pathology and reported as benign. What are the correct CPT® and ICD-10-CM codes for this patient encounter?

45384, 45385-59, Z12.11, D12.3, D12.2, Z80.0 Rationale: In the CPT® Index, look for Polyp/Colon/Removal which directs you to 44392, 44394, 45384, and 45385. Two different removal techniques (hot forceps and snare) were used and can be coded. Use 45384 for hot forceps and 45385 for the snare procedure. Modifier 59 is appended to the secondary procedure to indicate this. The codes are reported by how the polyps were removed, not by the number of polyps removed. This is because the code description indicates polyp(s). The letter s in parenthesis means this code is used when only one polyp or when more than one polyp is removed. According to ICD-10-CM Coding guidelines I.C.21.c.5, "a screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis. The Z code indicates that a screening exam is planned." In the ICD-10-CM Alphabetic Index, look for Screening/colonoscopy which directs you to Z12.11. A condition of polyps is discovered during the screening exam, the code for the condition is reported as an additional code. Look for Polyp, polypus/colon/transverse referring you to D12.3 and then look for the subterm ascending referring you to D12.2. Next, code the family history of colon cancer to further support the reason for the colonoscopy. Look for History/family (of)/malignant neoplasm/gastrointestinal tract directing you to code Z80.0. Remember to verify all the codes in the Tabular List.

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

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

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

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

A 45 year-old woman underwent a laparoscopic cholecystectomy. The procedure was performed for recurrent bouts of acute cholecystitis. What CPT® and ICD-10-CM codes are reported?

47562, K81.0 Rationale: In the CPT® Index, look for Cholecystectomy/Laparoscopic which directs you to 47562-47564. 47600 and 47605 are open cholecystectomy codes. By turning to the numeric section of CPT and reviewing the code descriptions, you can verify that 47562 is the appropriate code for a laparoscopic cholecystectomy with no additional procedures performed. Acute cholecystitis is indexed in ICD-10-CM Alphabetic Index under Cholecystitis/acute for code K81.0. Verify code selection in the Tabular List.

Surgical laparoscopy with a cholecystectomy and exploration of the common bile duct for cholelithiasis. What CPT® and ICD-10-CM codes are reported?

47564, K80.20 Rationale: Look in the CPT® Index for Cholecystectomy/Laparoscopic which refers you to 47562-47564. Code 47564 is accurate for laparoscopic cholecystectomy when the exploration of the common bile duct is also performed. There is a diagnosis of cholelithiasis but no mention of obstruction and not with cholecystitis. The correct ICD-10-CM code is K80.20. In the ICD-10-CM Alphabetic Index, look for Cholelithiasis (cystic duct) (gallbladder) (impacted) (multiple) which instructs you to see Calculus, gallbladder. Look for Calculus/gallbladder you are directed to K80.20. Verify code selection in the Tabular List.

A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis including a chocolate cyst (endometrioma) of the right ovary, right fallopian tube and peritoneum. The endometriomas are all small, less than 5 cm, and laser is used to ablate them, except the ovarian cyst, which is excised. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?

49203, 58611, N80.1, N80.2, N80.3, Z30.2 Rationale: The exploratory laparotomy is not a separately billable service because it is no longer just examination of the intraabdominal organs; it became a surgical procedure in which the endometriomas were destroyed by laser. Remember a surgical laparotomy always includes a diagnostic (exploratory) laparotomy. Look in the CPT® Index for Endometrioma/Abdomen/Destruction/Excision referring you to 49203-49205. 49203 is correct for destruction for 1 or more tumors with the largest less than 5 cm in diameter. The second procedure is a tubal ligation (female sterilization in which the fallopian tubes are sealed or severed). Look in the CPT® Index for Fallopian tube/Ligation referring you to 58600, 58611. Add-on code 58611 is correct to report because the tubal ligation was performed at the same time as another intra-abdominal surgery. Modifier 51 is not appended because 58611 is an add-on code. The endometriosis included the ovary and the right fallopian tube. Look in the ICD-10-CM Alphabetic Index for Endometriosis/ovary guiding you to code N80.1. Next look in the Alphabetic Index for Endometriosis/fallopian tube referring you to code N80.2. Then look for Endometriosis/peritoneal directing you to code N80.3. Reporting a diagnosis for the tubal ligation is found by looking in the Alphabetic Index for Encounter (with health service) (for)/sterilization guiding you to code Z30.2. Verify all codes in the Tabular List.

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

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

A 40 year-old male patient is in the surgical suite to have an incarcerated hernia of his belly button repaired. What CPT® and ICD-10-CM codes are reported?

49587, K42.0 Rationale: In the CPT® Index look for Repair/Hernia/Umbilical/Incarcerated directing you to 49582, 49587, 49653 or Hernia Repair/Umbilicus/Child, 5 years and up/Incarcerated directing you to 49587. Code 49587 appropriately represents this procedure. Look in the ICD-10-CM Alphabetic Index for Hernia, hernia (acquired) (recurrent)/umbilicus, umbilical/with obstruction, which directs the coder you to K42.0. Verification of this code in the Tabular List confirms code K42.0 represents an incarcerated umbilical hernia

What is the correct CPT® code for a percutaneous pyelostolithotomy with dilation and basket extraction measuring 1 cm?

50080 Rationale: Pyelostolithotomy/Percutaneous in the CPT® Index refers you to code range 50080-50081. Code selection is based on the size of the kidney stone (calculus). Code 50080 is a percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm.

Patient is a 68 year-old male admitted for left flank nephrectomy with partial ureterectomy. He has left renal atrophy and chronic renal inflammation. The pathology report reveals marked glomerulosclerosis, chronic inflammation of the kidney, renal pelvis and ureter. What CPT® and ICD-10-CM codes are reported for this service?

50220-LT, N26.9, N28.89 Rationale: In the CPT® Index look for Nephrectomy/with Ureters. CPT® code 50220 describes the nephrectomy including a partial ureterectomy. CPT® code 50230 describes a radical nephrectomy procedure with regional lymphadenectomy, and in this case, there is no documentation to support a radical procedure. HCPCS Level II modifier LT is used to indicate the left side. In the ICD-10-CM Alphabetic Index look for Glomerulosclerosis directing you to see also Sclerosis, renal. Look for Sclerosis, sclerotic/renal directing you to N26.9. To find inflammation of the ureter, look in the ICD-10-CM Alphabetic Index for Ureteritis directing you to N28.89. Verify all code selections in the Tabular List.

A patient comes in for removal of a calculus from the renal pelvis via renal endoscopy through an established nephrostomy. What CPT® code is reported?

50561 Rationale: Renal endoscopy codes are divided into two code sets: 50551-50562 and 50570-50580. The difference between the two is whether the procedure is performed through an established nephrostomy or pyelostomy or a new nephrostomy. For this scenario, the procedure is performed through an established nephrostomy. In the CPT® Index locate Endoscopy/Kidney/Removal/Calculus. Code 50561 is reported.

Left ureteral stent placement and Extracorporeal Shock Wave Therapy or Lithotripsy (ESWL) of the left kidney are performed. What CPT® code(s) is/are reported for this service?

50590-LT, 52332-51-LT Rationale: Two procedures are performed. CPT® code 52353 describes laser lithotripsy and does not include ESWL. CPT® code 52332 describes the stent placement, but does not include the ESWL. CPT® code 50590 describes the ESWL but not the placement of the stent. CPT® code 50590 and 52332 describe both procedures performed. Modifier LT is appended to 50590 to indicate the lithotripsy was performed on the left kidney. Modifiers 51 and LT are appended to code 52332 to indicate more than one procedure was performed on the left side. Look in the CPT® Index for Lithotripsy/Kidney and Insertion/Stent/Ureteral.

The patient has a 3.6 cm tumor in the lower pole of the right kidney. A percutaneous right renal cryosurgical ablation is performed. What CPT® code is reported for this service?

50593-RT Rationale: In the CPT® Index look for Ablation/Cryosurgical/Renal Tumor/Percutaneous and you are directed to 50593. CPT® codes 50541 and 50542 describe laparoscopic procedures and are not considered because the procedure was performed percutaneously. CPT® code 50250 is ablation of renal mass lesion(s). HCPCS Level II modifier RT is used to indicate the right side.

The patient has significant morbid obesity and her pannus has been retracted to help with dissection. The planned procedure is to place a catheter/tube to drain the bladder. It is apparent she has quite a bit of scarring from her previous surgeries and appears to have an old sinus tract just above the symphysis. A midline incision is made following her old scar from just above the symphysis for a length of about 4-6cm. The sinus tract was excised, as this was also in the midline, and carefully dissected down to the level of the fascia. It does not appear to be an actual hernia, as there are no ventral contents within it. Again, there is quite a bit of distortion from previous scarring because of the obesity, but staying in the midline, the fascia is incised just above the symphysis of a length of about 2cm. The fat and scar are incised above the fascia more superiorly and with palpation, mesh from a previous hernia repair is felt. This was not palpable prior to the incision because of her body habitus. The mesh was not exposed or entered, it comes down quite close to the symphysis and certainly is too close to place a suprapubic (SP) tube. There is concern the mesh may become infected with an SP tube tract right there. Therefore, decision to abort the procedure is made. What CPT® code and modifier are reported for this service?

51040-53 Rationale: The intended procedure is cystostomy. In the CPT® Index look for Cystostomy/with Drainage. Modifier 53 is appended when the procedure is terminated due to the well-being of the patient and is appended to the initial procedure intended. CPT® code 51102 describes insertion of a suprapubic catheter by aspiration of the bladder; this is not the correct code to report.

A 63 year-old gentleman comes into the ED complaining of the urge to urinate but has been unable to empty his bladder. The provider decides to place a Foley catheter to relieve the urine retention due to prostate hypertrophy. What is the code selection for the procedure and diagnosis codes?

51702, N40.1, R33.8 Rationale: In the CPT® Index look for Catheter/Bladder referring you to codes 51701-51703. CPT® code 51702 is correct to report for this scenario since an indwelling catheter (for example a Foley catheter) is left in the bladder and urine is drained. Code 51701 is used when a non-indwelling catheter is inserted to determine post void residual urine; this is sometimes called a straight cath. The patient is diagnosed with urine retention and prostate hypertrophy. In the ICD-10-CM Alphabetic Index look for Enlargement, enlarged/prostate/with lower urinary retention guiding you to code N40.1. In the Tabular List locate N40.1 and you are directed to use additional code for associated symptoms. Code R33.8 is used to describe urinary retention. Verify code selection in the Tabular List.

Diagnosis: Bulbar urethral strictures Procedure: Cystoscopy and dilation of urethral stricture. Medical Necessity: A very pleasant 36 year-old male with post void hematuria. Description: A 17 French cystoscope was introduced in the patient's urethra up to the level of the stricture, but I was unable to pass the urethral stricture with a Super Stiff wire, so I first passed over the Glidewire, removed the cystoscope, placed a Pollock catheter over the Glidewire, and exchanged the Glidewire for a Super Stiff wire. We then removed the Pollock catheter leaving the Super Stiff wire in place as our safety wire. I dilated the patient's urethra to 26 French without difficulty. We reintroduced the cystoscope and noted ablation of the stricture. No masses were noted within the bladder. What CPT® code(s) is/are reported for this service?

52281 Rationale: CPT® code 52281 describes a cystoscopy with calibration and/or dilation of urethral stricture or stenosis and does not limit the coder to the type of treatment, for example Goodwin sounds, filiform, dilator, etc. In the CPT® Index look for Cystourethroscopy/Dilation/Urethra. Codes 53605 and 53620 are used for the dilation of the urethra using a method other than cystourethroscopy. Code 52000 is only the cystourethroscopy and has a separate procedure designation. Codes designated as a separate procedure should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

Patient is status post left extracorporeal shock wave therapy (ESWL) performed three weeks ago; there is no global time for this procedure. He returns today for scheduled left ureteroscopy with basket extraction of ureteral calculi. What CPT® code is reported for this service?

52352 Rationale: Many times, after an ESWL, the provider will schedule the patient for follow up extraction of the remaining stone fragments. In the CPT® Index, look for Calculus/Removal/Ureter directing you to several codes. Code 52352 is the appropriate code. Modifiers 58 and 78 are used for additional procedures performed during a global period and modifier 76 is used for a repeat of the same procedure. These modifiers aren't appropriate in this case because there is no global period.

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

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

A 63 year-old male presents for the insertion of an artificial inflatable urinary sphincter for urinary incontinence. A 4.5 cm cuff, 22 ml balloon, 61-70 mmHg artificial inflatable urinary sphincter was inserted. What CPT® code is reported for this service?

53445 Rationale: In the CPT® Index look for Insertion/Prosthesis/Urethral Sphincter. You're directed to 53444-53445. Codes 53446-53448 are for the removal or removal/replacement of the inflatable sphincter. CPT® code 53445 describes the insertion of an inflatable urethra/bladder neck sphincter, including placement of pump, reservoir and cuff.

The patient is a 53-year-old male with benign prostatic hypertrophy causing urinary obstruction and requires the placement of a temporary urethral stent. What CPT® code is reported for this service?

53855 Rationale: Urethral stents are inserted to maintain patency of the urethra. In the CPT® Index look for Stent/Placement/Ureter. CPT® code 53855 describes placement of a temporary prostatic urethral stent.

Patient is status post radical retropubic prostatectomy with erectile dysfunction, presenting for penile implant. An inflatable penile prosthesis is inserted. What CPT® code is reported for this service?

54401 Rationale: Penile prosthesis insertion codes are described as either noninflatable or inflatable. CPT® code 54416 is removal and replacement of an inflatable penile prosthesis. CPT® code 54408 is for repair of an inflatable penile prosthesis. Code 54400 is reported for the insertion of a noninflatable prosthesis. Code 54401 is the correct code to report for the initial insertion of an inflatable penile prosthesis. Look in the CPT® Index for Prosthesis/Penis/Insertion.

The patient presents for replacement of inflatable penile prosthesis through an infected field. What CPT® code(s) is/are reported for this service?

54417 Rationale: In the CPT® Index look for Prosthesis/Penis/Replacement for the code range. To report code 54411, you will need to see the word multi-component to report it. The correct code is 54417 which indicates the replacement of inflatable penile prosthesis through an infected field. Documentation does not support debridement of a necrotizing soft tissue infection eliminating 11004 as an option.

A fracture of the corpus cavernosum penis is repaired. What is the correct code?

54440 Rationale: Repair for penile injury is reported using CPT® code 54440. Do not report CPT® codes used for treatment of priapism when there is injury to the penis. In the CPT® Index look for Repair/Penis/Injury.

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

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

Cryosurgical ablation of the prostate is performed for prostate cancer. What CPT® and ICD-10-CM codes are reported for this service?

55873, C61 Rationale: In the CPT® Index look for Cryosurgery/Prostate or Ablation Prostate. Code 55873 describes the cryosurgical ablation of the prostate. Ultrasonic guidance and monitoring are not reported separately. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/prostate (gland) and select from the Malignant Primary column directing you to C61. Without mention of the cancer as in situ or as secondary/metastasized, ICD-10-CM codes C79.82 and D07.5 are not reported.

A 67 year-old gentleman with localized prostate cancer will be receiving brachytherapy treatment. Following calculation of the planned transrectal ultrasound, guidance was provided for percutaneous perineal placement of 1-125 seeds into the prostate tissue. What CPT® code is reported for needle placement to insert the radioactive seeds into the prostate?

55875 Rationale: Brachytherapy is a form of radiation in which radioactive seeds or pellets are implanted directly into the tissue being treated to deliver their dose of radiation in a direct fashion and longer period of time. The placement of the seeds is performed percutaneously. The code is indexed in the CPT® Index under Prostate/Insertion/Needle guiding you to code 55875.

The patient presents with a recurrent infection of the Bartholin's gland which has previously been treated with antibiotics and I&D. At this visit her gynecologist incises the cyst, draining the material from it and tacks the edges of the cyst open creating an open pouch to prevent recurrence. How is this procedure coded?

56440 Rationale: Marsupialization is a procedure where a scalpel is used to cut an opening in the top of the abscess pocket. The leaflets created by this procedure are pulled away from the pocket and attached to the surrounding skin with stitches or glue. This creates an open pouch to help prevent recurrence of the abscess. Look in the CPT® Index look for Bartholin's Gland/Cyst/Marsupialization or Marsupialization/Cyst/Bartholin's Gland directing you to code 56440. Marsupialization of Bartholin's gland cyst is reported with CPT® code 56440.

Patient with genital warts has cryotherapy of an extensive number of lesions on her mons pubis, labia and perineum. How is this procedure coded?

56515 Rationale: The mons pubis and labia are part of the vulva. In the CPT® Index look for Destruction/Lesion/Vulva/Extensive and you are referred to 56515. The extensive code is reported due to the extensive number of lesions. Verify the code in the numeric section.

A pregnant patient presents to the hospital in active labor. The obstetrician providing her prenatal care is contacted to perform the delivery. The provider delivers twins vaginally. The obstetrician will also provide the postnatal care. What CPT® code(s) describe this procedure?

59400, 59409-51 Rationale: The delivery is vaginal. Look in the CPT® Index for Vaginal Delivery directing you to codes 59400, 59610-59614. As the physician has provided the prenatal care and will provide the postpartum care, the vaginal delivery for twin A is the global service described by 59400. The delivery of twin B is coded with 59409 with modifier 51 appended indicating this is a multiple procedure. Prenatal and postpartum care applies to the total care of the patient and not to both deliveries.

A woman presents for hysterectomy after ECC (endocervical curettage) and EMB (endometrial biopsy) indicates endometrial cancer. Transabdominal approach (incision) is chosen for exposure of all structures possibly affected. The abdomen is thoroughly inspected with no gross disease outside the enlarged uterus but several lymph nodes are enlarged and the decision is made to perform a hysterectomy with bilateral removal of tubes and ovaries and bilateral pelvic lymphadenectomy with periaortic lymph node sampling. Specimens sent to pathology confirm endometrial cancer but find normal tissue in the lymph nodes. What are the CPT® and ICD-10-CM codes reported for this service?

58210, C54.1 Rationale: An open approach is performed to remove the uterus, cervix, tubes, ovaries and bilateral pelvic lymph nodes along with sampling (biopsy) the peri-aortic lymph nodes. In the CPT® Index look for Hysterectomy/Abdominal/Radical referring you to 58210. The key to choosing this code from the other choices is the removal of the pelvic lymph nodes and a biopsy of the peri-aortic lymph nodes (radical procedure) which is located in the description for code 58210. Because the lymph nodes were benign, the endometrial cancer is the only diagnosis to report. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/endometrium/Malignant Primary column referring you to C54.1. Verify in the Tabular List.

A patient with previous tubal ligation decides that she would like to have another child and requests reversal of the previous procedure. Re-anastomosis of the ligated tubes is performed successfully by low transverse incision. It is found that the fimbriated end of the right tube has adhesions to the ovary and fimbrioplasty is also performed. What is/are the CPT® code(s) reported for this procedure?

58750-50, 58760-51-RT Rationale: There are two different procedures performed in this scenario. The first one is the reversal of the tubal ligation. The closed portions of the fallopian tube are excised (removed) and are connected by suturing the clean edges together (anastomosis). In the CPT® Index look for Anastomosis/Fallopian tube or Tubotubal directing you to code 58750. The question indicates tubes, meaning the anastomosis was performed on both tubes and modifier 50 is appended to the code. The second procedure performed is reconstruction of the fimbriae (finger-like projections at the end of the fallopian tubes) or fimbrioplasty due to adhesions found at the end of the right tube. In the CPT® Index, look for Fimbrioplasty/Uterus guiding you to code 58760. Two modifiers are appended to this code: Modifier 51 to indicate more than one procedure was performed and modifier RT to indicate only the right tube was involved. Both of these procedures were performed with an incision, not laparoscopically.

Patient presents with no menses and positive pregnancy test but ultrasound finds no uterine contents. Embryo has implanted on left ovary and this is treated with laparoscopic oophorectomy. What are the CPT® and ICD-10-CM codes reported for this procedure? Do not code the ultrasound.

59151, O00.202 Rationale: When an embryo implants on the ovary, it is an ectopic (ovarian) pregnancy. In the CPT® Index look for Ectopic Pregnancy/Laparoscopy with Salpingectomy and/or Oophorectomy and you are referred to 59151. For the diagnosis, look in the ICD-10-CM Alphabetic Index for Pregnancy/ovarian and you are directed to O00.20. Locate the code in the Tabular List. A sixth character is needed for laterality. Sixth character 2 is used for left ovary.

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

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

A patient with a previous low transverse incision cesarean delivery is attempting VBAC (vaginal birth after cesarean), also known as TOLAC (trial of labor after cesarean) with her second child. During labor her uterus ruptured. She had an emergency cesarean section followed immediately by hysterectomy to remove her ruptured uterus. Mother and baby survived. The same obstetrician provided her antepartum and postpartum care. What are the CPT® and ICD-10-CM codes reported for this service?

59618, 59525, O71.1, O34.211, Z3A.00, Z37.0 Rationale: This patient has a previous history of caesarean delivery and is attempting to deliver her second child vaginally (VBAC). Due to her uterus rupturing, the planned vaginal delivery was changed to a caesarean delivery. Look in the CPT® Index for Cesarean Delivery/Previous Cesarean/Unsuccessful Attempted Vaginal Delivery/Routine Care referring you to code 59618. After the delivery a hysterectomy was performed. The procedure is located in the CPT® Index by looking for Cesarean Delivery/with hysterectomy referring you to 59525. Modifier 51 is not appended to this code, because it is an add-on code. The first-listed diagnosis will reflect the rupture of the uterus during labor which is the reason for the cesarean. Look in the ICD-10-CM Alphabetic Index for Rupture/uterus/during or after labor O71.1. Next look for Delivery/cesarean (for)/previous/cesarean delivery/classical (vertical) scar, O34.212. Notes at the beginning of Chapter 15 states to use an additional code from category Z3A to identify the weeks of gestation. The weeks of gestation are not provided. In the ICD-10-CM Alphabetic Index look for Pregnancy/weeks of gestation/not specified and you are referred to Z3A.00. The last code to report is the outcome of the delivery. In the Alphabetic Index look for Outcome of delivery/single NEC/live born, referring you to Z37.0. Verify the codes in the Tabular List.

What CPT® code is reported for a subtotal thyroidectomy for malignancy, with removal of only a few selected lymph nodes?

60252 Rationale: The removal of all of the lymph nodes of the neck during a thyroidectomy is considered a radical neck dissection. When limited removal of all of the lymph nodes of the neck is performed, it is reported with 60252. The thyroidectomy is performed due to the patient having a malignancy. In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Limited Neck Dissection.

A patient has a total thyroidectomy to remove thyroid cancer. Removal of all the lymph nodes along with the spinal accessory nerve, jugular vein and sternocleidomastoid muscles are performed to remove a malignant lymphatic chain. What CPT® and ICD-10-CM codes are reported?

60254, C73 Rationale: In the CPT® Index look for Thyroidectomy/Total/for Malignancy/Radical Neck Dissection directing you to 60254. A radical neck dissection includes removal of all lymph nodes. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/thyroid (gland) and select from the Malignant Primary column directing you to C73. Verification in the Tabular List confirms code selection.

What is the appropriate modifier to use when two surgeons perform separate distinct portions of the same procedure?

62

A patient with a status post (after or following) lumbar puncture headache receives an epidural blood patch. The patient's venous blood is injected into the lumbar epidural space; this blood forms a clot sealing the leak of CSF from the lumbar puncture. What CPT® and ICD-10-CM codes are reported?

62273, G97.1 Rationale: In the CPT® Index look for Spinal Cord/Injection/Blood directing you to 62273. In ICD-10-CM Alphabetic Index, look for Headache/lumbar puncture directing you to G97.1. Verification in the Tabular List confirms code selection.

A patient with a displaced cervical disc undergoes a cervical laminotomy with a partial facetectomy and excision of the herniated disc at cervical interspace C3-C4. What CPT® and ICD-10-CM codes are reported?

63020, M50.21 Rationale: A laminotomy is also known as a hemilaminectomy. In the CPT® Index look for Hemilaminectomy directing you to code range 63020-63044. The procedure performed was a cervical (C3-C4) laminotomy with partial facetectomy and excision of the herniated disc which makes 63020 the correct code. In the ICD-10-CM Alphabetic Index, look for Hernia/intervertebral cartilage or disc directing you to see Displacement, intervertebral disc. Look for Disorder/disc (intervertebral)/cervical/displacement/C3-C4 referring you to code M50.21. Verification in the Tabular List indicates a 5th character is reported to identify the intervertebral interspace of C3-C4. The 5th character 1 is chosen.

A 59 year-old is suffering from foraminal spinal stenosis. Patient is to have a L4-L5 laminectomy on the right side. Under general anesthesia a knife dissection was made on the back and was taken down to the fascia. The fascia on the right side of the spine was stripped. The deep Taylor retractor was placed. Using an intraoperative X-ray, the physician traced out the foramen of L4-L5. There appeared to be some compression at this lamina into the foramen and significant stenosis. The provider removed the spinous process and lamina. Nerve roots canals are freed by removal of the facet. Compression is relieved by removing bony overgrowth around the foramen. What CPT® code is reported for this procedure?

63047 Rationale: In the CPT® Index look for Laminectomy/with Facetectomy directing you to 63045-63048, 0202T, 0274T, 0275T. A laminectomy with knife dissection is being performed for spinal stenosis eliminating codes 0202T, 0274T, and 0275T. Codes 63045-63048 are reported based on location. This was performed on the lumbar, making the correct code 63047. 63030 is a code specific to the interspaces and codes 63001 and 63017 specifically state without facetectomy making them incorrect choices.

A 47 year-old female presents to the OR for a partial corpectomy to three thoracic vertebrae. One surgeon performs the transthoracic approach while another surgeon performs the three vertebral nerve root decompressions necessary. How should each provider involved code their portion of the surgery?

63085-62, 63086-62 x 2 Rationale: Two co-surgeons performed distinct parts of the same surgery. The surgery performed is a vertebral corpectomy, thoracic. Look in the CPT® Index for Vertebral/Corpectomy directing you to code range 63081-63103, 63300-63308. 63300-63308 are for excision of intraspinal lesions. The code selection for 63081-63103 is based on location, approach and number of vertebral segments. Code 63085 is for a transthoracic approach, thoracic, single segment. The additional two segments are reported with code 63086. As indicated by the CPT® subsection guidelines for this section, codes 63075-63091, each provider will report the same CPT® code and append a modifier 62.

A 47 year-old male presents with chronic back pain and lower left leg radiculitis. A laminectomy is performed on the inferior end of L5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left. The entire intraspinal lesion was evacuated. What CPT® code(s) is/are reported for this procedure?

63267, 69990 Rationale: In the CPT® Index look for Laminectomy/for Excision/Intraspinal Lesion/Other than Neoplasm directing you to code range 63265-63268 and 63270-63273. The code range is divided based on whether the lesion is extradural or intradural. In this case, it is extradural narrowing the range to 63265-63268. The range is further divided based on the location of the spine the lesion is located. Laminectomy with evacuation of an intraspinal lesion in the lumbar spine is described by code 63267. The use of a microscope is documented to perform microdissection. In the CPT® Index look for Operating Microscope directing you to 69990.

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

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

The provider creates an opening in the opaque posterior lens capsule of the patient's right eye by cutting an inverted U shape in the tissue. The cut is made using a YAG laser. The tissue within the inverted U falls down, and out of the patient's field of vision. The procedure is done to improve the vision of a patient with a secondary cataract. What CPT® code is reported?

66821-RT Rationale: In the CPT® Index look for Cataract/Incision/Laser. Documentation states that this is performed on a secondary cataract with a laser. The cataract is not removed from the eye, just from the line of vision. The cutting or incision through a part is a dissection. The procedure is described by code 66821. Modifier RT is used to indicate the procedure was performed on the right eye.

Operative Report PREOPERATIVE DIAGNOSIS: Prolapsed vitreous in anterior chamber with corneal edema POSTOPERATIVE DIAGNOSIS Same OPERATION PERFORMED Anterior vitrectomy The patient is a 72 year-old woman who approximately 10 months ago underwent cataract surgery with a YAG laser capsulotomy, developed corneal edema and required a corneal transplant. The patient has done well. Over the last few weeks, she developed posterior vitreous detachment with vitreous prolapse to the opening in the posterior capsule with vitreous into the anterior chamber with corneal touch and adhesion to the graft host junction and early corneal edema. The patient is admitted for anterior vitrectomy. PROCEDURE: The patient was prepped, and draped in the usual manner after first undergoing retrobulbar anesthetic. A lid speculum was inserted. An incision was made at approximately the 10 o'clock meridian 3 mm in length, 2 mm posterior to the limbus, and grooved forward into clear cornea with a 3.2 mm anterior chamber. An anterior vitrectomy was carried out, placing a visco-elastic substance in the anterior chamber to maintain it. A Sinskey hook was used to sweep vitreous away from the corneal wound and this was removed with the disposable vitrectomy instrument. The patient's pupil is noted to be round. There was no vitreous to the wound. The wound self-sealed without aqueous leak. Cautery was used to close the conjunctiva. Subconjunctival Decadron and Gentamicin was given. The patient tolerated the procedure well and was discharged to the recovery room in good condition. What CPT® code(s) is/are reported?

67010 Rationale: In the CPT® Index look for Vitrectomy/Anterior Approach/Subtotal. This was a subtotal removal using a mechanical tool to sweep the vitreous away. Subtotal using a mechanical tool is reported with 67010.

Repair of right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. Vitrectomy, drainage of subretinal fluid, silicone oil tamponade, and endolaser photocoagulation are performed to correct the tear. What are the procedure and diagnosis codes for this service?

67113, H33.031, W21.03XA Rationale: In the CPT® Index look for Retina/Repair/Detachment/with Vitrectomy referring you to 67108, 67113. Code 67113 is used for the repair of a giant tear of the retina, with vitrectomy, and endolaser photocoagulation. In the ICD-10-CM Alphabetical Index look for Detachment/retina/with retinal/break/giant referring you to H33.03-. In the Tabular List a 6th character 1 is reported for the right eye. In the ICD-10-CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/baseball referring you to W21.03-. In the Tabular List seven characters are reported to complete the code. The 6th character is a placeholder X and the 7th character A is used to identify the initial encounter. Surgical management represents an initial encounter.

What CPT® code(s) is/are reported for the placement of two adjustable sutures during strabismus surgery involving the horizontal muscles?

67312, 67335 Rationale: Code 67312 represents strabismus surgery on two (2) horizontal muscles. In the CPT® Index look for Strabismus/Repair/Two Horizontal Muscles. In the numeric section below code 67316, there is a parenthetical note with instructions to use code 67335 in addition to codes 67311-67334 when adjustable sutures are used for primary procedure reflecting number of muscles operated on. Code 67335 is an add-on code and exempt from multiple procedures modifier 51. This is located in the CPT® Index by looking for Strabismus/Repair/Adjustable Sutures.

Under general anesthesia, a provider excises one chalazion from each upper eyelid. What are the procedure and diagnosis codes for the service?

67808-E1-E3, H00.11, H00.14 Rationale: In the CPT® Index look for Chalazion/Excision/Under Anesthesia directing you to 67808. Code 67808 describes the use of general anesthesia to excise single or multiple chalazion(s). Modifiers E1 and E3 can be reported to indicate which eyelids were operated on. In the ICD-10-CM Alphabetic Index look for Chalazion/right/upper H00.11 and Chalazion/left/upper H00.14. Verify code selection in the Tabular List.

A 70 year-old female has a drooping left eyelid obstructing her vision and has consented to having the blepharoptosis repaired. A skin marking pencil was used to outline the external proposed skin incision on the left upper eyelid. The lower edge of the incision was placed in the prominent eyelid crease. The skin was excised to the levator aponeurosis. An attenuated area of levator aponeurosis was dehisced from the lower strip. Three 6-0 silk sutures were then placed in mattress fashion, attaching this attenuated tissue superiorly to the intact tissue inferiorly. This provided moderate elevation of the eyelid. What CPT® code is reported?

67904-E1 Rationale: In the CPT® Index look for Blepharoptosis/Repair/Tarso Levator Resection/ Advancement/External Approach. You are referred to 67904. Review the code in the numeric section to verify accuracy. This is the correct code because the external approach of cutting the skin of the eyelid was performed and dissection is carried to the levator tendon. The provider uses sutures to advance the levator tendon to create a new eyelid crease. Append modifier E1 for Upper left, eyelid.

The patient was taken to the operating room. The provider everts the upper eyelid and places clamps across the everted undersurface of the upper lid. The tissue distal to the clamps is excised or resected. This tissue includes conjunctiva, tarsus, Muller's muscle and the distal insertion of the levator aponeurosis. The remaining tissue is reattached and sutured. What CPT® code is reported?

67908 Rationale: This is a repair of blepharoptosis. In the CPT® Index, look for Blepharoptosis/Repair directs you to code range 67901-67909. The codes are selected based on the approach and technique. After verifying in the numeric section, code 67908 is the correct code.

A 12 year-old male patient has an abscess located at the external auditory meatus. The ENT incises the abscess and packs it to absorb the drainage. What CPT® code is reported?

69020 Rationale: The external auditory meatus is also referred to as the external auditory canal which starts from the opening of the ear to the eardrum. If you look in the CPT® Index under Ear Canal it refers you to See Auditory Canal. Look up Auditory Canal/External/Abscess/Incision and Drainage which guides you to codes 69000, 69005 and 69020. Verify the correct code in the numeric section. 69020 is the correct code for an abscess of the auditory canal. The other codes refer only to the external ear.

The provider makes an incision in the patient's left tympanic membrane in order to inflate eustachian tubes and aspirate fluid in a patient with acute eustachian salpingitis. The procedure is completed without anesthesia. What CPT® and ICD-10-CM codes are reported?

69420, H68.012 Rationale: In the CPT® Index look for Myringotomy and you are directed to 69420-69421. Verify the code in the numeric section. In the ICD-10-CM Alphabetical Index, look for Salpingitis/eustachian (tube)/acute and you are directed to H68.01-. Verification in the Tabular List indicates a 5 th character is needed for laterality. 5 th character of 2 for the left ear.

An ENT performs a patch repair on the left eardrum of a 10 year-old patient. What CPT® code is reported?

69610-LT Rationale: The medical term for eardrum is tympanic membrane. In the CPT® Index look for Repair/Tympanic Membrane which directs you to code 69450, 69610. Repair of the tympanic membrane with or without site preparation of perforation for closure, with or without patch is the description for code 69610 is confirmed in the numeric section. Modifier LT is used to indicate the procedure was performed on the left side.

How many components are included in an effective compliance plan?

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

A contrast radiograph of the salivary glands and ducts is performed, resulting in a diagnosis of salivary fistula. What are the CPT® and ICD-10-CM codes for the supervision and interpretation of this procedure?

70390-26, K11.4 RATIONALE: Contrast radiography of the salivary gland and ducts is considered sialography. Code 70390 describes sialography supervision and interpretation. Look in the CPT® Index for Salivary Glands/X-ray/with contrast. The patient is diagnosed with a salivary fistula, which is found in the ICD-10-CM Alphabetic Index under Fistula/salivary duct or gland K11.4. Verify code selection in the Tabular List.

A DXA body composition study is performed on a patient. What CPT® code(s) would be reported for the scan?

76499 RATIONALE: Dual energy X-ray absorptiometry (DXA) studies are indexed under Dual X-ray Absorptiometry (DXA) in the code range 77080-77086. Under 77081 is a parenthetical instruction stating to use 76499 for a DXA body composition study.

A complete B-scan ultrasound without duplex Doppler of the kidney is performed in the physician's office on a patient following a kidney transplant. What is the CPT® code for the ultrasound?

76775 RATIONALE: Look in the CPT® Index for Ultrasound/Kidney, 76770-76776. CPT® code 76776 is an ultrasound for a transplanted kidney, including real-time and duplex Doppler with image documentation. A duplex Doppler of the kidney is not performed. The parenthetical instruction under CPT® 76776 indicates to report 76775 for an ultrasound of transplanted kidney without duplex Doppler. The correct code is 76775.

A patient with left breast pain and a lump in the breast visits her physician. After examination, the physician orders a mammogram of the left breast. The mammography is performed using computer-aided detection software. What CPT® code is reported for the mammography?

77065 RATIONALE: The physician ordered a unilateral diagnostic mammogram with computer-aided detection (CAD). Code 77065 describes a diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.

A patient with osteoporosis reports to her physician's office for a DXA bone density study of her spine to monitor the severity of her condition. What is the correct CPT® code for the DXA scan?

77080 RATIONALE: DXA is dual-energy X-ray absorption. The site is of the spine, which is part of the axial skeleton. For DXA-See Dual X-ray Absorptiometry (DXA); Dual X-ray Absorptiometry (DXA)/Axial Skeleton. In this case, one site (spine) is involved in the study. The correct code is 77080.

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

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

CASE 10 Clinical Indications: Inpatient day 32 in ICU with fever, hematuria, generalized edema, pneumonia URINE FUNGAL CULTURE - Urine Special Requests: None Culture: No fungus isolated in 30 days LOWER RESP FUNGAL W/DIR. EXAM - Sputum Special Requests: None Stain for Fungus: No fungi seen Culture: One colony Candida albicans BLOOD FUNGAL CULTURE - Blood Arm, Right Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks BLOOD FUNGAL CULTURE - Blood Right IJ Catheter SWAN Special Requests: Aerobic bottle Culture: No fungus isolated in 4 weeks What are the CPT®and ICD-10-CM codes?

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

CASE 6 Requested by R Simon, MD CYTOLOGY REPORT Collected: 1/26/20XX Received: 1/27/20XX, Pathologist performing the service is an employee of the lab. SPECIMEN SOURCE: A. Peritoneal Fluid SPECIMEN DESCRIPTION: 100mls yellow fluid CYTOPREPARATION: 2 ccf PERTINENT CLINICAL DATA AND CLINICAL DIAGNOSIS: 26-year-old female with end-stage renal disease (ESRD) due to type 1 diabetes presents for elective kidney transplant. CYTOLOGIC IMPRESSION: Peritoneal dialysis drain fluid: No cytologically malignant cells are identified. COMMENT: 100 mls yellow fluid is received from which two Papanicolaou stained cytocentrifuged slides are made. Slides contain mesothelial cells with a spectrum of reactive changes and histiocytes. No malignant cells are identified. What are the CPT® and ICD-10-CM codes?

88108 E10.22 N18.6 Z99.2 CPT® code: The test performed is cytopathology on the peritoneal fluid. The documentation indicates cytocentrifuged, meaning that the fluid was removed to concentrate the cells for the smears placed on the slides. In the CPT® Index, look for Cytopathology/Smears/Concentration Technique referring you to 88108. Review of the code description verifies 88108 is the correct code. ICD-10-CM codes: The patient is diagnosed with type 1 diabetes and end-stage renal disease (ESRD). The patient presents for a kidney transplant but the procedure has not been performed yet. The ESRD is a manifestation of the diabetes. In the ICD-10-CM Alphabetic Index, look for Diabetes/type 1/with/chronic kidney disease referring you to E10.22. In the Tabular List there is an instructional note for E10.22 to use additional code to identify stage of chronic kidney disease (N18.1-N18.6). The patient has end-stage renal disease (ESRD) N18.6. There is an instructional note for N18.6 to use additional code to identify dialysis status (Z99.2). Because the case note under Cytologic impression states, "Peritoneal dialysis drain fluid" it is appropriate to also report Z99.2.

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

88307 88300 T86.19 N28.0

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

88307 88311 L97.511

A pregnant female is Rh negative and at 28 weeks gestation. The child's father is Rh positive. The mother is given an injection of a high-titer Rho (D) immune globulin, 300 mcg, IM. What CPT® and ICD-10-CM codes are reported?

90384, 96372, O36.0130, Z3A.28 Rationale: When a mother is Rh negative and the father is Rh positive, the fetus is generally Rh positive, and fetal hemolytic anemia may develop in the fetus. In the CPT® Index look for Immune Globulins/Rho (D) and you are directed to code range 90384-90386. A full dose is 300 mcg. Code 90384 is reported. According to the guidelines for Immune Globulins an administration code is also reported. In the CPT® Index look for Immune Globulin Administration/Injection directing you to 96372. The administration code for intramuscular injection is 96372. In the ICD-10-CM Alphabetic Index look for Rh (factor)/incompatibility, immunization or sensitization/affecting management of pregnancy NEC/anti-D antibody which directs you to O36.01-. Tabular List shows seven characters are needed to complete the code. The 6 th character 3 is used to indicate the patient is in her 3 rd trimester. The 7 th character 0 is used to indicate this is a single gestation. Next look for Pregnancy/weeks of gestation/28 directing you to Z3A.28.

What is the correct code for the administration of one vaccine given intramuscularly for a child under eight years of age when the physician counsels the parents?

90460 Rationale: In the CPT® Index, look for Immunization Administration/One Vaccine/Toxoid/with Counseling. You are directed to use code 90460.

A young child received a mumps, measles, rubella and varicella (MMRV) injection at a neighborhood clinic with provider counseling. What CPT® code(s) are reported?

90710, 90460, 90461 x 3 Rationale: In the CPT® Index look for Vaccine and Toxoids/Measles, Mumps, Rubella and Varicella (MMRV) referring you to 90710. According to the CPT® guidelines for Vaccines and Toxoids, an administration code from 90460-90474 is also reported. In the CPT® Index look for Immunization Administration/Toxoid/with Counseling. Because counseling was included, a code from 90460-90461 is used for the administration. According to the guidelines, 90460 and 90461 are reported per component of the vaccine. Although it is one vaccination, there are four separate components, 90460 is reported for mumps and 90461 x 3 (measles, rubella, and varicella).

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

A patient is seen to have an esophageal motility procedure with acid perfusion study performed. What CPT® code(s) is/are reported?

91010, 91013 Rationale: This is a diagnostic gastrointestinal procedure. Look in the CPT® Index for Gastroenterology, Diagnostic/Esophagus Tests/Motility Study which directs you to codes 91010, 91013. 91010 best describes the motility study with add-on code 91013 used to identify the acid profusion study. Parenthetical note under add-on code 91013 indicates it is reported with code 91010.

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.

CLINICAL SUMMARY: The patient is a 41 year-old female with known coronary disease and recent recurrent chest pain, cardiac catheterization demonstrated subtotal occlusion of the diagonal artery at its takeoff from the left anterior descending artery. PROCEDURE: With informed consent obtained, the patient was prepped and draped in the usual sterile fashion. With the right groin area infiltrated with 2% Xylocaine, the patient was given 2 mg of Versed and 50 mcg Fentanyl intravenously for conscious sedation and pain control. The right femoral artery was cannulated with a modified Seldinger technique and a 6 French catheter sheath placed. A 6 French JL3.5 catheter with no side holes was utilized as a guiding catheter. After the initial guiding picture had been obtained, the patient was given Angiomax per protocol, and a short Cross-it 100 wire was advanced to the LAD and then into the diagonal vessel. A 2.0. 15-mm-long Maverick balloon was used for dilatation of the diagonal artery ostium with inflation pressure up to 8 atmospheres applied. Final angiographic documentation was carried out after the patient received 200 mcg of intracoronary nitroglycerine. The guiding catheter was then pulled, the sheath secured in place. The patient is now being transferred to telemetry for post coronary intervention observation and care. RESULTS: The initial guiding picture of the left coronary system demonstrates the high-grade ostial stenosis of the diagonal artery taking off within the LAD. Following the coronary intervention with balloon angioplasty there is complete resolution of the stenosis with less than 10 percent residual narrowing observed, no evidence for intimal disruption, no intraluminal filling defect, and good antegrade TIMI III flow preserved. CONCLUSION: Successful coronary intervention with balloon angioplasty to the ostial/proximal segment of the second diagonal vessel. What CPT® is reported?

92920-LD Rationale: Percutaneous balloon angioplasty (Maverick balloon used for dilatation) performed in the diagonal artery of the left anterior descending coronary artery (LD). A base code for angioplasty of a major coronary artery or branch is reported. Look in the CPT® Index for Coronary Artery/Angioplasty which directs you to 92920-92921. The angioplasty 92920 is reported with modifier LD. Conscious sedation is included in the procedure.

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 directing you to see Percutaneous Transluminal Angioplasty. Under Percutaneous Transluminal Angioplasty/Artery/Coronary. Code 92920 is used for the main coronary artery which is the left anterior descending. The add-on code 92921 is used to report the PTCA to a branch off of the left anterior descending - the first diagonal.

INDICATIONS FOR CORONARY INTERVENTION: Acute inferior myocardial infarction. Documented mildly occlusive plaque with much clot in the right coronary artery. PROCEDURE: Insertion of temporary pacemaker in the right femoral vein. Primary stenting of the right coronary artery with a 4.5 x 16 mm Express stent. Angio-Seal to the vessels of the right common femoral artery post procedure, and also Angio-Seal of the right common femoral vein. TECHNIQUE: Judkins percutaneous approach from the right groin with Perclose at the arterial puncture site post procedure. CATHETERS: 4 French Angio-Jet catheter device, insertion of a 5 French temporary pacing wire, a 4.5 x 16 mm Express stent. PRESSURES: Aortic Pressure: 107/78 RESULTS: Coronary stenting procedure of the right coronary artery: The right coronary artery was primarily stented with a 4.5 x 16 mm Express stent. It was expanded to 12 atmospheres. There was no residual stenosis. IMPRESSION: Successful Angio-Jet and stenting of the distal right coronary artery with no residual stenosis. Angio-Seal to the right femoral vein post procedure. PROCEDURE: Through the femoral artery sheath, the EBU was advanced to the right coronary. Following this a PT graphic intermediate wire was used to cross the lesion. Following this angioplasty of the lesion was performed, utilizing a 2.5 x 20 millimeter CrossSail balloon at multiple sites to ten atmospheres. Following this there was a fair result; however, there was a significant stenosis and significant calcification at the area, and the decision was made to pursue trying to stent the lesion. Multiple stents were attempted, including a 2.5 x 9 millimeter zipper MX and a 2.5 x 13 millimeter Guidant stent. This was abandoned, and in switching out to a balloon for further ballooning, the patient became hypertensive and with difficulty in terms of her respiratory status. Angiography revealed an occlusion of the mid left anterior descending and thrombus throughout the proximal left anterior descending extending into the left main. Recheck of ACT showed the ACT to be at eight seconds. This likely represented subtherapeutic range for her anticoagulation. A check of her medications revealed that instead of Angiomax, the patient had been given ReoPro without antithrombotic agent. She was therefore given IV heparin up to 12,000 units, and her ReoPro was continued. The lesion was then rewired, and an AngioJet was used to try to suction out this area of thrombus. Unfortunately, the AngioJet was unable to cross the mid left anterior descending lesion and therefore was somewhat limited in its use for a more distal thrombus, although it did suction out the proximal left anterior descending thrombus. At this point, the patient was emergently intubated, and multiple pressors were started, including dopamine, Levophed, vasopressin, and epinephrine. Following this, a laser was attempted to cross the lesion an excimer laser X80 Spectranetics 0.9 Vitesse; however, this laser was unable to cross the lesion. Therefore, a long balloon, a 2.0 x 40 millimeter CrossSail balloon, was used to cross the lesion and inflate multiple segments of the mid left anterior descending up to a maximum inflation pressure of ten atmospheres. This improved flow though by no means restored it back to normal. Therefore, following this, longer balloon inflations were performed utilizing a 2.0 x 20 millimeter CrossSail balloon up to fourteen atmospheres for one and a half minutes. This did not improve significantly the flow distally, and therefore the decision was made to try to stent the mid segment with a 2.5 x 9 millimeter zipper MX stent to a maximum inflation pressure of fourteen atmospheres. This resolved the issue in terms of the mid left anterior descending lesion; however, beyond the stent there continued to be residual stenosis, and multiple balloons were used to balloon this up to a 2.5 x 20 millimeter balloon up to fourteen atmospheres. The final result in the left anterior descending revealed a lesion in the mid-left anterior descending that was approximately 40 percent, there was TIMI III flow throughout the proximal and mid left anterior descending. However, at the level of the apex, there was TIMI 0 flow. Throughout the angioplasty, the patient had episodes of bradycardia, and a temporary pacemaker was placed, and this was removed at the end of the procedure. IMPRESSION: Successful stent to the mid left anterior descending, complicated by thrombotic event in the left anterior descending system. Final result was a successful stent to the mid left anterior descending with residual TIMI 0 flow in the distal left anterior descending. We returned to the right coronary artery and successfully employed a 4.5 x 16 mm Express sent. At the end of the case, an intra-aortic balloon pump was placed in the left femoral artery sheath, and the patient was sent to the Coronary Care Unit on multiple pressors including epinephrine, vasopressin, Levophed and dopamine. What CPT® coding is reported?

92928-RC, 92928-LD, 33967, 92973 Rationale: Only one base code is reported per major coronary artery. In this case angioplasty and stent placement was performed in the right coronary artery (92928-RC) and in the left anterior descending (92928-LD). Look in the CPT® Index for Coronary Artery/Angioplasty/with Stent Placement directing you to 92928-92929. A thrombectomy was performed by AngioJet in the LD reported with 92973. Look in the CPT Index for Coronary Artery/Thrombectomy which directs you to 92973. A temporary pacemaker was inserted through the femoral vein; however, it is bundled with the cardiac catheterization. At the end of the procedure, an intra-aortic balloon pump was inserted, 33967. Look in the CPT® Index for Insertion/Balloon/Intra-Aortic which directs you to 33967, 33973.

Intracoronary stents are placed percutaneously in the right coronary and left anterior descending arteries for a patient with stenosis. Percutaneous transluminal balloon angioplasty is performed on the left circumflex coronary artery. Choose the correct CPT® codes for this procedure.

92928-RC, 92928-LD, 92920-LC Rationale: Only one base intervention is reported for each major coronary artery. The hierarchy from highest to lowest is as follows: atherectomy, stent placement, followed by angioplasty. The base intervention code 92928 is reported for the stent placement in the right coronary (92928-RC) and the left anterior descending arteries (92928-LD). Each is reported with the corresponding coronary artery modifiers. Look in the CPT® Index for Coronary Artery/Angioplasty/with Stent Placement and you are directed to 92928-92929. To locate the angioplasty code, look in the CPT® Index for Coronary Artery/Angioplasty which directs you to 92920-92921. The base code 92920-LC is reported for the angioplasty of the left circumflex.

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

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

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. Codes 93000, 93010. 93000 includes the 12 lead EKG in addition to the interpretation and report. The provider only provided the interpretation and report making 93010 the correct code choice. Modifier 52 to report reduced services is not appropriate because there are codes that can specifically report each component.

Mrs. Salas had angina decubitus that lasted for 30 minutes and was admitted to the Coronary Care Unit with a diagnosis of r/o MI. The cardiologist (private practice based) takes her to the cardiac catheterization suite at the local hospital for a left heart catheterization. Injection procedures for selective coronary angiography and left ventriculography were performed and imaging supervision and interpretation for the selective coronary angiography and left ventriculography was provided. What CPT® code(s) is/are reported for the services?

93458-26 Rationale: Left heart catheterization in the CPT® Index refers you to Cardiac Catheterization/Left Heart/with Ventriculography. Code 93452 is for the left heart catheterization for left ventriculography alone. Code 93458 includes coronary artery angiography, left heart catheterization and injection procedures for coronary angiography and left ventriculography with imaging supervision and interpretation. Modifier 26 is reported for the professional component of radiologic services.

During an inpatient hospitalization, a patient who suffered myocardial infarction had a combined right and left heart catheterization. Access was achieved through the right femoral artery and the right femoral vein. Selective catheterization of the coronary arteries and selective catheterization of the left ventricle were followed by injections of contrast and angiography. During right heart catheterization, angiography of the right atrium was performed. Imaging supervision, interpretation and report for all angiography was performed during the cardiac catheterization. Select the CPT® coding for this procedure by the cardiologist.

93460-26, 93566 Rationale: There are three parts to cardiac catheterization: selective catheter placement, injection of contrast, and radiologic supervision and interpretation and report which are included in most of the cardiac catheterization codes. In the CPT® Index look for Cardiac Catheterization/Combined Left and Right Heart/with Left Ventriculography which directs you to 93453, 93460-93461. Code 93460 includes right and left heart catheterization, coronary angiography, and left ventriculography. None of the combined right and left heart catheterizations include right atrial angiography; therefore, the add-on code 93566 is reported. Modifier 26 is required to report the professional service. The add-on code 93566 for the injection procedure is a professional service, and modifier 51 is not required.

What is the CPT® code used to report a right heart cardiac catheterization for congenital anomalies?

93530 Rationale: In the CPT® Index, look for Catheterization/Cardiac directs you to See Cardiac Catheterization. Cardiac Catheterization/Right Heart/Congenital Cardiac Anomalies directs you to code 93530.

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

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

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

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

A 70 year-old male presents with localized edema in his legs. He has hypertension and congestive heart failure and is currently on medication for both conditions. The provider ordered a complete venous duplex scan of his lower extremities. The femoral, superficial femoral, posterior tibial and popliteal veins were assessed. There was no evidence of thrombus. The study was normal. What CPT® and ICD-10-CM codes are reported?

93970, R60.0, I11.0, I50.9 Rationale: In the CPT® Index look for Duplex Scan/Venous Studies/Extremity. Code 93970 indicates a complete bilateral study. For the ICD-10-CM codes, since the study was normal, the symptoms indicating the test are reported. In the ICD-10-CM Alphabetic Index look for Edema/legs or Edema/localized which refers you to code R60.0. The hypertension and congestive heart failure has a causal relationship. In the Alphabetic Index, look for Hypertension/heart/with/heart failure (congestive) referring you to I11.0. Instructional note in the Tabular List for I11.0 indicates to also identify the type of heart failure. Look for Failure, failed/heart/congestive which refers you to I50.9. Verification in the Tabular List confirms code selections.

A patient who has had two recent seizures underwent a 3-hour continuous EEG recording, without video. The physician interpreted the study and documented a report in the patient's medical record. What CPT® code is reported?

95717 Rationale: In the CPT® Index look for EEG directing you to See Electroencephalography (EEG). Look for Electroencephalography (EEG)/Recording/Detection. The patient had a 3 hour continuous EEG without use of video which the physician interpreted, not an EEG technologist. The correct code to report is 95717.

A patient diagnosed with amyotrophic lateral sclerosis has increasing muscle weakness in the upper extremities. The provider orders needle electromyography (EMG) to record electrical activity of the muscles. What CPT® and ICD-10-CM codes are reported?

95861, G12.21 Rationale: In the CPT® Index look for Electromyography/Needle/Extremities. Code selection is based on the number of extremities studied. In this case, two extremities (upper) are studied making 95861 the correct code selection. Amyotrophic lateral sclerosis (ALS) is also known as Lou Gehrig's disease. In the ICD-10-CM Alphabetic Index, look for Amyotrophia, amyotrophy, amyotrophic/lateral sclerosis or Sclerosis/amyotrophic (lateral) which directs you to code G12.21. Verification in the Tabular List confirms code selection.

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

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

A patient with carcinoma of the descending colon presents for chemotherapy administration at the infusion center. The infusion was started with 1000 cc of normal saline. Heparin, 1000 units was added and then Fluorouracil, 800 mg was added and infused over 2 hours. Dexamethasone, 20 mg was administered, IV push. At the end of the 2 hours, the IV was disconnected and the patient was discharged. What codes are reported?

96413, 96415, 96375, J9190 x 2, J1100 x 20, J1644, Z51.11, C18.6 Rationale: In the CPT® Index look for Chemotherapy/Intravenous/Infusion. Chemotherapy infusion administration ran for two hours and is reported with 96413 for the 1st hour and 96415 for each additional hour. Dexamethasone was administered as a push technique. Dexamethasone is not a chemotherapy agent. In the CPT® Index, look for Injection/Intravenous Push referring you to 96374-96376. This is a sequential infusion following the initial service of chemotherapy and is reported with add-on code 96375. The chemotherapy drugs are Fluorouracil and Heparin. The Fluorouracil is reported with J9190 (HCPCS Level II). It is listed as 500 mg therefore 2 units are charged for 800 mg administered. Heparin (J1644) is listed as 1,000 units, therefore one unit is reported for the 1000 units given. Dexamethasone is packaged in 1 mg; charge 20 units for the 20 mg administered (J1100). Per ICD-10-CM guideline I.C.2.e.2 a visit for the purpose of chemotherapy is reported with Z51.11 with the primary and the malignancy sequenced second. In the ICD-10-CM Alphabetic Index, look for Chemotherapy(session) (for)/cancer which directs you to Z51.11. Report also the reason for the chemotherapy. In this case, it is carcinoma of the descending colon. Look in the Alphabetic Index for Carcinoma which states see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/intestine, intestinal/large/descending and select from the Malignant Primary column which refers you to C18.6. Verification in the Tabular List confirms code selection.

A patient mangled his left hand in machinery requiring amputation at the wrist. The wound has healed and the patient is fitted with an artificial hand. The device has a molded socket, flexible elbow hinges and triceps pad. A total of 30 minutes was spent training the patient to use the prosthesis. What codes are reported for the prosthesis, training and diagnosis?

97761 x 2, L6050, Z44.8, Z89.112 Response Feedback: Rationale: In the CPT® Index look for Training/Prosthetics and you are directed to 97761. The code is reported for each 15 minutes. Since 30 minutes were spent training, 2 units are reported. In the HCPCS Level II codebook look for Wrist/Disarticulation prosthesis, and you are directed to codes L6050, L6055. Based on the description the prosthesis is reported with code L6050. The wound has healed and is ready for fitting of the prosthesis. In the ICD-10-CM Alphabetic Index look for Fitting (and adjustment) (of)/device NOS/prosthetic (external)/specified NEC directing you to code Z44.8. In the Alphabetic Index look for Absence (of) (organ or part) (complete or partial)/hand and wrist (acquired) referring you to code Z89.11-. Tabular List shows 6 th character of 2 to indicate left hand amputation site.

An 11 month-old patient presented for emergency surgery to repair a severely broken arm after falling from a third story window. What qualifying circumstance code(s) may be reported in addition to the anesthesia code?

99100, 99140 Rationale: In the CPT® Anesthesia Guidelines under the subheading Qualifying Circumstances each of the qualifying circumstances codes identifies a different circumstance, and more than one may be appended when applicable, unless the reported anesthesia code already contains the risk factor. In this case, 99100 is assigned for extreme age of one year or younger and 99140 is assigned for emergency conditions. Note: Qualifying Circumstances codes may also be found in CPT® Medicine Subsection Miscellaneous Services/Qualifying Circumstances for Anesthesia.

A 30 year-old male cut his right hand on a nail repairing the gutter on his house. Six days later it became infected. He went to the intermediate care center in his neighborhood, his first visit there. The wound was very red and warm with purulent material present. The wound was irrigated extensively with sterile water and covered with a clean sterile dressing. An injection of Bicillin CR, 1,200,000 units was given. The patient was instructed to return in three to four days. The provider diagnosed open wound of the hand with cellulitis. A problem focused history and examination with a low MDM were performed. What are the codes?

99201, 96372, J0558 x 12, S61.411A, L03.113, W45.0XXA, Y93.H9 Rationale: The patient is a new patient to the clinic. Code selection is made from 99201-99205 for the office visit. For a new patient, all three key components must be met. The clinic visit is reported as 99201. In the CPT® Index look for Antibiotic Administration/Injection. Code selection is based on the route of administration. The administration of the antibiotic is reported with 96372. The Bicillin CR is found in the HCPCS Level II codebook in the Table of Drugs and Biologicals. Look for Bicillin C- which directs you to code J0558. The code descriptor for J0558 is 100,000 units. Report 12 units to correctly charge for the 1,200,000 units delivered to the patient, J0558 x 12. In the ICD-10-CM Alphabetic Index look for Wound, open/hand/laceration which states to see Laceration, hand. Look for Laceration/hand/right directing you to S61.411-. Tabular Lists indicates a 7 th character is needed to complete the code. Report A for the initial encounter. Next, look in the Alphabetic Index for Cellulitis/hand which states to see Cellulitis, upper limb. Look for Cellulitis/upper limb referring you to L03.11-. Complete code in the Tabular List to indicate right hand, L03.113. Then look in the ICD-10-CM External Cause of Injuries Index for Contact (accidental)/nail referring you to W45.0-. The Tabular List indicates the code is complete with seven characters. The complete code requires placeholders be placed at the 5 th and 6 th characters and a 7 th character A for initial encounter. The second external cause code is used to identify the activity. In the External Cause of Injuries Index look for Activity/maintenance/property referring you to Y93.H9. Verification in the Tabular List confirms code selection.

A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

99203 Rationale: Patient is coming to the provider's office for help to quit smoking. The patient is new. The provider documents that 20 minutes of the 30 minute visit was spent counseling the patient. E/M Guidelines identify when time is considered the key or controlling factor to qualify for an E/M service. When counseling and/or coordination of care is more than 50% face to face time in the office or other outpatient setting, time may be used to determine the level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.

A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist.

99212 Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Problem Focused (HPI Brief, ROS None, PFSH Pert), Exam Problem Focused, MDM Moderate (Management options: 1 stable problem, one new problem with workup; Data reviewed: lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.

A 45 year-old established female patient is seen today at her provider's office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the provider documents a moderate complexity MDM. What CPT® code is reported for this visit?

99214 Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Detailed (HPI Extended; ROS Extended, PFSH Complete), Exam Detailed, MDM Moderate. 99214 is the level of visit supported.

A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

99214, K37, R12 Rationale: This is an established patient E/M level of service due to the indication she returning to her provider for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-10-CM guidelines I.B.4 or I.B.18, a definitive diagnosis is reported when it has been established. Look in the ICD-10-CM Alphabetic Index for Appendicitis which directs you to K37. Guideline I.B.5 indicates any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code, refer to guideline I.B.6. Look in the Alphabetic Index for Heartburn which directs you to R12. Verification in the Tabular List confirms code selections.

A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PM Detailed History, Detailed Exam, Low MDM Discharge date/time: 01/22/20XX 8:15 AM Discharge time: 20 minutes What CPT® code(s) is/are reported for the admission and discharge to Observation Care?

99218, 99217 Rationale: Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code 99217 states this code is to be utilized to report all services provided to a patient on discharge from observation status if the discharge is on other than the initial date of observation status Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge.

A 90 year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

99235 Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate." The provider performed a comprehensive history, comprehensive exam, and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

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

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

ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric. PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema. LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate. IMPRESSION Hypoxic respiratory failure Community acquired pneumonia Septic shock Non-oliguric acute renal failure PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90 Usual labs ordered for tomorrow. Critical care time: 35 minutes What CPT® code(s) is/are reported?

99291 Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient's condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45 minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?

99291-25, 31500, 36510, 94610 Rationale: When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). According to CPT® Critical Care Services guidelines these procedures are not included in the critical care codes. Therefore, they can be reported separately in addition to critical care services with modifier 25 appended to code 99291.

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

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

A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI.What CPT® code(s) is/are reported for this visit?

99393, 99213-25 Rationale: The physical exam code is selected from the Preventive Medicine Services and selected based on whether the patient is new or established and by age. The pediatrician also evaluates and treats the URI. The additional work for the URI allows us to report an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.

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

99475 A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?

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.

What disease is characterized by enlarged skeletal parts?

Acromegaly

ABN stands for _____.

Advanced Beneficiary Notice

Which provider is NOT a mid-level provider?

Anesthesiologist Rationale: Mid-level providers include physician assistants (PA) and nurse practitioners (NP). An anesthesiologist is a physician. Mid-level providers are also known as physician extenders because they extend the work of a physician.

How often are HCPCS Level II permanent national codes updated?

Annually

When coding for surgery performed on the Skull Base (61580-61598) what term describes the method used to gain exposure to the lesion?

Approach procedure Rationale: The approach procedure is the method used to access the lesion. The approach procedure to the skull base is reported using codes 61580-61598. In the CPT® Index look for Skull Base Surgery and you will see that many of the subterms indicate Approach, with a code range of 61580-61598.

A 23 year-old woman delivers her second child by cesarean delivery. Her first child was delivered by cesarean (vertical incision) and the decision is made early in her pregnancy for a repeat cesarean. The patient started her antenatal (prenatal) care in Arizona and then moved to Wisconsin when her husband was transferred to a new job. She had two antenatal visits during the first trimester in Arizona and 10 more antenatal visits with her new provider for her second and third trimesters in Wisconsin before the repeat cesarean delivery was performed. She delivered a healthy baby girl. She will follow up with her Wisconsin physician after discharge for postpartum care. What are the procedure and diagnosis codes for her Arizona physician and her Wisconsin physician including her antenatal care, delivery and postpartum care procedures?

Arizona: 2 E/M codes, one for each visit - Z34.81; Wisconsin: 59515- O34.212, Z3A.00, Z37.0, 59426 - Z34.82, Z34.83 Rationale: According to CPT®, if the physician does not provide all the antepartum care, you cannot report a global obstetric service. Instead, you must itemize the services provided using either E/M codes or the codes for antepartum care only and delivery with postpartum care only. Not all insurers follow CPT® rules. The Arizona provider may bill two visits with E/M codes depending on the documentation of the visits because she only had 2 antenatal visits. Wisconsin provider delivered the baby and will be providing the postpartum care. Look in the CPT® Index for Cesarean Delivery/Delivery with Postpartum Care and you are referred to 59515. Next in the CPT® Index look for Obstetrical Care/Antepartum Care and you are directed to 59425, 59426. The Wisconsin physician provided 10 antenatal visits, so 59426 is reported. Look in the ICD-10-CM Alphabetic Index for Pregnancy/prenatal care only/specified Z34.8-. This is not her first pregnancy and the encounters occurred during the first trimester so Z34.81 is reported for the Arizona physician and then codes Z34.82 and Z24.83 for the Wisconsin physician for the antenatal visits for the second and third trimesters. Code 59515 the Wisconsin physician will report diagnosis code O34.212 for a previous cesarean delivery code, Z3A.00 to indicate unspecified weeks of pregnancy and Z37.0 for the single birth. In the ICD-10-CM Alphabetic Index look for Cesarean delivery, previous, affecting management of pregnancy/classical (vertical) scar and you are referred to O34.212. In the Alphabetic Index look for Pregnancy/weeks of gestation/unspecified weeks and you are directed to Z3A.00. Next look in the Alphabetic Index for Outcome of delivery/single NEC/live born, referring you to code Z37.0. Verify all codes in the Tabular List.

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

As though it was a simple closure Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one-layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material is coded using the appropriate E/M code.

What is being removed for hallux valgus surgery?

Bunion

What temporary HCPCS Level II codes are required for use by Outpatient Prospective Payment System (OPPS) Hospitals?

C codes

Operative Report: Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheek Suspicious lesion, left nose Suspicious lesion, left forehead Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear margins Compound nevus, left nose with clear margins Epidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47 year-old white man with a biopsy proven basal cell carcinoma of his forehead and a biopsy proven basal cell carcinoma of his right cheek. We were not quite sure of the patient's location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6 mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well. What ICD-10-CM codes are reported?

C44.319, D22.39 Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/forehead (skin)/basal cell carcinoma/Malignant Primary column referring you to C44.319. Next, is basal cell carcinoma, right cheek; look for Neoplasm, neoplastic/cheek/external/basal cell carcinoma/Malignant Primary column referring you to C44.319. Because both basal cell carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the Alphabetic Index for Nevus/skin/nose (external) directing you to D22.39. Then, in the Alphabetic Index look for Nevus/skin/forehead directing you to D22.39. Because the codes are the same, the code is reported only once. Verify all code selections in the Tabular List.

A patient is taken to surgery for removal of a squamous cell carcinoma of the right thigh. What is the correct diagnosis code for today's procedure?

C44.722 Rationale: In the ICD-10-CM Alphabetic Index look for Carcinoma, there is a note to see also Neoplasm by site, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/skin NOS/limb NEC/lower/squamous cell carcinoma/Malignant Primary column refers you to subcategory code C44.72-. In the Tabular List the 6 th character 2 indicates the right lower limb (thigh).

What ICD-10-CM code is reported for carcinoma of the bladder dome?

C67.1 Rationale: Neoplasm codes of the bladder, as well as other organs, are specific to site. In the ICD-10-CM Table of the Neoplasms look for Neoplasm, neoplastic/bladder (urinary)/dome and select the code from the Malignant Primary column which directs you to code C67.1. If the provider's documentation does not report the exact location of the tumor, use the unspecified diagnosis code C67.9. Verify code selection in the Tabular List.

What form is used to submit a provider's charge to the insurance carrier?

CMS-1500

What parts make up the large intestine?

Cecum with vermiform appendix, ascending colon, transverse colon, descending colon, sigmoid colon, rectum and anus

What does CMS-HCC stand for?

Centers for Medicare & Medicaid Services - Hierarchal Condition Category

Bile empties into the duodenum through what structure?

Common bile duct Rationale: The liver produces bile which passes from the bile duct of the liver and finds its way into the small intestine by way of common bile duct.

The OIG recommends that provider practices enforce disciplinary actions through well publicized compliance guidelines to ensure actions that are ______.

Consistent and appropriate Rationale: The OIG recommends that a provider practice's enforcement and disciplinary mechanisms ensure that violations of the practice's compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual.

Which plane divides the body into anterior and posterior sections?

Coronal

Which option best describes what is being done during strabismus surgery?

Corrects the muscle misalignment.

The minimum necessary rule applies to

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

What is the correct diagnosis code to report treatment of a melanoma in-situ of the left upper arm?

D03.62 What is the correct diagnosis code to report treatment of a melanoma in-situ of the left upper arm?

A patient with hypertension presents to the outpatient hospital radiology department for an ultrasound due to a suspected suspicious mass. The patient's provider performed an ACTH and a 24-hour urinary free cortisol and short suppression test confirming the diagnosis of Cushing's disease. The radiology report indicated a 5.5 cm right adrenal mass that appeared well circumscribed and rounded. The final diagnosis indicated Cushing's disease secondary to a right adrenal tumor. The hypertension is due to the Cushing's syndrome. What ICD-10-CM codes are reported?

D49.7, E24.9, I15.2 Rationale: The patient has Cushing's disease secondary to an adrenal tumor. First code the adrenal tumor. We are told that there is a right adrenal tumor; however, we are not given more information as to a specific type of adrenal tumor and whether it is benign or malignant. In the ICD-10-CM Alphabetic Index look for Tumor (see also Neoplasm, unspecified behavior, by site). Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/adrenal and use the code from the Unspecified Behavior column directing you to D49.7. Next, in the ICD-10-CM Alphabetic Index find Cushing's/syndrome or disease which directs the coder to E24.9. The unspecified code for Cushing's syndrome is used because we are not given the specific type of Cushing's the patient has. The Cushing's syndrome is associated to the hypertension. Look for Hypertension/due to/endocrine disorder referring you to code I15.2. Verify all codes in the Tabular List.

What is the term for uncontrolled muscle movements?

Dyskinesia

Friends brought a young male with type 1 diabetes to the emergency department, in a comatose state. He was admitted with ketoacidosis and was resuscitated with saline hydration via insulin drip. After regaining consciousness, the patient reported that the morning of admission he was experiencing nausea and vomiting and decided not to take his insulin because he had not eaten. He was treated with intravenous hydration and insulin drip. By the following morning, his laboratory work was within normal range and he was experiencing no symptoms. What ICD-10-CM code(s) are reported?

E10.11 Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/ketoacidosis/with coma guiding you to code E10.11. Code Z79.4 Long term use of insulin is not required for a type 1 diabetic because these patients are insulin dependent. Verify code selection in the Tabular List.

A patient with type 2 diabetes presents with diabetic macular edema and proliferative diabetic retinopathy in the right eye. What ICD-10-CM code(s) is/are reported?

E11.3511 Rationale: Look in the ICD-10-CM Alphabetic Index Diabetes, diabetic (mellitus) (sugar)/type2/with/retinopathy/proliferative/with macular edema which directs you to E11.351-. There is a checkmark next to the code in the Alphabetic Index reminding the coder to check the Tabular List for the 7 th character to show laterality. From the Tabular List, assign 7 th character 1 to identify the right eye.

What diagnosis codes should be reported for a patient with polyneuropathy as a result of vitamin B deficiency?

E53.9, G63 Rationale: In the ICD-10-CM Alphabetic Index look for Polyneuropathy/in (due to) deficiency (of)/B (-complex) vitamins guiding you to codes E53.9 [ G63]. Code G63 is a manifestation code. In the Tabular List the description is Polyneuropathy in other diseases classified elsewhere. There is an instructional note stating to code first underlying disease such as nutritional deficiency (E40-E64). Verify code selection in the Tabular List.

What is the correct ICD-10-CM code for a 30 year-old obese patient with a BMI of 32.5?

E66.9, Z68.32 Rationale: In the ICD-10-CM Alphabetic Index, look for Obesity. You are directed to E66.9. In the Tabular List under category code E66 there is an instructional note to use additional code to identify body mass index (BMI), if known (Z68.-). Code Z68.32 represents an adult BMI of 32.0-32.9.

EHR stands for:

Electronic health record

The provider sees a 70 year-old patient with a documented history in the past few months of being combative and aggressive in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation on her combative and aggressive behavior. What ICD-10-CM code(s) is/are reported?

F03.91 Rationale: In ICD-10-CM Alphabetic Index look for Dementia/with/aggressive behavior directing you to F03.91. Next, look for Dementia/with/combative behavior directing you to F03.91. Verify the codes in the Tabular List. Both manifestations are reported with the same code, so it is only reported once according to ICD-10-CM guideline I.B.12.

A young female was brought to the clinic by her sister. She has had periods of severe depression for many years and is on Lithium. Her provider also manages her manic-depressive psychosis, hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for Lithium adjustment. Diagnoses are moderate manic-depressive bipolar with circular current manic state, hypothyroidism, and migraine. What ICD-10-CM codes are reported?

F31.12, E03.9, G43.909 Rationale: In the ICD-10-CM Alphabetic Index look for Disorder/bipolar/current (or most recent) episode/manic/without psychotic features/moderate guiding you to code F31.12. No code assignment is necessary for depression because depression is a component of bipolar disorder. Although not psychiatric conditions, both hypothyroidism and migraine headaches are coexisting conditions under treatment and are coded. In the Alphabetic Index, look for Hypothyroidism which directs you to E03.9 and look for Migraine directing you to code G43.90-. Verify the codes in the Tabular List. When reviewing code G43.90 in the Tabular List, a 6th character of 9 is selected because there is no mention of an intractable migraine or status migrainosus.

A young male was brought to the clinic by his mom. He has had periods of major depression for many years and is on Lithium. His provider also manages his migraine headaches and epilepsy. During the past week, he became psychotic, hearing voices to kill himself and intense feelings of worthlessness. On the day of the clinic visit, he had an epileptic seizure that could not be controlled by medication. He was admitted for Lithium adjustment. Final diagnoses are: Severe depression with psychotic behavior and epileptic seizure poorly controlled with medication. What ICD-10-CM codes should be reported?

F33.3, G40.919 Rationale: Only two final diagnoses are documented, the depression and epilepsy. The migraine headache is not coded because it was not treated or listed as a final diagnosis. In the ICD-10-CM Alphabetic Index look for Depression/major recurrent - see Disorder, depressive, recurrent. Look for Disorder/depressive/major recurrent referring you to code F33.9. The patient has severe depression and became psychotic. Look for Disorder/depressive/recurrent/current episode/severe/with psychotic symptoms referring you to code F33.3. Next, in the Alphabetic Index look for Epilepsy, epileptic, epilepsia (attack) (cerebral) (convulsion) (fit) seizure)/intractable G40.919. The mention of poorly controlled with medication makes the epilepsy intractable.

Services provided in the home by an agency are considered

Facility services

Hallux rigidus is a condition affecting what part of the body?

Foot

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

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

What ICD-10-CM code is used for intractable grand mal seizures without status epilepticus?

G40.419

A 50 year-old female presents to her provider with symptoms of insomnia and upset stomach. The provider suspects she is premenopausal. She is diagnosed with impending menopause. What diagnosis code(s) should be reported?

G47.00, K30 Rationale: ICD-10-CM guideline I.B.11 states to reference the ICD-10-CM Alphabetic Index to determine if the condition has a subentry for impending or threatened and also reference main term entries for Impending and Threatened. If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. Look in the Alphabetic Index for Impending. There is not a subterm for menopause; therefore, the symptoms are coded. Look for Insomnia (organic) which directs the coder to G47.00. Next, look for Upset/stomach which directs the coder to K30. Verify code selection in the Tabular List.

What is the term that describes the removal of a portion or all of the stomach?

Gastrectomy Rationale: The prefix gastr- refers to the stomach and the suffix -ectomy indicates removal of.

What are the three classifications of anesthesia?

General, Regional and Monitored Anesthesia Care Rationale: An epidural is a type of regional anesthesia. Moderate or conscious sedation is typically provided by the same physician performing the service sedation supports and requires the presence of an independent observer to monitor the patient.

What type of print indicates new additions and revisions in the CPT® code book each year?

Green print

After referral from the ED, a patient sees an ophthalmologist to examine an old injury with a retained magnetic iron metal foreign body in his posterior wall within the right eye. There is concern for an infection. What ICD-10-CM codes are reported?

H44.641, Z18.11 Rationale: In the ICD-10-CM Alphabetic Index look for Foreign body/intraocular/old, retained/magnetic/posterior wall guiding you to code H44.64-. In the Tabular List, 6 th character 1 is assigned for the right eye. Subcategory code H44.6 has instructions to use an additional code to identify the foreign body (Z18.11). Z18.11 identifies a retained magnetic fragment. Verify code selection in the Tabular List.

If a CPT® code and a HCPCS Level II code exist for the same service, which one does Medicare prefer to report?

HCPCS Level II code

Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security?

HITECH: The Health Information Technology for Economic and Clinical Health Act (HITECH) was enacted as a part of the American Recovery and Reinvestment Act of 2009 (ARRA) to promote the adoption and meaningful use of health information technology. Portions of HITECH strengthen HIPAA rules by addressing privacy and security concerns associated with the electronic transmission of health information.

What does the acronym HCPCS stand for?

Healthcare Common Procedure Coding System

What is the term for paralysis affecting one side of the body?

Hemiplegia

What term relates to connection of skin to underlying muscles?

Hypodermis

Patient is seen in his physician's office and diagnosed with benign hypertension and stage 3 chronic kidney disease.

I12.9, N18.3 Rationale: ICD-10-CM Coding Guideline I.C.9.a.3 states a causal relationship is always assumed with hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for Hypertension/kidney/with/stage 1 through stage 4 chronic kidney disease which directs you to I12.9. Verify the code in the Tabular List. The note below code I12.9 instructs you to report an additional code for the stage of chronic kidney disease. This is stage 3; therefore, N18.3 is also reported.

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

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

What ICD-10-CM code is used for the first episode of an acute myocardial infarction?

I21.9 Rationale: In the ICD-10-CM Alphabetic Index, look for Infarct, infarction/myocardium, myocardial (acute) (with stated duration of 4 weeks or less) guiding you to I21.9. Verify code selection in the Tabular List.

A patient is admitted after being found unresponsive at home. The patient had right-sided hemiplegia and aphasia from a previous CVA. The provider documents a current cerebral infarction due to occlusion of the right middle cerebral artery as the final diagnosis and the patient is transferred for rehabilitation. What ICD-10-CM code(s) is/are reported?

I63.511, I69.351, I69.320 Rationale: Refer to ICD-10-CM guideline I.C.9.d.2. Look in the ICD-10-CM Alphabetic Index for Infarct, infarction/cerebral/due to/occlusion NEC/cerebral arteries directing you to code I63.5-. Report I63.511 Cerebral infarct due to unspecified occlusion or stenosis of right middle cerebral artery. This patient has a history of CVA with right-sided hemiplegia and aphasia. Look in the Alphabetic Index for Sequelae (of)/infarction/cerebral/hemiplegia which directs the coder to I69.35-. Also look for Sequelae/infarction/cerebral/aphasia I69.320. Verify in the Tabular List I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Per ICD-10-CM guideline I.C.9.d.1 because the right side was affected and we do not know the dominant side, the default for dominance is right.

A patient suffered postoperative left heart failure following repair of an abdominal aortic aneurysm. What ICD-10-CM code(s) is/are reported?

I97.131, I50.1 Rationale: In the ICD-10-CM Alphabetic Index look for Complication(s) (from) (of)/postprocedural/heart failure/following other surgery or Failure, failed/heart/postprocedural directing you to code I97.131. Verify the code selection in the Tabular List. There is a note under subcategory I97.13 to use additional code to identify the heart failure (I50.-). The patient is in left heart failure. In the Alphabetic Index look for Failure, failed/heart/left (ventricular) which instructs you to see Failure, ventricular, left. In the Alphabetic Index look for Failure, failed/ventricular/left which guides you to code I50.1. Verify the code selection in the Tabular List. You do not code the abdominal aortic aneurysm because the patient no longer has that condition.

According to ICD-10-CM guideline I.B.1 use both ____ and ____ when locating and assigning a diagnosis code.

ICD-10-CM Alphabetic Index and Tabular List

The Table of Drugs in the HCPCS Level II book indicates various medication routes of administration. What abbreviation represents the route where a drug is introduced into the subdural space of the spinal cord?

IT Rationale: In the HCPCS Level II code book, there is an appendix that lists the abbreviations and acronyms and their meanings. IT stands for Intrathecal. IT is the route where a drug is introduced into the subdural space of the spinal cord.

Did you review Chapter 9 yet?

If not please do it :)

What does IOL stand for?

Intraocular lens

What is the value of a remittance advice?

It states what will be paid and why any changes to charges were made.

What is the ICD-10-CM code for strep throat?

J02.0

A 10 month-old comes into the pediatrician's office for a harsh, bark-like cough. She is diagnosed with croup. The mother also wants the pediatrician to look at a rash that has developed on her leg. The pediatrician prescribes over the counter medication of acetaminophen for the croup and hydrocortisone cream for the rash on the leg. She is to follow up in five days or return earlier if the conditions worsen. What ICD-10-CM code(s) should be reported for this visit?

J05.0, R21 Rationale: Signs and symptoms that are associated with a disease process should not be reported, refer to ICD-10-CM guideline I.B.5. ICD-10-CM code R05 is not reported because cough is a symptom of croup. Codes for signs and symptoms that are not routinely associated with a definitive diagnosis should be reported, according to ICD-10-CM guidelines 1.B.4 and I.B.5. The rash is reported because it is not related or associated with croup. Look for Croup in the ICD-10-CM Alphabetic Index referring you to code J05.0. Look for Rash in the Alphabetic Index referring you to code R21. Verify both codes in the Tabular List.

A patient is seen in the physician's office for a 2,400,000 U injection of Bicillin L-A. What code represents this drug and the units given?

J0561 x 24 Rationale: In the HCPCS Level II Table of Drugs, look up Bicillin L-A, which directs you to code J0561. One unit of J0561 represents 100,000 U, so 24 units are reported for 2,400,000 U.

What is the ICD-10-CM code for hay fever?

J30.1 Rationale: Look in the ICD-10-CM Alphabetic Index for Fever/hay (allergic) J30.1. Verify code selection in the Tabular List.

A 65 year-old female patient returns to her primary care provider for follow up of an upper respiratory infection diagnosed the previous week. Her condition has not improved and her cough has increased. She has a long history of smoking. She currently smokes one pack a day and is dependent on the cigarettes. She uses a bronchodilator for her COPD. The provider changes her antibiotics to treat her acute bronchitis with COPD. What ICD-10-CM codes are reported for this visit?

J44.0, J20.9, F17.210 Rationale: In the ICD-10-CM Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive/with/acute bronchitis J44.0. In the Tabular List, there is an instructional note to code also to identify the infection. For this example, the infection is reported with a code from category code J20 Acute Bronchitis. Because there is no indication of the infectious agent for the acute bronchitis, an unspecified code is used. Look for Bronchitis/acute or subacute (with bronchospasm or obstruction) J20.9. In the Tabular List category J44 has a note to code also the type of asthma which is not applicable to this case, so it is not coded. J44 also has a note to report an additional code for use of or exposure to smoke. The patient is currently still smoking and is dependent on cigarettes. Look for Dependence (on)/nicotine/cigarettes F17.210. Verify code selection in the Tabular List.

A patient is dependent on a respiratory ventilator and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site at the skin of the neck. Under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using skin flap rotation from the adjacent tissue of the neck. What ICD-10-CM codes are reported?

J95.09, L90.5, Z99.11 Rationale: ICD-10-CM guideline I.C.19.g.5 indicates that intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes are sequenced first, followed by a code(s) for the specific complication, if applicable. In the ICD-10-CM Alphabetic Index look for Complications/tracheostomy/specified type NEC directing you to J95.09. Next, look in the Alphabetic Index for Scar, scarring directing you to L90.5. The code for scarring of the trachea is not used because the scar is of the skin of the neck, not the trachea itself. Verify both code selections in the Tabular List. Z43.0 Encounter for attention to tracheostomy, is not reported. In the Tabular List Z43.0 has an Excludes1 note that excludes J95.0-. We also need to report the patient's dependence on the ventilator. Look in the Alphabetic Index for Dependence/on/ventilator directing you to Z99.11. Verify code selection in the Tabular List.

What ICD-10-CM code is reported for non-erosive duodenitis?

K29.80 Rationale: Look in the ICD-10-CM Alphabetic Index for Duodenitis (nonspecific) (peptic) K29.80. An additional code is listed including the description of bleeding K29.81. There is no mention of bleeding so verification of both codes in the Tabular List confirms code selection is K29.80.

A 22 year-old is in an outpatient facility for an inguinal hernia repair. Just before surgery, the surgeon discovers the patient is positive for MRSA and the surgery is canceled. Which ICD-10-CM code(s) should be reported for the outpatient service?

K40.90, A49.02, Z53.09 Rationale: ICD-10-CM guidelines for outpatient services IV.A.1 states to report the reason for surgery as the first listed diagnosis even if the surgery is canceled due to a contraindication. Look in the ICD-10-CM Alphabetic Index for Hernia/inguinal referring you to code K40.90. Next, look for MRSA (Methicillin resistant Staphylococcus aureus)/infection referring you to code A49.02. Lastly, look for Canceled procedure (surgical)/because of/contraindication referring you to code Z53.09. Verify code selection in the Tabular List.

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

K91.840 After a routine and uncomplicated appendix surgery, the patient began bleeding post-operatively. What ICD-10-CM code is reported?

What is the correct HCPCS Level II code for a removable metatarsal foot arch support that is pre-molded?

L3050 Rationale: In the HCPCS Level II Index, look for Support/arch. You are directed to see codes L3040-L3090. When you review the L codes, L3050 represents a removable, pre-molded, metatarsal foot arch support.

What is the ICD-10-CM code for hives?

L50.9

A 24 year-old woman developed a keloid scar as a result of a third degree burn on the left upper arm. What ICD-10-CM code(s) is/are reported?

L91.0, T22.332S Rationale: A keloid is a type of scar resulting from granulation tissue at the site of healed skin injury. This would be considered a sequela (late effect) after the acute phase of the burn. Per ICD-10-CM guideline I.B.10, Coding of sequela generally requires two codes sequenced in the following order: The condition or nature of the sequela is sequenced first (keloid). The sequela code is sequenced second. In the ICD-10-CM Alphabetic Index look for Scar, scarring/keloid directing you to L91.0. To find the late effect code, look for Sequelae (of) (see also condition)/burn and corrosion - code to injury with seventh character S. Look for Burn/above elbow/left/third degree which directs you to subcategory T22.332. Verify code selection in the Tabular List. 7 th character S is used to indicate sequela.

What information does ICD-10-CM add to many of the codes for eye disorders or injuries?

Laterality (eye affected).

Which main coronary artery bifurcates into two smaller ones?

Left

Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.

Location, quality and duration

A 70-year-old female patient presents with a complaint of left knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain. AP, lateral and sunrise views of the left knee are ordered and interpreted. The diagnosis is left knee pain secondary to underlying primary degenerative arthritis. What ICD-10-CM code(s) is/are reported?

M17.12 Rationale: The scenario is reported with one ICD-10-CM code. In the ICD-10-CM Alphabetic Index look for Arthritis, arthritic/degenerative, which directs you to see Osteoarthritis. Osteoarthritis/primary/knee directs you to M17.1-. A 4th character is required to report the laterality. Report code M17.12 for left knee. You do not report the ICD-10-CM code for knee pain as this is a symptom of the degenerative arthritis and is not reported separately.

A patient underwent debridement of the acromion, subacromial bursectomy, division of the coracoacromial ligament, and an abrasion acromioplasty with Mitek suture placement for recurrent dislocation of the right shoulder in the hospital outpatient surgery department. What ICD-10-CM code is reported?

M24.411 Rationale: Look in the ICD-10-CM Alphabetic Index for Dislocation/recurrent/shoulder which directs you to M24.41-. This code requires a 6 th character to specify laterality. Verify code selection in the Tabular List.

What ICD-10-CM code is used to report effusion of the right ankle joint?

M25.471 Rationale: Look in the ICD-10-CM Alphabetic Index for Effusion/joint/ankle and you are referred to M25.47-. In the Tabular List, code M25.47- requires the application of a 6 th character to specify the location (foot or ankle) and laterality. Report M25.471 for effusion of the right ankle.

What does MAC stands for?

Medicare Administrative Contractor

If an NCD (national coverage determination) does not exist for a particular service/procedure performed on a Medicare patient, who determines coverage?

Medicare Administrative Contractor (MAC)

What does MRSA stand for?

Methicillin Resistant Staphylococcus Aureus

In ICD-10-CM when both CKD and ESRD are reported what code(s) is/are reported?

N18.6 Rationale: Kidney or renal failure can be acute N17 or chronic N18. Chronic kidney disease (CKD) is classified in ICD-10-CM by severity (N18). The severity of CKD is designated by stages 1-5 (N18.1-N18.5). Code N18.6 for End stage renal disease (ESRD) is reported when documentation supports ESRD. If both CKD and ESRD are supported by the documentation, only N18.6 is reported as supported by the Excludes1 note under N18.5. Look in the ICD-10-CM Alphabetic Index for Disease/end stage renal which directs you to N18.6. Verify code selection in the Tabular List.

Preoperative diagnosis: Hematuria. Postoperative diagnosis: Right renal calculi and bladder calculus. What ICD-10-CM code(s) is/are reported for this service?

N20.0, N21.0 Rationale: The preoperative diagnosis indicates the reason for the surgery. The postoperative diagnosis indicates what was found during the surgery. Hematuria is a symptom of renal calculi and bladder calculus, and not coded separately. Refer to ICD-10-CM guideline 1.B.4 or I.B.18. Look in the ICD-10-CM Alphabetic Index for Calculus, calculi, calculous/kidney which directs you to code N20.0 and Calculus, calculi, calculous /bladder which directs you to code N21.0. Verify the code selections in the Tabular List.

What ICD-10-CM code is reported for male stress incontinence?

N39.3 Rationale: Look in the ICD-10-CM Alphabetic Index for Incontinence/stress (female) (male) which directs you to N39.3. The terms male and female are enclosed in parenthesis making them nonessential modifiers for code selection. Verify code selection in the Tabular List.

The patient is a pleasant 51 year-old male with morbid obesity, weighing approximately 560 pounds with a BMI of 85.1. He has uncontrolled diabetes and was evaluated due to testicular pain. He was found to have erythema, edema and possible areas of eschar on the scrotum. He was transferred to the hospital, evaluated and found to be stable with cellulitis and suspect early Fournier's gangrene. What are the appropriate ICD-10-CM codes reported?

N49.2, E11.9, E66.01, Z68.45 Rationale: There is incomplete information to determine if the scrotal cellulitis is a complication of the diabetes, therefore, you choose diabetes mellitus without mention of complication. There is not a specific indexing for cellulitis under the main term Diabetes/with in the ICD-10-CM Alphabetic Index therefore provider documentation must link the conditions to report it as complication of the diabetes. Cellulitis is confirmed. The scrotal cellulitis and diabetes are the appropriate diagnosis codes. In the ICD-10-CM Alphabetic Index look for Cellulitis/scrotum directing you to N49.2. Look for Diabetes/type 2 directing you to E11.9. Look for Obesity/morbid directing you to E66.01. Look for Body, bodies/mass index (BMI)/adult/70 and over Z68.45. Though Fournier's gangrene is suspected, you do not code a suspected condition. Verify all codes selected in the Tabular List.

The diagnosis caudal cervical inflammatory spondylopathy is assigned ICD-10-CM code M46.82 and is an example of what ICD-10-CM coding convention?

NEC (not elsewhere classifiable) The abbreviation NEC (not elsewhere classifiable) is used in the ICD-10-CM Alphabetic Index to indicate there is no separate code for the condition, even though the statement may be very specific. In the Tabular List, these conditions may include words such as other. In the Alphabetic Index look for Spondylopathy/inflammatory/specified type NEC/cervical region.

A PCP transfers a patient to a cardiologist for management of the patient's congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?

New patient office visit Rationale: The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient since the cardiologist accepted the patient and is taking over the care of a specific problem.

What does "non-facility" describe when calculating Medicare Physician Fee Schedule payments?

Non-hospital owned physician practices

What category of codes should be used to report an evaluation and management service provided to a patient in a psychiatric residential treatment center?

Nursing facility services Rationale: The guidelines for Nursing Facility Services state, "These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center."

What is the abbreviation for EACH EYE?

O.U. Rationale: O. U. stands for each eye or both eyes. O.D. stands for the right eye. O.S. stands for the left eye.

Patient presents with no menses and positive pregnancy test, but an ultrasound reveals no uterine contents. An embryo has implanted on the left ovary and this is treated with laparoscopic oophorectomy. What ICD-10-CM code is reported for this procedure?

O00.202 Rationale: For the diagnosis, look in the ICD-10-CM Alphabetic Index for Pregnancy/ovarian directing you to O00.20-a 6th character is required to identify laterality. 2 is assigned for the left ovary. In the Tabular List, there is an instructional note to use an additional code from category O08 to identify any associated complication. No complication is documented. Verify code selection in the Tabular List.

At 39 weeks gestation, a 26 year-old woman is admitted for precipitous labor and vaginally delivers a healthy baby girl. What ICD-10-CM codes are reported on the maternal record?

O62.3, Z37.0, Z3A.39 Rationale: The labor is precipitous. In the ICD-10-CM Alphabetic Index, look for Delivery (childbirth) (labor)/complicated/by/precipitate labor directing you to O62.3. ICD-10-CM guideline I.C.15.n.1 states that code O80 is reported for a full-term normal delivery of a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is not to be reported with any other pregnancy complication code from chapter 15. In this case, O62.3 is reported for the complication and the normal delivery code (O80) is not reported. The outcome of delivery is also reported. Look in the Alphabetic Index for Outcome of delivery/single/liveborn directing you to Z37.0. Code Z38.00 is only to be used on the newborn's record, not the maternal record. At the beginning of chapter 15, there is a note to use an additional code to report the weeks of gestation. The patient is 39 weeks gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation/39 weeks directing you to Z3A.39. Verify the code selection in the Tabular List.

Following labor and delivery, the mother developed acute kidney failure. What ICD-10-CM code is reported?

O90.4 Following labor and delivery, the mother developed acute kidney failure. What ICD-10-CM code is reported?

A patient was admitted three weeks following a normal vaginal delivery with a postpartum breast abscess. What ICD-10-CM code is reported?

O91.12 Rationale: In the ICD-10-CM Alphabetic Index look for Abscess/breast (acute) (chronic) (nonpuerperal)/puerperal, postpartum, gestational which guides you to see Mastitis, obstetric, purulent. Look for Mastitis (acute) (diffuse) (nonpuerperal) (subacute)/obstetric/purulent/associated with/puerperium guiding you to code O91.12. In the Tabular List, the description under O91.12 includes puerperal mammary abscess. The puerperium is the period of six weeks or 42 days following childbirth.

What document assists provider offices with the development of Compliance Manuals?

OIG Compliance Program Guidance: The OIG has offered compliance program guidance to form the basis of a voluntary compliance program for physician offices. Although this was released in October 2000, it is still considered as active compliance guidance today.

What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services?

OIG Work Plan: Twice a year, the OIG releases a Work Plan outlining its priorities for the fiscal year ahead. Within the Work Plan, potential problem areas with claims submissions are listed and will be targeted with special scrutiny.

Under HIPAA, what would be a policy requirement for "minimum necessary"?

Only individuals whose job requires it may have access to protected health information.

According to the Tabular List in the ICD-10-CM codebook, category code H80 Otosclerosis, includes what other disorder?

Otospongiosis

A young child is having lens surgery related to traumatic glaucoma due to an injury during birth. The anesthesiologist listed congenital glaucoma as the diagnosis. What ICD-10-CM code is reported?

P15.3 Rationale: In ICD-10-CM Alphabetic Index look for Glaucoma/traumatic/newborn (birth injury) which directs you to code P15.3. ICD-10-CM guideline I.C.16.a.1 indicates that Chapter 16 codes may be used throughout the life of the patient if the condition is still present. Note: Congenital is defined as present at birth, such as a birth defect. This injury was caused or acquired during the birth.

What is an example of an eponym?

Paget's Disease Rationale: An eponym is a word derived from someone's name. Paget's disease is a disorder that involves abnormal bone destruction and regrowth which results in deformity. It was described by surgeon and pathologist Sir James Paget.

The four parts to Medicare Program are:

Part A: inpatient/hospital coverage Part B: outpatient/medical coverage Part C: offers an alternative way to receive your Medicare benefits Part D: provides prescription drug coverage

The Medicare program is made up of several parts. Which part is affected by the Centers for Medicare & Medicaid Services - Hierarchical Condition Categories (CMS-HCC)?

Part C: Rationale: Accurate and thorough diagnosis coding is important for Medicare Advantage (Part C) claims because reimbursement is impacted by the patient's health status. The Centers for Medicare & Medicaid Services-hierarchical condition category (CMS-HCC) risk adjustment model provides adjusted payments based on a patient's diseases and demographic factors. If a coder does not include all pertinent diagnoses and comorbidities, there may be loss of additional reimbursement to which the provider is entitled.

Who would NOT be considered a covered entity under HIPAA?

Patients: Covered entities in relation to HIPAA include Health Care Providers, Health Plans, and Health Care Clearinghouses. The patient is not considered a covered entity although it is the patient's data that is protected.

According to the OIG, internal monitoring and auditing should be performed by what means?

Periodic audits

What type of provider goes through approximately 26 ½ months of education and is licensed to practice medicine with the oversight of a physician?

Physician Assistant (PA)

The path of the X-ray beam is known as?

Projection

What is exophthalmos?

Protrusion of the eyeballs.

A CRNA is personally performing a case with medical direction from an anesthesiologist. What modifier is appropriately reported for the CRNA services?

Q Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA with medical direction from an anesthesiologist is appropriately reported with modifier QX. Any time the CRNA is working with medical direction, the anesthesia procedure is reported with QX. The anesthesiologist reports QY if only directing one CRNA and QK if directing 2 to 4 CRNAs.

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

QX Rationale: In the HCPCS Level II codebook locate where the HCPCS Level II Modifiers are listed. A CRNA service under medical direction is coded with modifier QX. Reporting modifier QZ indicates the anesthesia was performed by non-medically directed CRNA and results in overpayment for the anesthesia service provided. The other two modifier selections are only reported for physician services. Modifier QX is assigned because there is no way the CRNA knows medical direction changed to medical supervision.

What modifier is used for medically-directed CRNA services?

QX Rationale: In the HCPCS Level II codebook look for where the modifiers are listed and refer to modifier QX. QX is the correct modifier for CRNA services when medically directed by a physician.

A 50 year-old patient has been diagnosed with elevated blood pressure. The patient does not have a history of hypertension. What is the correct ICD-10-CM code to report?

R03.0 Rationale: ICD-10-CM guideline I.C.9.a.7 tells us to assign code R03.0 Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. To find the code using the ICD-10-CM Alphabetic Index look for Elevated, elevation/blood pressure/reading (incidental) (isolated) (nonspecific), no diagnosis of hypertension which directs you to R03.0. The code is confirmed in the Tabular List.

What is the ICD-10-CM code for chest pain?

R07.9

What is the ICD-10-CM code for nausea?

R11.0

A patient is seen in the nursing home for dizziness and a healed stage II pressure ulcer is also noted. What ICD-10-CM code(s) is/are reported?

R42 Rationale: Dizziness is found in the ICD-10-CM Alphabetic Index by looking for Dizziness and verified in the Tabular List as R42. The pressure ulcer is stated as healed and would not be coded according to ICD-10-CM guideline I.C.12.a.4, "No code is assigned if the documentation states that the pressure ulcer is completely healed."

What ICD-10-CM code is reported for vertigo?

R42 Rationale: Look in the ICD-10-CM Alphabetic Index for vertigo. There are many different subentries for the type of vertigo; however, the type of vertigo is not specified. R42 is the default code for vertigo. Verify code selection in the Tabular List.

What is the ICD-10-CM code for headache?

R51

A patient with sinusitis and left vocal cord paralysis is sent for a CT scan of the brain. The impression is vague, low-density white matter changes in the right frontal region. This is a nonspecific finding. The radiologist requests an MRI scan for further characterization. What diagnosis code(s) should the radiologist report for the reading of the CT?

R93.0, J32.9, J38.01 RATIONALE: The findings of the CT were nonspecific and are not considered a final diagnosis. The first diagnosis reports the nonspecific findings. Because the findings were inconclusive, you also report the signs and symptoms for which the CT was ordered. In the ICD-10-CM Alphabetic Index, look for Findings, abnormal, inconclusive, without diagnosis/radiologic (X-ray)/head R93.0. Next, look in the Alphabetic Index for Sinusitis J32.9. The last code is found in the Alphabetic Index under Paralysis/vocal cords /unilateral J38.01. Verify all code selections in the Tabular List.

What is the eponym for a pancreatoduodenectomy?

Rationale: A Whipple procedure is also known as a pancreatoduodenectomy. Look in the CPT® Index for Whipple Procedure; it refers you to code 48150. The code description verifies that this procedure involves a pancreatectomy and duodenectomy. The other eponyms can be found in the CPT® Index and do not involve the removal of the pancreas and duodenum.

Looking in the CPT® manual the Nervous System is divided into what subheadings?

Rationale: CPT® divides the nervous system into three primary subheadings: 1. Skull, Meninges, and Brain (61000-62258) 2. Spine and Spinal Cord (62263-63746) 3. Extracranial Nerves, Peripheral Nerves, and Autonomic Nervous System (64400-64999)

Which option below is NOT a covered entity under HIPAA?

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

The Global Surgical Package applies to services performed in what setting?

Rationale: The services included in the global surgical package may be furnished in any setting, including hospitals, ASCs, and physicians' offices. Visits to a patient in an intensive or critical care unit are also included if made by the surgeon.

CPT® Category III codes reimburse at what level?

Reimbursement, if any, is determined by the payer

SOAP Notes

S - Subjective: patient's statement about their health, including symptoms O - Objective: The provider's examination and documentation of the patient's illness using observation, palpation, auscultation, and percussion A - Assessment: Evaluation and conclusion made by provider P - Plan:

Patient is in the ED due to a football hitting his nose when playing tackle football in the park. X-ray shows a displaced nasal fracture. What ICD-10-CM codes are reported?

S02.2XXA, W21.01XA, Y93.61, Y92.830 Rationale: In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/nasal (bone(s)) S02.2. In the Tabular List, seven characters are needed to complete this code. Placeholder X is used for the 5 th and 6 th characters and A is assigned as the 7 th character for initial encounter for closed fracture. The dislocation code and the open fracture code are not reported. Should a fracture and dislocation occur in the same site, only the fracture code is reported. Look in the Alphabetic Index for Dislocation/with fracture and you are referred to see Fracture and a displaced fracture is a closed fracture. External cause codes are used to report the circumstances surrounding the injury. In the ICD-10-CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/football W21.01. In the Tabular List seven characters are needed to complete the code. A placeholder X is used for the 6 th character and A is assigned for the 7 th character for the initial encounter. Next, look in the External Cause of Injuries Index for Activity/football (American)/tackle directing you to Y93.61 and Place of occurrence/park (public) directing you to Y92.830. The Y codes do not require a 7 th character. Verify code selection in the Tabular List.

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

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

A 14 year-old male patient was injured while skateboarding. The injuries included a displaced transverse fracture of the right femur shaft with multiple significant abrasions of the right thigh. What ICD-10-CM codes are reported?

S72.321A, V00.138A, Y93.51 Rationale: Look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/femur, femoral/shaft/transverse (displaced) which directs the coder to S72.32- . In the Tabular List, 7 characters are needed to complete the code. The complete diagnosis code is S72.321A because the 6 th character is 1 for the right and this is the initial encounter for closed fracture identified with a 7 th character A. ICD-10-CM guideline I.C.19.b.1 states separate codes for more superficial injuries of the same site (such as abrasions) should not be assigned. To find the external cause code look in the ICD-10-CM External Cause of Injuries Index for Accident/transport/pedestrian/conveyance (occupant)/skate board, guiding you to V00.138. In the Tabular List the 7 th character A is chosen for initial encounter. Next, you report an external cause code for the activity by looking for Activity/skateboarding in the Index to External Causes of injuries guiding you to Y93.51. There is no mention of the place of occurrence, so it is not coded. Verify code selection in the Tabular List.

A 23 year-old patient presents to the Emergency Department with a cut on his leg. He is a confirmed AIDS patient as documented in the record. What ICD-10-CM codes should be reported?

S81.819A, B20 Rationale: Per ICD-10-CM guideline I.C.1.a.2.b, if a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition is the principal diagnosis. In the ICD-10-CM Alphabetic Index, look for Laceration/leg (lower) referring you to S81.819-. Because this is an ED visit, it is considered an initial encounter. In the Tabular List, 7 th character A is reported for the initial encounter. AIDS is reported as the secondary diagnosis. Look in the Alphabetic Index for AIDS referring you to B20. Verify code selections in the Tabular List.

What section of the ICD-10-CM guidelines contains instructions on how to code for a patient receiving diagnostic services only in an outpatient setting?

Section IV

A 7 year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the puncture wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What ICD-10-CM codes are reported?

S81.852A, Z20.3, Z23, W54.0XXA Rationale: The child had puncture wounds to her left leg from a dog bite. Look in the ICD-10-CM Alphabetic Index for Bite(s) (animal) (human)/leg (lower) S81.85-. In the Tabular List, 6 th character 2 is reported for the left leg and 7 th character A is applied for the initial encounter. She did not have rabies but was exposed to it because the dog was known to have rabies. This exposure to rabies is reported. Look in the Alphabetic Index for Exposure (to)/rabies directing you to Z20.3. She received a rabies vaccination. Look in the Alphabetic Index for Immunization/encounter for directing you to Z23. Next, the circumstances for the injury are reported. The only thing we know is that it is a dog bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/dog directing you to W54.0-. In the Tabular List the 7 th character A is applied for the initial encounter. Placeholder X is used for the 5 th and 6 th characters to keep the 7 th character in the 7 th position. Verify code selection in the Tabular List.

A 60 year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. The fracture is healing normally. What ICD-10-CM code(s) is/are reported?

S92.002D, W11.XXXD Rationale: A comminuted fracture is one in which a bone is broken, splintered, or crushed into a number of pieces; therefore, it is considered displaced. Look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/tarsal bone(s)/calcaneus directing you to subcategory S92.00-. The Tabular List indicates seven characters are needed to complete the code. The 6 th character 2 indicates laterality as left. The patient has completed the initial fracture treatment phase and is healing normally; therefore, the 7 th character D is chosen for subsequent encounter for fracture with routine healing. Cast change and removal are listed as examples of fracture aftercare in the ICD-10-CM guideline I.C.19.c.1. ICD-10-CM guideline I.C.20.a.2 instructs you to use the external cause code for the length of the treatment. In the ICD-10-CM External Cause of Injuries Index look for Fall, falling/from, off, out of/ladder directing you to category W11. In the Tabular List, there is a note that the code requires seven characters. The 4 th, 5 th, and 6 th characters are reported with placeholder Xs and the 7 th character chosen is D for subsequent encounter. The complete code is W11.XXXD. Verify code selection in the Tabular list.

Procedures involving which of the following structures found in the vulva are NOT coded in the female reproductive system section of CPT®?

Skene's gland

Evaluation and management services are often provided in a standard format such as SOAP notes. What does the acronym SOAP stand for?

Subjective, objective, assessment, plan

A patient is coming in for follow up of a second-degree burn on the left forearm. The provider notes the burn is healing well. He is to come back in two weeks for continued care to checkup on the healing of the burn. What ICD-10-CM code is reported?

T22.212D Rationale: In the ICD-10-CM Alphabetic Index look for Burn/forearm/left/second degree, guiding you to subcategory T22.212. Per ICD-10-CM guideline I.C.19.a indicates that the 7 th character D subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition." Verify code selection in the Tabular List.

What is the correct diagnosis code to report initial treatment of an infected post procedural stitch abscess of the right leg from a previous excision of a squamous cell carcinoma?

T81.41XA Rationale: In the ICD-10-CM Alphabetic Index look for Abscess/stitch or Complication/surgical procedure/stitch abscess or Stitch/abscess referring you to T81.41-. In the Tabular List, seven characters are needed to complete the code. The 5th character identifies the depth of infection. Since the infection is a stitch abscess, 1 is the correct 5th character. One X placeholder is for the 6th character and the 7th character A is reported for initial encounter (or treatment). An instructional note indicates to use an additional code to identify the infection. We do not know what the type of infection, so it is not coded.

The patient is seen for an initial replacement of a leaking dialysis catheter. What ICD-10-CM code is reported?

T82.43XA Rationale: A leaking dialysis catheter would be a complication. In the ICD-10-CM Alphabetic Index look for Complication/catheter (device) NEC/dialysis (vascular)/mechanical/leakage, guiding you to subcategory code T82.43. The Tabular List indicates seven characters are needed to complete the code. The 6 th character is for the placeholder X and the 7 th character is A for the initial encounter. T82.43XA is the correct code.

To code for the operating microscope, what verbiage are you looking for in the medical record?

The operating microscope was sterilely draped and brought into the surgical field. Rationale: A loupe is a single vision magnifying glass most often identified with jewelers or watchmakers. An operating microscope is a binocular microscope used to see and repair small intricate parts of the body, such as nerves and blood vessels. It is not an instrument that can be sterilized so it must be sterilely draped for use in the operating room

In ICD-10-CM what condition is reported as the default code when the provider documents urosepsis?

The provider must be queried before an ICD-10-CM code can be applied. Rationale: ICD-10-CM guideline I.C.1.d.1.a.(ii) indicates urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. Urosepsis does not have a default code. If the provider documents urosepsis without additional information, the provider must be queried before an ICD-10-CM code can be applied.

What will the scope of a compliance program depend on?

The size and resources of the provider's practice

Which of the following is a BENEFIT of electronic transactions?

Timely submission of claims

What is the definition of medical coding?

Translating documentation into numerical/alphanumerical codes used to obtain reimbursement.

Which statement describes a medically necessary service?

Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition.

What external cause code(s) are reported for a passenger involved in an MVA that lost control on the highway and hit a guardrail?

V47.6XXA, Y92.411 Rationale: In the ICD-10-CM External Cause of Injuries Index (after the ICD-10-CM Table of Drugs and Chemicals), look for Accident/transport/car occupant/passenger/collision (with)/stationary object (traffic), guiding you to V47.6-In the Tabular List a 7 th character A is necessary for the initial encounter. You would use an additional external cause code when a place of occurrence (for example, home or parking lot) is documented. In this case, the location is documented as the highway. In the External Cause of Injuries Index, look for Place of occurrence/highway (interstate), guiding you to code Y92.411. Verify code selection in the Tabular List.

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.

Vulvar cancer in situ can also be documented as:

VIN III Rationale: Vulvar intraepithelial neoplasia stage III or VIN III is coded as cancer in situ. The other VINs listed are coded as hyperplasia and adenocarcinoma is a primary malignancy. In ICD-10-CM Alphabetic Index go to the Table of Neoplasms and look for Neoplasm, neoplastic/vulva/Ca in situ column directing you to D07.1. Verification of this code in the Tabular List confirms D07.1 is reported for VIN III.

What does the root word colp/o stand for?

Vagina

What information is required to accurately code PVD with diabetes in ICD-10-CM?

Whether the patient has gangrene. Rationale: PVD is the abbreviation for Peripheral Vascular Disease. ICD-10-CM indexes PVD with diabetes with one code. For proper code selection the provider must document if the patient has gangrene or not. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/with/peripheral angiopathy which directs the coder to E11.51.

Can Z codes be listed as a primary code?

Yes; Z codes can be sequenced as primary and secondary codes. Rationale: ICD-10-CM guideline I.C.21.a indicates Z codes may be used as either a first listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Z codes are not external cause codes. The external cause codes are listed in chapter 20 in the Tabular List and begin with alpha characters V, W, or Y, and can only be reported as secondary codes.

Mr. Davis has his yearly preventive medicine exam. The physician orders a chest X-ray as part of the preventive exam. What diagnosis is reported for the chest X-ray?

Z00.00 RATIONALE: For encounters for routine radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z00.00. Because there were no signs or symptoms for the chest X-ray, and it was routinely performed as part of a preventive medicine exam, ICD-10-CM Z00.00 is reported. In the ICD-10-CM Alphabetic Index, look for Examination/annual (adult) or Examination/radiological (as part of a general medical examination) Z00.00. In the Tabular List, the note under subcategory code Z00.0 indicates the code is for an, "Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations."

A 6 month-old patient is seen at the clinic for a routine well-child visit and vaccinations. During the examination the provider finds that the child has a fever and a diagnosis of acute otitis media in the right ear is documented. Vaccinations are not given at this time. What ICD-10-CM code(s) is/are reported?

Z00.121, H66.91, Z28.01 Rationale: According to ICD-10-CM guideline I.C.21.13: During a routine exam, should a diagnosis or condition be discovered, it should be coded with abnormal findings. The abnormal finding should be coded as an additional code. Look in the ICD-10-CM Alphabetic Index for Examination (for) (following) (general) (of) (routine)/child (over 28 days-old)/with abnormal findings which directs you to Z00.121. To report the abnormal finding, look in the Alphabetic Index for Otitis (acute)/media/acute, subacute which directs you to H66.90. Verify code selection in the Tabular List. Subcategory code H66.9 is for Otitis media, unspecified. Report H66.91 for the right ear. Next, in the Alphabetic Index look for Vaccination/not done which states see Immunization, not done, because (of). Immunization/not done/because (of)/acute illness of patient directs you to Z28.01. Verify code selection in the Tabular List.

A patient with hypertension is scheduled for same day surgery for removal of her gallbladder due to chronic gallstones. She is examined preoperatively by her cardiologist to be cleared for surgery. What ICD-10-CM codes are reported by the cardiologist?

Z01.810, K80.20, I10 Rationale: In the ICD-10-CM Alphabetic Index look for Examination/preoperative; there is a note - see Examination, pre-procedural. Look for Examination/pre-procedural/cardiovascular which refers you to Z01.810. Next, look for Calculus/gallbladder which refers you to K80.20 and Hypertension which refers you to I10. Verify all code selections in the Tabular List. Correct codes and sequencing are Z01.810, K80.20 and I10. Sequencing of preoperative clearance first (the reason for the visit), then the reason for the surgery, and last, any other findings or diagnoses. (Sequencing rule from Official Coding Guidelines of ICD-10-CM Section IV.M.)

A 65 year-old is seen by her cardiologist for preoperative evaluation for clearance for removal of her gallbladder due to gallstones. The cardiologist notes that she has hypertension. Medication is given to control her hypertension. What diagnosis codes are reported?

Z01.810, K80.20, I10 Rationale: When a patient is receiving a preoperative evaluation only, a Z code from subcategory code Z01.81- is reported first. Then assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Next code any finding(s) related to the pre-operative evaluation. Refer ICD-10-CM guideline IV.M. The evaluation code is located in the ICD-10-CM Alphabetic Index for Examination/pre-procedural (pre-operative)/cardiovascular referring you to code Z01.810. Next, look for Gallstone which directs you to see also Calculus, gallbladder. Look in the Alphabetic Index for Calculus/gallbladder referring you to K80.20. There is no documentation that the gallstones are causing an obstruction making the correct 5 th character zero. Look in the Alphabetic Index for Hypertension referring you to code I10. Verify code selection in the Tabular List.

A patient is seen in the ED for having unprotected sexual intercourse a few months prior. She recently found out that the individual she was with has HIV. She is only being tested for HIV. What ICD-10-CM code(s) is/are reported?

Z11.4 Rationale: Per ICD-10-CM guideline I.C.1.a.2.h, if a patient is being seen to determine her HIV status use code Z11.4. In the ICD-10-CM Alphabetic Index look for Screening/disease/human immunodeficiency virus (HIV) Z11.4. Verify in the Tabular List.

Mr. Smith presents to the office for a screening test to detect sickle cell disorder. What ICD-10-CM code(s) is/are reported?

Z13.0 Rationale: This is considered a screening. Per ICD-10-CM guideline I.C.21.c.5, "Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease." In the ICD-10-CM Alphabetic Index look for Screening (for)/sickle-cell disease or trait, guiding you to code Z13.0. Verify this is the correct code in the Tabular List. The patient does not have a known sickle cell disorder so a code from D57 is not reported; results from the screening test will determine if the patient has sickle cell disorder.

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 which refers you to 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 the CPT® or HCPCS codes.

Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still symptomatic and is diagnosed with ischemic heart disease. What is (are) the correct ICD-10-CM code(s) for this condition?

Z51.89, I25.9 Rationale: Because it is past four weeks since the myocardial infarction and the patient is still symptomatic, ICD-10-CM guideline, I.C.9.e.1, indicates that the appropriate aftercare code is assigned rather than a code from category I21. Look in the ICD-10-CM Alphabetic Index for Aftercare directing you to Z51.89. Verify code selection in the Tabular List. The instructional note under category Z51 indicates to code also condition requiring care. Look in the Alphabetic Index for Disease/heart/ischemic (chronic or with a stated duration of over 4 weeks) directing you to I25.9. Verify in the Tabular List.

What ICD-10-CM code is reported for personal history of transitional cell carcinoma of the bladder?

Z85.51 Rationale: Look in the ICD-10-CM Alphabetic Index for History/personal (of)/malignant neoplasm/bladder which directs the coder to Z85.51. Verify code selection in the Tabular List.

The acronym BKA means:

below knee amputation